From the Office of Congresswoman Nancy Pelosi

Pelosi Seeks Explanation from HHS Secretary for Devastating $4 Million Cut in San Francisco AIDS Funding

San Francisco, CA -- House Democratic Leader Nancy Pelosi sent the following letter today to Health and Human Services Secretary Tommy Thompson in response to the $4 million cut in San Francisco’s Ryan White CARE Act Title I award:

March 12, 2004

The Honorable Tommy G. Thompson
Department of Health and Human Services
Hubert H. Humphrey Building
200 Independence Avenue, S.W.
Washington, D.C. 20201

Re: Ryan White CARE Act

Dear Secretary Thompson:

I am writing to express my strong concern about the $4 million cut in San Francisco’s Ryan White CARE Act Title I award, which was announced on March 1st. This reduction will have a devastating impact on HIV/AIDS services in the Bay Area.

San Francisco was one of the first epicenters of the AIDS epidemic and continues to be one of the hardest hit areas in the country. With an estimated 23,000 people living with HIV/AIDS, the San Francisco eligible metropolitan area (EMA) has the highest per-capita rate of total AIDS cases, the third highest number of total AIDS cases, the fifth largest number of people living with AIDS, and the tenth highest rate of new AIDS cases in the nation. In addition to the disproportionate rate of AIDS cases, the rate and prevalence of HIV infection in the population of our EMA are increasing. It is estimated that 1 in 40 San Franciscans are infected with HIV.

We are all grateful that improved access to care and increasingly effective HIV treatments have resulted in a decline in deaths among persons living with HIV/AIDS. However, fewer deaths and increasing rates of infection mean there are more people living with HIV/AIDS and, consequently, more people in need of Ryan White CARE Act services than ever before.

The San Francisco EMA bears a significant share of the HIV/AIDS epidemic and relies heavily on Title I funds to provide vital services and increase access to care. The sizeable population in San Francisco living with HIV/AIDS is increasingly impoverished, homeless, and struggling with co-morbidities such as hepatitis C, addiction and mental illness. In addition, San Francisco is one of the most expensive places in the country to provide medical care, and housing costs continue to be among the highest in the nation.

We expected a funding reduction of $545,110, or 3.3 percent, in our Title I formula award pursuant to the hold harmless provision in the Ryan White CARE Act Amendments of 2000. However, the San Francisco EMA was unprepared for an additional $3.5 million, or 21 percent cut, in our supplemental award, which combined with the formula reduction resulted in a 12.1 percent overall reduction. San Francisco experienced the largest dollar reduction of any EMA and the third highest reduction by percentage.

The San Francisco EMA cannot sustain a loss of this magnitude without undermining the safety net for the most vulnerable persons living with HIV/AIDS in our community. A $4 million reduction would force San Francisco to cut 1,171 hours of treatment adherence services, 554 days of adult day health care services, 1,779 dental procedures, integrated case management for 527 people, and numerous other services that are critical to maintain and improve the health of people living with this terrible disease.

Our EMA has consistently scored well on its previous Title I supplemental applications, as evidenced by its supplemental award as a percentage of its formula award. The Health Resources and Services Administration (HRSA) has historically identified few weaknesses, and has even cited San Francisco's application as an example of a well-written proposal.

After reviewing the Summary Report from HRSA for the EMA’s 2004 application, I am concerned that the evaluation contains several inaccuracies and clear contradictions. The following are just two examples of misinformation contained in HRSA’s Summary Report:

Under Scoring Factor 3 - Severe Need, one weakness reads, “The needs of each population included are not addressed in a meaningful, specific way.” However, a strength in this same category indicates, “The application provides very comprehensive information on the disproportionate impact on certain populations, and sub-populations.” It is difficult to see where the application is lacking in this regard, particularly since San Francisco received a sizeable Minority AIDS Initiative award, which is based upon the same application.

Another weakness in Scoring Factor 3 states, “The application does not adequately address gender in epidemiological data; the application does not to [sic] even mention men in the gender section.” However, a strength in this same category reads, “The application includes very comprehensive epidemiological data, including several instances of prevalence estimates (e.g., among homeless MSM) and comparisons between groups.” Indeed, the application clearly states in several places (pp. c, 33, 34, 39, 40) that men who have sex with men (MSM) account for the largest share of the epidemic in the EMA.

I respectfully request a detailed explanation of the process by which allocations were made, a response to the concerns raised above, and documentation that allocations were made in an equitable and accountable way. In addition, I hope that we will be able to work together to identify other funds within the Department of Health & Human Services to help offset these cuts and prevent reductions in vital health services for people living with HIV/AIDS in the San Francisco Bay Area.

Thank you for your immediate attention to this matter. I look forward to working with you to ensure that people living with HIV/AIDS in the Bay Area and across the country have access to the Ryan White CARE services they need to stay healthy.



House Democratic Leader




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