When the U.S. Congress passed the Ryan White Comprehensive AIDS Resources Emergency (CARE) Act in August 1990, it honored a young man who had acquired HIV from a blood transfusion five years earlier at age 13.
White, who became a world-renown symbol of resistance to HIV prejudice, died in April 1990 from AIDS.
For 35 years, the Ryan White HIV/AIDS Program born from the CARE Act has provided comprehensive HIV/AIDS medical care, treatment and support services in the United States for approximately 500,000 people annually. According to the federal government's Health Resources and Services Administration, the agency overseeing the Ryan White Program, the medical care it provided in 2023 resulted in a record-breaking 90.6% HIV suppression rate (number of people with undetectable virus) among those it served.
In a new Johns Hopkins Medicine-led study, researchers predict that ending federal funding for the Ryan White Program could increase HIV infections across 31 U.S. cities by 49% in the next five years.
The study appears online today in the Annals of Internal Medicine.
"The most powerful form of prevention is making sure we treat people with HIV effectively," says study senior author Todd Fojo, M.D., M.H.S., assistant professor of medicine at the Johns Hopkins University School of Medicine. "Providing medical treatment for HIV is a public health issue in that it is a lifelong condition. With antiretroviral therapy, people with HIV can expect to live a normal lifespan and do not transmit HIV."
Study researchers used a mathematical model, informed by survey data, to estimate the effect of interrupting or stopping the Ryan White HIV/AIDS Program in 31 U.S. cities, chosen because they reported the highest incidence of HIV.
The model represented the population of each city as groups of people. The groups were split by age, race and sex.
The researchers surveyed Ryan White clinic directors and administrators to estimate the proportion of Ryan White clients who would lose viral suppression if services stopped, and used the responses to inform the computer simulation of that stoppage.
"Based on the way HIV infections have trended over the past few decades, we projected it forward another five years," says study lead author Ryan Forster, Ph.D., a postdoctoral research fellow at the Johns Hopkins Bloomberg School of Public Health. "It gave us an estimate of how many infections there could be in the future."
The researchers found that ending the program would incur some 75,000 more HIV infections during the next five years than if funding continued uninterrupted — a 49% increase in new infections.
They also looked at the effects of brief interruptions in Ryan White funding — for 18 months and 42 months — on HIV incidence. Both scenarios predict higher incident rates — 19% and 38% more infections, respectively, by 2030.
Fojo adds that if Ryan White funding is stopped now, the predicted increase in HIV infections in Baltimore City by 2030 would easily be the worst among the cities on the list.
"I'm dismayed to see that Baltimore City's infections would increase by 110%, meaning infections over the next five years would double," Fojo says.
The researchers say the next steps are to look at individual states and predict the impact if the Ryan White HIV/AIDS Program is terminated.
No matter what those studies learn, they add, the findings reported in the Annals of Internal Medicine study show that federal funding for HIV and AIDS prevention and treatment makes a significant difference.
"Thanks in a large part to Ryan White funding, our ability to provide high-quality HIV care has changed dramatically since the program began at Johns Hopkins Medicine in 1984," says study co-author Joyce Jones, M.D., director of the adult Ryan White program and the Ryan White-supported John G. Bartlett Specialty Practice at The Johns Hopkins Hospital, and assistant professor of infectious diseases at the Johns Hopkins University School of Medicine. "Due to advances in HIV treatment — and our ability to provide that treatment regardless of income through Ryan White and other programs — we now see the majority of people with HIV living full, healthy lives by keeping the virus well controlled with as little as one pill a day or an injection every two months."
Besides Fojo, Forster and Jones, the other study team members from Johns Hopkins Medicine are Keri Althoff, Ph.D., M.P.H.; David Dowdy, M.D., Ph.D.; Kelly Gebo, M.D., M.P.H.; Parastu Kasaie, Ph.D.; Catherine Lesko, Ph.D.; Melissa Schnure, Ph.D.; and Maunank Shah, M.D., Ph.D.
Team members from other institutions are D. Scott Batey, Ph.D., M.S.W., Tulane School of Social Work; Isolde Butler, M.D., Ph.D., Crescent Care; Mamta Jain, M.D., M.P.H., University of Texas Southwestern Medical Center and Parkland Health; Karen Musgrove, Ph.D., M.Ed., Birmingham AIDS Outreach; and Dafina Ward, J.D., Southern AIDS Coalition.
