This spring, as the Senate Health and Education Committee finished up a year of wrangling over renewal of  the Ryan White Care Act, the crucial bill providing most federally funded AIDS services, a new battle broke out, pitting big cities against small ones. In April, the Government Accountability Office reported that Ryan White provided positive people in urban areas with more cash per capita because under the first of the Act’s four titles—Title I—only cities with at least 500,000 people and 2,000 AIDS cases can get funds for treatment and HIV facilities. “There’s absolutely no doubt that there are funding discrepancies,” says Kathie Hiers, chief executive officer of AIDS Alabama and cochair of the Southern AIDS Coalition. “You cannot just take resources from places with the highest levels of HIV. It will exacerbate existing problems,” counters Ernest Hopkins of the Communities Advocating Emergency AIDS Relief (CAEAR) Coalition, which represents urban areas.

When Congress approved the Ryan White Act in 1990, AIDS was considered a mostly urban virus. But HIV has increasingly affected more people in rural areas, especially in the South. Southern states now house 41% of the nation’s HIV infections, but only 34% of the population. While the highest HIV concentrations remain in urban areas, 79% of people on the Ryan White–funded AIDS Drug Assistance Program (ADAP) waiting list live in the South. While the CAER Coalition contends that the funding evens out if all four titles are averaged, Hiers disagrees, saying that while these other titles deal with testing and education, they do not adequately cover treatment. “What good is it to test them, tell them they’re infected but say we don’t have the resources to treat them?” she says. The current Senate draft expands Title I to make cities with as few as 500 AIDS cases and a population of 50,000 eligible for funding. This means places like Birmingham, Alabama (the state with the nation’s longest ADAP waiting list) will get covered. But no matter what happens with the final vote (imminent as POZ went to press), both sides agree that they could agree if the Feds would just send more funds Ryan White’s way nationwide.   

It isn’t exactly news that a life with HIV can be expensive. But the journal Clinical Infectious Diseases has picked up the tab and studied it closely, breaking down the average yearly cost of health care per person—and per CD4 cell. The report ( didn’t factor in emergency room costs or insurance coverage. Ka-ching.

  • Total cost for people with at least 350 CD4s: $13,885
  • Total cost for people with 50 CD4s or fewer: $36,533
  • Percent both groups spent on visiting doc: 2
  • Percent both groups spent on HAART: 71 to 84