Medicaid Estate Recovery

The Texas Health and Human Services Commission has sent the following notice"

In compliance with federal law, Texas has implemented the Medicaid Estate Recovery Program. With this program, the state may file a claim against the estate of a deceased Medicaid recipient, age 55 or older, who applied for certain long-term care services on or after the program's effective date, March 1, 2005.

Officials with the Department of Aging and Disability Services, which manages the program in Texas, say claims will not be filed when:

• There is a surviving spouse.
• There is a surviving child or children under 21 years of age.
• There is a surviving child or children of any age who are blind or
  permanently and totally disabled under Social Security requirements.
• There is an unmarried adult child residing continuously in the Medicaid recipient's homestead for at least one year before the time of the Medicaid recipient's death.
  

[Website information]

HB 43 Hearing

The hearing broadcast begins at 1:31:25 on the first session archived for March 22. It continues for about 15 minutes at the beginning of the second session archived for the day.

SB 127 -- Disease Control Programs

Disease control, harm reduction, needle exchange--we've seen this issue every session since I've been working for Texas AIDS Network. Some really fine folks have carried these bills in both the House and the Senate. Very often, the bills have died in committee, especially in the House. The Senate has been a little more collegial, allowing bills to be voted out of committee, but then they mysteriously never seem to get to the floor for debate and vote.

SB 127 was heard in the Senate Health and Human Services Committee yesterday afternoon. Several folks testified in support of the bill. No one spoke against it. Senator Jane Nelson chaired the hearing and was quite engaged in the issue. She asked several pertinent questions and seemed to have an honest interest in trying to figure out a way to support the bill. Her biggest concern was not the "moral" issue of needle exchange but the "message" issue, i.e., her concern that supporting needle exchange would send the wrong message to our youth with the apparent implication being that drug use is okay because we are giving needles to addicts and allowing them to continue to break the law by using illegal drugs. Or something like that.

Chairman Nelson was about to leave the bill pending in committee, since a quorum was not present, when several Senators began trickling in through various doors of the chamber. Senator Lindsay had marshalled his votes--and the bill passed.

The next challenge is to get the bill to the Senate floor for a vote.

HB 43 - Mandatory HIV Testing in Texas Prisons

Rep. Yvonne Davis' bill requiring HIV tests for all Texas inmates just prior to release will be heard this morning in the House Committee on Corrections. Texas AIDS Network will testify on the bill.

It took some doing, but we finally got a chance to talk to an aide in Davis' office about the bill and share our concerns. Our understanding is that Rep. Davis will introduce a committee substitute, but the only addition is to clarify reporting requirements for test results.

The bill is deceptively simple, as we discussed earlier. It simply changes "may" to "shall" or "must," applies to both state prisons and state jails, and applies to prisoners about to be released from the institutions. The fiscal note for the bill says that it won't impact the state's budget.

On one hand, the Network would like to support the bill.

• The incidence of HIV is about 7 times higher in the Texas criminal justice system than it is in the general population. The state releases a little more than 100 HIV-positive prisoners each month, according to the Texas State Epidemiologic Profile, 2005. The actual number of HIV-positive prisoners may be higher.
• Upon release, ex-prisoners often seek to do those things that they were not allowed to do while in prison. This may include behaviors that can lead to the transmission of HIV or other infectious diseases.
• The over-representation of African Americans in the Texas prison system, coupled with their over-representation in current HIV surveillance reports, suggests that there might be some net benefit to prevention, especially for that community, if some policy like what is being proposed in HB 43 is implemented.

On the other hand, we have some concerns about the bill.

• The Network bases its advocacy on a set of policy principles that provide a framework for progressive public policy for HIV/AIDS education, prevention, and treatment. Principle 9 says:

"There are no scientifically valid grounds for the mandatory HIV testing of specific groups of persons. Public health policy regarding HIV testing should be firmly grounded in current scientific evidence regarding risk of HIV transmission and should take into account the social and economic impact of HIV testing."

• The Network would rather see the testing protocol be "routine" rather than "mandatory." This would allow a prisoner to opt out of the test if he/she really objected to being tested. Our justification for this is simply a matter of human rights, allowing the individual to make an informed decision regarding his/her own health.
• That matter of "informed decision" is also a concern. Any HIV test administered in the state of Texas is supposed to be accompanied by pre-test counseling which allows the individual to have the information needed to make a decision regarding testing. If testing becomes mandatory in Texas prisons, there appears to be no concomitant requirement that any sort of counseling or education precede the test.
• In the case of a positive test result, Texas law also requires post-test counseling regarding prevention and treatment. This law is often disregarded, so we think it would be worthwhile to reference the relevant part of the statute to make sure that this counseling occurs.
• When this counseling occurs is also important. A positive test result is not like saying, "Beef! It's what's for dinner!" This is a life-altering moment. This is news that pretty much shuts out the world and all that it might have to say while the individual processes the fact that he/she has a life-threatening disease that is more than a little socially unacceptable. (Not only are you going to die, people won't like you anymore!) HB 43 makes no provision for timing of the test--and therefore does not allow time for an individual to adjust to a positive test result or make arrangements for living with HIV after release. Just as important from the perspective of the bill as a prevention bill, there needs to be some time allowed for the individual to be able to receive and understand the prevention information that he/she now needs in order to protect future sexual partners.
• The bill makes no reference to after care. There is some indication that after care is now a concern at the Texas Department of Criminal Justice, but there is also anecdotal evidence that what is said to happen doesn't always happen. The Network would prefer an explicit reference in the bill to TDCJ's responsibility to provide referrals and assistance in making connection with local community HIV services and, when appropriate, the Texas HIV Medication Program. For community services, this might include introduction to a case manager, even if only by telephone, and setting up an appointment to begin services, preferably within 30 days of release.

We'll see how it goes.

[Edited to correct embarrassing error in the number of prisoners released each month.]

US under fire over needle exchanges for AIDS prevention

The controversy regarding the current administration's stand on needle exchange is expanding. In a letter coordinated with 300 organizations from 56 countries, Human Rights Watch laid out concerns about the US' pressure on the UN not to support needle exchange programs. While the "mainstream" view is that needle exchange is a public health solution to a public health problem, the US is taking the position that needle exchange contributes to drug use and is, therefore, part of the public health problem. The US, not surprisingly, is advocating abstinence.

The result:

"We must not deny these addicts any genuine opportunities to remain HIV negative," Antonio Maria Costa, head of the UN Office on Drugs and Crime (UNODC) told in Vienna on Monday the 48th session of the UN Commission on Narcotic Drugs (CND).


Costa said that contaminated syringes were a major source of transmission of the HIV virus and other diseases including hepatitis, especially among drug users whose capacity for rational thought was diminished.


"We reject the false dichotomy that either drug control prevails, with no consideration for HIV, or that HIV prevention prevails with no consideration for drug abuse," he added.

. . .

Costa had said in a letter sent in November to the US State Department that the controversy over US objections to needle exchanges "continue to place... (Costa's office) in a difficult position," according to a copy of the letter obtained by AFP.


Costa said the United Nations does not "endorse needle exchanges as a solution for drug abuse nor support public statements advocating such practices" and feels such "prophylactic measures to prevent the spread of HIV/AIDS should be undertaken only within the overall effort to reduce druge abuse," the letter said. (sic)

Progress on state HIV appropriations

Items from Article II that were pended from the March 3 meeting of the Senate Finance Committee were sent to a workgroup, chaired by Sen. Judith Zaffirini (D-Laredo). The workgroup reported back on March 8 with its recommendations for items to be included in the final appropriations bill. The recommendation included $15 million for HIV and did pass.

The background of passage is a bit more interesting. You can listen to the archived broadcast of the March 8 meeting by scrolling down on the linked page to March 8, Finance Committee (part II). The relevant section occurs at about 2:19:00 in the broadcast.

The committee minutes are fairly cut and dried on this portion of the meeting:

The chair recognized Senator Zaffirini to lay out the workgroup recommendations and riders for Article II.

Senator Zaffirini moved to adopt the workgroup recommendations for Article II. There was a roll call vote. The motion carried with a record vote of 11 ayes, 3 nays, and 1 absent. Senator Averitt, Senator Barrientos, and Senator Staples requested unanimous consent to be shown voting aye, and Senator West and Senator Shapleigh requested unanimous consent to be shown voting nay; without objection, it was so ordered.

When Sen. Zaffirini reported that the workgroup recommended $15 million for HIV, she was challenged by Sen. Nelson. Sen. Zaffirini then reported that the item had initially been defeated in the workgroup on a 1-3 vote. A second vote had the same results. The third vote ended in a tie (2-2). Sen. Nelson questioned why the amount was brought forth as a recommendation. Sen. Zaffirini made reference to Chairman Ogden's support, there was laughter in the chamber, and the matter was dropped. Sen. Ogden was heard to make the comment: "That's my compassionate side showing."

All of these bits and pieces make for several important points:

1. The possibility of getting an appropriation of $15 million for HIV is one step closer. The Senate Finance Committee's recommendation must be approved by the full Senate. Now would be a good time to make sure that one's own Senator will support the Finance Committee's recommendation for $15 million for HIV.
2. Senators Shapleigh and West would ordinarily have been supportive of the request for funding for HIV. Since the vote on HIV funding came in the same package as several other issues, one or more of those other issues may have determined their need to vote "no" on the entire package, including, unfortunately, HIV. Since their late vote didn't affect the outcome (and Sen. Nelson was the only "nay" during the live vote), there is every likelihood that there was some other driver for their votes. Indeed, Sen. Shapleigh spoke up in support of HIV funding during the discussion. However, it would be good to know why Senators Shapleigh and West voted "no" and to encourage them to support HIV funding in the future. This would, of course, come best from people who live in their districts and should be done with great politeness.
3. It is worth noting that this vote is perhaps the single most critical vote in the entire process that leads to a final appropriations bill. There are still several points at which funding for HIV can be defeated, but this was the point at which HIV funding had to be added to the bill. Sen. Zaffirini's strong stand in the face of opposition--and Sen. Ogden's decisive support--were clearly heroic. They deserve our thanks.

Drugs, Lies, and Needle Exchange

Kevin Drum's blog has a post about an editorial in the Washington Post (registration required)that started a lively discussion about the effectiveness of needle exchange and the degree to which the current administration in Washington adheres to the truth. The central focus of the WP editorial is an interview with an anonymous Washington official regarding needle exchange and the anonymous source's assertion that at least three scientific studies showed that needle exchange was ineffective. The WP reporter then called the researchers responsible for all of those studies and asked what their conclusions were. In all three cases, their conclusions were that needle exchange programs were indeed effective rather than ineffective, as the anonymous source had asserted.

In the past, the tactics used to oppose needle exchange programs at the federal level centered on the quality of science in the research about needle exchange. As that has improved, apparently the new tactic is just to invert the outcome of the research and to assert that it says what NEP opponents wish it would say.

The context for the WP editorial is actually international. Most of its discussion centers on the need for needle exchange programs in other countries (e.g., Russia) and pressure being applied to the United Nations to abandon those programs. However, there is also relevance for the issue here at home.

• There is a current ban on spending federal funds for needle exchange programs.
• Texas paraphernalia laws make it difficult for needle exchange programs to operate out in the open in Texas.
• Of course, no state funds are being provided to support needle exchange programs either.
• Injecting drug use is a significant driver for the HIV epidemic in Texas.

Senator Jon Lindsay has introduced SB 127, to allow for the legalization of needle exchange programs in Texas. The bill was also introduced in the last legislative session, received a favorable vote from the Senate Health and Human Services Committee, but failed to receive a second reading in the Senate (i.e., someone blocked it). Senator Lindsay's stature is such that the bill is likely to get a hearing this session and may well be voted out of committee. The problem will be to get it to the Senate floor (and then, of course, through the House).

One thing that will help, I think, is for there to be an accurate representation of the science that considers needle exchange. The possibility that the same tactics being used in Washington will be used in Austin exist. It's our job to counter that with the truth.

HIV Advocacy Day, 2005

It's in the history books now. Seventy-five advocates, 2 training sessions, 181 visits to legislative offices, 181 green folders. HIV Advocacy Day was, by all accounts, a grand success. Not the least of our success were the meeting reports that advocates completed to let us know what happened during their meetings. Good stuff in there!

Thanks to all the organizers in Houston, Dallas, San Antonio, and Fort Worth for bringing all these wonderful folks together. It was nice to see old friends and make new ones. Ham that I am, I thoroughly enjoyed providing the briefing sessions for such a receptive audience.

Now, as always, the paperwork still has to be completed. I hear that folks are getting their thank you letters written. (This is excellent!) I have already entered the registration forms into a database and the certificates are being printed out as I type this. Getting them mailed will take a bit of work (I've stuffed more than enough envelopes for one lifetime, thank you very much), but they will get to you pretty soon, I think. There are still a couple of steps to go before I actually start stuffing those dreaded envelopes. Hang in there!

HIV Infection Rate Among Blacks Doubles

Jeff Donn reports for the Associated Press on research presented in Boston at the 12th Annual Retrovirus Conference that:

The HIV infection rate has doubled among blacks in the United States over a decade while holding steady among whites — stark evidence of a widening racial gap in the epidemic, government scientists said Friday.

The study on which Donn's report is based excluded the homeless, soldiers, and prisoners, making it likely that the infection rate in the African-American community may be higher. Adding insult to injury, the study shows that as much as 44 percent of those who need to be in treatment in this country are not.

FDA Approves First Ever Treatment for Hepatitis C in Patients with HIV

A press release by Roche pharmaceutical company talks about its new FDA approval and what it means for people living with HIV and Hepatitis C:

Roche announced today that the U.S. Food and Drug Administration (FDA) has approved the first and only hepatitis C treatment, Pegasys(R) (peginterferon alfa-2a) in combination with Copegus(R) (ribavirin, USP) for patients coinfected with HIV.

Hepatitis C and HIV are the two most prevalent blood-borne infections in the United States. It is estimated that approximately 30 percent of Americans with HIV are believed to be infected with the even more common blood-borne virus hepatitis C. Chronic hepatitis C affects approximately 2.7 million Americans and HIV, almost one million. Research has shown that hepatitis C is more resistant to treatment in people with HIV.

The approval of Pegasys combination therapy for the treatment of hepatitis C in HIV patients was based on results from the largest study of its kind conducted to date. The results showed that 40 percent of the 860 patients treated had the levels of their virus become and stay undetectable for at least 24 weeks after finishing a course of treatment.

In Texas, this sort of treatment would be available through private insurance and Medicaid (both are listed on the Medicaid formulary as preferred drugs that do not require prior authorization). The Texas HIV Medication Program does not provide treatment for co-infection with either Hepatitis C or tuberculosis.

Happy Valentine's Day

Watch this video. (Watch it all the way to the end. It can get loud, so close the door or adjust your sound.)

It's more fun if I don't give away the surprise, but this link tells you why this video seems appropriate for Valentine's Day.

Senator Lautenberg Introduces Legislation to Provide Comprehensive Sex Education in Schools

In a refreshing change, bills have been introduced in Congress to fund reality-based sexuality education in the schools. Neither text nor numbers are available on Thomas yet, but here is Sentator Lautenberg's press release on his bill.

WASHINGTON, D.C. -- At a press conference today, United States Senator Frank R.
Lautenberg and Rep. Barbara Lee announced the introduction of the "Responsible Education About Life (REAL) Act"; legislation that will bring a comprehensive
approach to teaching young people about the risks of sex, and the steps necessary to prevent unwanted pregnancies and Sexually Transmitted Diseases (STDs).

The measure will create a grant program administered by the Department of Health and Human Services (HHS) that would award $206 million per year to states for comprehensive sexuality education programs that would include medically accurate information about both abstinence and contraception. While $206 million in federal funding currently exists for "abstinence only before marriage education", there is no funding dedicated to comprehensive sex education.

"Abstinence only education only tells young people half the story, and they need the full picture," said Senator Lautenberg. "The abstinence-only programs funded by the federal government are not getting the job done."

Even the Heritage Foundation finds that "Some 75 percent of parents want teens to be taught about both abstinence and contraception." A Hickman-Brown 1999 poll reports that 93 percent of Americans support teaching comprehensive sex education in high schools.

"The REAL Act is a step in a more effective direction. It brings sex education up-to-date in a way that will reflect the serious issues and real life situations millions of children find themselves in every year," said Lautenberg.

I'm guessing that this won't pass, but it could open the dialogue, and dialogue is sorely needed. While abstinence is a good strategy for some people at certain points in their lives, unless one is making a lifelong vow of abstinence, there will come a point when some information about sex is going to be needed. That's the point at which reality-based information about contraception, disease prevention, and sexual health would come in mighty handy.

Routine HIV testing urged

Linda Johnson writes for the Associated Press that two major studies are advocating routine HIV testing. Such testing would be cost effective since the savings in detection and early intervention would outweigh the cost of testing, except for the celibate and monogamous. The VA participated in one of the studies and appears likely to go ahead with routine testing.

Testing is now routine for pregnant women in Texas. Women can opt out of the test, but the overwhelming majority consent to be tested. This has reduced the rate of perinatal transmission in Texas dramatically.

Texas budget hearings

The House Appropriations Subcommittee on Health and Human Services held its hearing on the Department of State Health Services legislative appropriations request yesterday. (The Senate Finance Committee hearing is today.) For most of the hearing, Commissioner Eduardo Sanchez held the hot seat, while he was grilled by committee members about various aspects of the budget.

The major good news related to HIV appropriations is that the 5 percent reduction originally mandated as an across-the-board cut for all state agencies has been eliminated for HIV. The Legislative Budget Board recommended restoring $4.1 million to HIV, keeping funding at 2005 levels.

However, new actuarial studies of the projected needs of the Texas HIV Medication Program show that the shortfall for FY 2006-2007 is higher than previously projected. The actual need is a little over $15 million (up from $11.7 million). Again, there is good news in that the Department of State Health Services has amended its legislative appropriations request to seek this higher amount of funding. (Historically, getting the Department to do that has been almost impossible.)

During the hearing, the subcommittee members asked several questions about HIV and STDs. All of them showed concern about the direction of the epidemic and the effectiveness of prevention.

• Rep. Isett (R-Lubbock) expressed concern about the apparent disparity between the low amount of funds being spent on abstinence education and the high amount of funds being spent on the treatment of HIV and STDs. He asked for more information about what other prevention programs were being provided. He also requested more information about funds being spent on HIV in other programs.
• Rep. Dukes (D-Austin) and others entered into a dialogue about the Texas A & M study of abstinence education in Texas.
• Rep. Luna (D-Corpus Christi), Vice-Chair of the Appropriations Committee, sat in on most of the hearing. She asked whether there was unmet need for HIV services. Are people who are not getting services from the Department going elsewhere for care, and does this involve cost-shifting to local communities?
• Rep. Davis (R-Houston), Chair of the Subcommittee, asked about the epidemiological trends for HIV and STDs and reasons for recent increases in new cases.

The Department will be providing additional information to committee members in response to their questions.

Thanks to Rep. Dukes, the hearing also included a lively discussion of Hepatitis C programming in the state. It appears that rumors that most Hep C programming would be abandoned are now not true. (We'll see.)

Texas AIDS Network testified in support of the the exceptional item request for $15 million for HIV medications, thanked the Legislative Budget Board for restoring the 5 percent reduction, and requested that Rider 29 (relating to abstinence education) not be amended.

AARP blogs Social Security

If you are trying to keep up with the debate on Social Security, AARP now has a blog which covers some of the basics and the ongoing dialogue. There is a very real concern that changes in Social Security will negatively affect support for disabled persons.

. . . via TPM.

FDA warns about home test kits

The FDA has issued the following warning:

The Food and Drug Administration (FDA) is warning consumers not to use unapproved home-use diagnostic test kits that have been marketed nationwide via the Internet by Globus Media, Montreal, Canada. In fact, no home-use test kits intended for diagnosing HIV*, syphilis and dengue fever are approved for sale in the U.S. The use of these products could result in false results (though there is no confirmed evidence of false positives) that could lead to significant adverse health consequences. The illegal kits are labeled as:

• Rapid HIV Test Kit
• Rapid Syphilis Test Kit
• One Step Cassette Style Cocaine Test
• One Step Cassette Style Marijuana (THC) Test
• One Step Cassette Style Amphetamine Test
• Rapid Dengue Fever Test
• One Step Midstream Style HCG Urine (Home) Pregnancy Test

FDA has not approved or evaluated the performance of any of Globus Media's products. As a result, consumers cannot know with any degree of certainty that test results are correct. For example, a person testing positive for HIV (human immunodeficiency virus, or the AIDS virus) using one of these tests may not be infected with HIV, or, worse, someone infected with HIV may test negative and not seek medical treatment, or spread the virus to others.

The tests were sold through websites and distributed throughout the U.S., usually by overnight delivery services. They have been made available for sale on several websites, including www.htkit.com and www.hstkits.com. The kits usually are contained in a paper envelope with instructions inside the packaging. The envelope, instructions and packaging may not accurately identify the manufacturer, packer or distributor. The name of the kit appears on the instructions. Consumers who have these products should not use them. Anyone who has used one of these test kits should be retested using valid test methods. The FDA has issued an import alert which alerts FDA field personnel to the possible importation of these devices, provides guidance as to their detention and refusal of admission into the U.S., and also advises U.S. Customs officials about these products. Other unapproved tests may also be available through the Internet. You can find a list of FDA approved / licensed tests for HIV and Hepatitis on the FDA website at http://www.fda.gov/cber/products/testkits.htm. [emphasis added]

*Please note that one licensed/approved diagnostic home collection kit for HIV, which is mailed to a laboratory for testing and confirmation, is commercially available in the United States.

Congressional Schedule

Congress' schedule for 2005 in now available.

• The HTML version lists the dates of various recesses and when Congress will reconvene.
• The PDF version is in calendar format, showing days in session in blue.

You can, for example, use these resources to plan visits to your congressional representatives' district offices.

Bush Budget May Harm PWAs

The response to the President's budget is starting to trickle in. The consensus is likely to be that this budget will cause some real problems for people living with HIV/AIDS. Not only is the proposed increase ($10 million) too small to fit the need (NASTAD recommended an increase of $197 million for AIDS drug assistance programs), cuts in other places will negate any potential benefit.

"This budget does not reflect the concern President Bush showed during his State of the Union for HIV and AIDS care and prevention," said HRC Vice President of Policy David M. Smith. "Unfortunately, the President's actions do not match his words."

. . .

In addition, the Centers for Disease Control saw a $4 million cut to its budget for HIV/AIDS prevention and surveillance. At the same time, unproven non-science-based abstinence-only programs, which do not include education about how HIV/AIDS is transmitted, received $38 million in additional funding. A recent study at Texas A&M University showed that teenagers taking abstinence-only sex education programs endorsed by the President became increasingly sexually active, which is the exact opposite effect that the program is designed to have. "Programs which focus on abstinence as the sole means of preventing HIV/AIDS put our young people at tremendous risk," said Smith. "The President has repeatedly stated his commitment to combating the spread of HIV. We have to question that commitment when his ideology consistently outweighs sound scientific facts."

. . .

Despite the President's recognition that HIV/AIDS is a growing problem in communities of color, the Minority AIDS initiative was flat-funded. Also, $14 million was cut from the Housing for Persons Living With AIDS program, which helps people living with HIV/AIDS afford housing. Having stable living conditions increases the chances of strict adherence to drug regimens, which is necessary for fighting HIV/AIDS and also prevents the development of medication-resistant strains of the virus.

President Bush's budget also includes Medicaid cuts of at least $45 billion over the next 10 years. These cuts would greatly affect a program that is responsible for providing health care to 55 percent of all adults living with AIDS and 90 percent of all children the HRC said.

The good news is that Congress still has something to say about all of this. Letting your congressional representatives know what impact this budget would have on you and your community would be a good place to start. See Texas AIDS Network's "Who Represents Me?" to find out how to contact your representatives.

The President's Budget (part 2)

Well, if I read this correctly(see page 429 [or 3 of 49 in this file]), the President is recommending only a $10 million increase for the Ryan White CARE Act with slightly more than half of that being earmarked for the AIDS drug assistance programs.

This amount will not be adequate to help Texas maintain current services for its clients in the Texas HIV Medication Program. It will effectively constitute another cut for other services provided under the CARE Act.

Ouch!

The President's Budget & HIV/AIDS

According to the federal Office of Management and Budget, President Bush has addressed HIV/AIDS thusly in his proposed budget for federal FY 2006:

Battling HIV/AIDS:
o The Budget devotes almost $18 billion for domestic AIDS prevention, treatment, and research, including almost $2.1 billion for the Ryan White CARE Act program (and its comprehensive approach to address the health needs of persons living with HIV/AIDS.)
o Under the President’s five-year, $15 billion Emergency Plan for AIDS Relief, the Administration has moved quickly and efficiently to mobilize the scientific and programmatic expertise,leadership, and resources of HHS and other Federal government agencies and their partners both here and abroad.

Without specific numbers, this sounds like so much smoke screen. The Ryan White CARE Act numbers don't sound like an increase, but, at this level of rounding, it would be hard to tell.