President’s budget, FY2006 final appropriations paint dim picture

ADAP waiting list near 1,000

Just when HIV/AIDS groups have adjusted to flat domestic HIV/AIDS funding for the past five years, the latest budget proposals arouse fear of budget cuts that could result in fewer prevention programs and longer waiting lists for antiretroviral drugs.

President Bush’s FY2007 budget request would cut all funding ($99 million) from prevention block grants in the budget of the Centers for Disease Control and Prevention (CDC), and it would continue the funding cut of the CDC’s DASH-HIV prevention education.(See domestic budget charts)

But the president’s proposal would add nearly $90 million to the CDC’s HIV prevention and surveillance and $95 million to the Ryan White CARE Act total.

Even the good news is greeted with skepticism by AIDS groups that have been through this process repeatedly in the past five years.

"We were excited to see there would be additional money in place for the CARE act for both testing and medications, however, the missing link is everything in between," says Diana Bruce, manager of government affairs for AIDS Alliance for Children, Youth & Families of Washington, DC.

"We represent women and children and young people living with HIV infection, and for our populations they need more than a doctor and pills," Bruce says.

"They need a comprehensive support network that outreaches to them, provides case management, and links them to care and treatment," Bruce explains. "They need comprehensive case management, transportation, and they need childcare."

There’s a funding bridge between positive HIV tests and HIV care and education, and that bridge was flat-funded for the third year in a row, Bruce says.

"It’s gone from $75 million in funding to $71 million in just a few years, while the new infections are still at 40,000," she says. "We were totally disappointed to see that Title IV, of which 88% of the clients are people of color, was flat-funded and left without the resources to meet the demand for care.’

The peak funding year was Fiscal Year 2003, but it’s been downhill since then, Bruce says.

"There’s a lot of confusion about where the new money is going for Ryan White," says Christine Lubinski, executive director of the HIV Medicine Association in Alexandria, VA.

"There’s discussion about targeting it to places with a clear need," Lubinski says. "But it’s unclear how they’re going to do it; and while the increase is welcome, how they do it really matters."

For example, one HIV Medicine Association board member’s HIV clinic will have to take a 5% cut in providing care services because of Ryan White Care Act Title III flat funding, Lubinski says.

"It concerns me that we would fund some sort of new program when current services are in trouble," Lubinski says.

The extra money proposed for the CDC is all for rapid testing and outreach, says Laura Hanen, director of government relations for the National Alliance of State & Territorial AIDS Directors (NASTAD) of Washington, DC.

And while this is a positive proposal, the CDC in the meantime is cutting FY2006 prevention funding by proposing a 2.98% cut in state cooperative agreements, Hanen says.

Initially, the CDC proposed a 4.6% cut in the agreements, but reduced it to a 2.98% cut, which still is greater than the average cut across the CDC of 2%, Hanen notes.

"They are making a disproportionate share of budget cuts on HIV and STD prevention," Hanen says.

States will receive letters about FY2006 awards, telling them of the cuts to their final awards, she says.

Another unknown factor in the president’s budget is the $25 million proposal to expand outreach efforts by providing new community action grants to faith-based community organizations, Hanen notes. "I would say the AIDS community and NASTAD will advocate with Congress to get the additional funds for Ryan White because this is a very tight budget year again, and, again, we want them to go through the traditional funding lines."

The biggest problem with the proposed budget and with what Congress is likely to decide about HIV/AIDS spending is providing care and treatment to the growing list of people infected with HIV, AIDS care advocates say.

Slow going on the Hill

Meantime, the budget work is moving slowly on Capitol Hill.

"All we know at this point [in early March] is the House and Senate is working together in closed door meetings twice a week," says Greg Smiley, MPH, public policy director with the American Academy of HIV Medicine in Washington, DC.

"We expect those [budget] pots to be the same size if note smaller than last year’s pots," Smiley says. "So in essence what that means is Ryan White will unlikely see a lot of increases."

The problem with flat-funding is that it becomes a decrease when across-the-board budget cuts are made, as has happened in recent years. Also, there are decreases in the money available because of the increased costs and increased numbers of people needing the care and services provided, Smiley says.

"We’re really losing ground, and it’s not just hundreds of dollars," Smiley says. "We’re losing millions of dollars."

Meantime, the Ryan White Reauthorization continues to be postponed, although Sen. Tom Coburn (R-OK) has introduced reauthorization legislation.

Congress appears to want to finish the reauthorization process by spring since there’s a limited window available for completing legislation, Hanen says.

Some fundamental issues related to how Ryan White funds are distributed have made the reauthorization complicated, Hanen notes. "What is the most appropriate way to fund states and cities to enable them to provide treatment and care and support services?" she says.

Basically, everyone wants to do something to address the problems faced by states that don’t receive Title I funding because they lack an eligible metropolitan area (EMA).

The problem is how to make the distribution of funding more fair to these states while not cutting services provided in the states that do have large cities impacted by HIV/AIDS, Hanen says.

"We have a proposal to get supplemental funding to states without EMAs, and it also includes two states that have more than 50% of cases outside of EMAs, Louisiana and Ohio," Hanen says.

Supplemental funding is the best way to approach this because if the funding is redistributed it could destroy infrastructure that has been in place for 16 years, Hanen notes.

Meantime, AIDS groups continue to work on improving funding for Ryan White and other programs directed at the HIV/AIDS epidemic, but all optimism is gone.

This year, even the National Institutes of Health (NIH) is looking at decreased funding, Smiley notes.

"It’s not just the Ryan White funding that we’re depressed and sort of anxious about, but the CDC under HIV prevention figures from the president took a huge cut, and the NIH, which is the darling of all health programs, is being cut," Smiley says.

Some institutes within NIH are looking at drastic cuts of 15%, so it’s not just HIV/AIDS programs being targeted, but all research programs at NIH, he adds.

"That gives you a picture of what we’re fighting against, so sometimes we take a flat funding and have a sigh of relief at the status quo," Smiley says.

AIDS groups have become resigned to the ongoing funding crises, he notes. "I think there’s a certain sense that you’re beating your head against the wall," Smiley says. "The reason why is because different members of Congress push the blame somewhere else: they say you have to talk to the president and get him to ask for higher funding; you go to the appropriations people, and they say, Where is it going to come from?’"

The blame could be placed on tax cuts, war, deficits, defense spending, hurricanes, etc., but the bottom line is there really isn’t any extra money to work with, Smiley says. "We can lobby as hard as we can, but if other interest groups are making the same case, and in essence every mother thinks her child is the prettiest, then you’re arguing to draw from the same pot of money," Smiley says. "And it’s very difficult to make the case that will result in those increases."