CDC change in funding could lead to big cuts

Existing prevention at risk

For nearly 20 years the Iowa Department of Public Health has provided HIV/AIDS prevention services to people at risk of infection across more than a half dozen cities. Now a change in how the Centers for Disease Control and Prevention (CDC) will fund prevention programs is expected to lead to cuts that likely will eliminate all but the most minimum of prevention contact with people newly diagnosed with HIV infection, an official says.

The CDC cuts will take the state office's $1.7 million budget down to less than half that amount within the next five years. The change is due to the CDC's Funding Opportunity Announcement (FOA) about HIV prevention activities for health departments, released this past summer.

Other states like Wisconsin and Hawaii will lose significant amounts of HIV prevention funding, and New York state could lose up to 80% of its money for HIV prevention work outside of New York City, officials say.

"I have a pretty lean staff of mostly support disease intervention specialists who directly contact people who test positive," says Randy Mayer, MS, MPH, chief of the Bureau of HIV, STD, and Hepatitis of the Iowa Department of Public Health in Des Moines, IA. The state's HIV prevention program relies entirely on federal funding.

"At the end of five years, I am not sure of what program they imagine we'd have in place," Mayer says.

Among the first prevention programs that will be axed are community-level prevention programs that focus on behavioral intervention, Mayer says.

"By five years, basically all programming will go away except for partner services," he adds. "When someone tests positive, we send out one staff member to interview them to try to find out who their partners are who also might have HIV or have been exposed to HIV."

Probably the African American community in Iowa will be the most impacted by the funding change because while it's a very small percentage of the state's population, it is disproportionately impacted by the HIV/AIDS epidemic, he notes.

"They make up 3% of Iowa's population, but 20% of the people living with HIV/AIDS in the state," Mayer says. "African Americans in Iowa are infected and diagnosed with HIV at rates eight to 10 times that of whites, yet their overall numbers are very low."

So how can the state target high-impact programs for this minority community without CDC funding, he asks.

Concerns expressed to the CDC

The Washington, DC-based National Alliance for State & Territorial AIDS Directors (NASTAD) has written letters to Thomas R. Frieden, MD, MPH, CDC director, about the organization's concerns over the funding change.

The CDC's planned cuts to state health departments for HIV prevention come at a time when there is an increased demand for these services in all jurisdictions, says Julie Scofield, executive director of NASTAD.

"We are seeing alarming increases in HIV incidence among young black gay men," she adds. "There is a demand for services that can't be met, including in places like Wisconsin and Minnesota that will see drastic reductions in the HIV prevention funding."

While NASTAD agrees in general with the direction the CDC is moving in HIV prevention, the way money is being allocated is an issue, she adds.

"They're not giving jurisdictions the opportunity to do thoughtful planning about how to get there," Scofield says.

Among NASTAD's concerns are these main points:

• Despite national budgetary pressures, the U.S. Congress continued HIV prevention funding, but the CDC's redistribution of the funding has resulted in a $20 million cut in category A for HIV prevention for health departments when compared with Fiscal Year 2010 levels, Scofield writes in a letter to Frieden, dated July 13, 2011.

"NASTAD believes there are a number of options for the CDC to restore Category A to at least FY2010 levels, including consideration of internal reprogramming of resources or utilizing a portion of the additional $30 million appropriated by Congress to CDC's HIV prevention programs in FY2011," Scofield writes.

• The CDC's new funding opportunity for health departments through Category C of the FOA is for state health departments to administer innovative demonstration projects. NASTAD and its members support new models to reduce infections, but they believe these should be initiated at a time when funding levels are stable and states are better able to sustain core prevention activities, Scofield says in the letter.

• The CDC's methodology for determining minimum awards needs greater transparency. The CDC's minimum award for a state is $750,000, and it is $250,000 for territories, but there is no explanation of how those numbers were derived.

And there are significant concerns that some states receiving the minimum award will be unable to conduct the required activities of Category A, Scofield writes.

CDC response

The CDC's news media office responded by email to AIDS Alert's questions about the FOA and funding changes by saying that the FOA enables health departments to better direct federal HIV prevention dollars to achieve a higher level of impact and meet the needs of their jurisdictions.

The total funding at $359 million is nearly unchanged, but is redistributed for greater impact. The overall amount shifted is approximately 10% of the total amount, but that very small adjustment will have profound, positive effects on the epidemic, according to the CDC.

"CDC recognized that, over time, its funding for the health department cooperative agreement had gradually shifted from the demographic and geographic features of the U.S. HIV epidemic. While not extreme, the shift was significant enough that some jurisdictions were receiving proportionately greater funding relative to their local HIV/AIDS burden than others. While CDC had already recognized the need to reallocate its funding so that it better aligned with the national HIV epidemic, the release of the National HIV/AIDS Strategy (NHAS) in 2010, coupled with a new, 5-year program cycle to begin in 2012, provided an ideal opportunity for CDC to initiate a process of readjusting its funding allocation to eliminate resource inequities," wrote Salina Cranor of the news media team at the CDC's NCHHSTP Office of Planning and Policy Coordination.

"CDC recognizes that health departments will face tough choices about how to make the best use of limited funds, and we are committed to helping them navigate this transition. To minimize disruption and help these jurisdictions plan, all funding changes will be phased in over the course of a 3-year period. Additionally, no state's funding will be reduced by more than a third of their previous year's budget," Cranor's email continues.

Jurisdictions that receive significant changes in funding will be offered post-award site visits and more in-depth assessments of budgets and spending plans by the CDC. These will help to identify changes that will help jurisdictions achieve the greatest impact from the available funds, she continues.

"In fact, CDC has amended the FOA to include a range of funding available and every jurisdiction presently slated to receive the minimum funding level can request and be considered for funding of no less than $750,000 and no more than $1,000,000 for a final amount. This increase would be dependent upon a budget review," Cranor writes.

The funding cuts still will leave big gaps in prevention care in some states, others say.

For instance, Iowa's health department had been funding an innovative prevention program through grants to community-based organization, Mayer says.

In addition to the funds from the state health department, the CBO had begun to receive funding directly from the CDC for the purpose of creating an Internet-based program to expand the base prevention work, he says.

"The premise of this was that the organization would have certain prevention components on the ground and then have an online presence too," Mayer explains. "Now, we will have to remove all money for the on-the-ground program after next year, but the organization will still get money for this online presence, which doesn't make sense."

Although many public health officials support the CDC's efforts to target and better focus HIV prevention work on the areas where this is most needed, they are concerned that the current approach will leave gaps in care and result in lost ground in prevention work.

"A number of us felt the money needed to move around a bit, and we wanted money to do different programming," Mayer says. "But we didn't think we'd lose the majority of our funding in 16 low incidence areas, making us lose our ability to do anything."