Federal funding climbs for HIV/AIDS

But is it too little, too late?

The good news is that HIV advocacy groups, clinicians, and others haven't seen so many HIV/AIDS program federal budget increases since the 1990s. The bad news is that it might be too little, too late in a recessionary environment in which state budgets are forcing draconian cuts.

The AIDS Budget and Appropriations Coalition shows in its compiled chart of HIV/AIDS and related program funding for fiscal years 2009, 2010, and proposed for 2011 that most sections have had increases. (See AIDS Budget and Appropriations Coalition FY2011 appropriations chart, below.)

These additional federal dollars for HIV/AIDS treatment and prevention funding are a positive change from budgets in the past decade when programs mostly were cut or flat-funded.

"We're overall encouraged with the president's FY2011 proposed budget when there was much talk of domestic funding being frozen," says Ronald Johnson, deputy executive director of AIDS Action Council of Washington, DC.

"In the context of a very tight budgetary situation, especially when it comes to discretionary domestic spending, we did see a demonstration of the president's commitment to the HIV/AIDS agenda," Johnson adds.

But with state funding for HIV/AIDS programs being slashed dramatically, there remain big problems.

For example, the state of South Carolina has rolled back its funding for AIDS Drug Assistance Programs (ADAPs) to the point that 900 HIV-infected patients are being disenrolled from the program, says William E. Arnold, director of T11 CANN (Community Access National Network) in Washington, DC.

According to a "Dear Provider" letter the South Carolina Department of Health and Environmental Control (DHEC) sent on April 27, 2010, the state's ADAP waiting list has 57 patients, but an additional 900 active patients will be removed from the program by Sept. 1, 2010, unless the state receives additional funding.

South Carolina's ADAP served 2,100 patients per month in 2009, a nearly 15% increase from 2008. Meantime, the state's base funding was cut 3%, and its supplemental funding was cut 21%.

"State funds will likely be cut by over 51%," the SCDHEC provider letter states.

And that number is not yet reflected in the national ADAP waiting list which has grown to 1,001 people in 10 states, as of May, 2010.

Also, ADAP client enrollment has increased at unprecedented numbers in recent years with an average increase of 1,554 new clients per month in FY2008, according to the National ADAP Monitoring Project Annual Report of May, 2010. The report is published by the National Alliance of State and Territorial AIDS Directors (NASTAD) in Washington, DC.

The national ADAP budget was $1.59 billion in FY2009, a 4% increase from FY2008, but the state funding contributions decreased by 34%, the annual report notes.

"This marks the lowest state funding contribution to ADAPs since 2003 and exemplifies the severity of state fiscal crises nationwide," the report says.

President Barack Obama's proposed budget for FY2011 proposes a $20 million increase to ADAP spending. This amount is inadequate to meet the need, but AIDS groups are more alarmed by today's ADAP funding crisis.

"We're all focused on getting emergency supplemental money for fiscal year 2010," Arnold says.

The main issue is that ADAPs depend a great deal on state funding. But the state money well is dry as state legislatures are forcing across-the-board budget cuts in efforts to balance budgets, as is required by law in many states. At the same time tax revenues have plummeted.

So states have cut back on many of the gains they've made in the past decade in funding ADAPs. For instance, Kentucky has pulled out all of its state ADAP funding, and the result is having 200 people on its waiting list, Arnold says.

North Carolina is coping with state ADAP cuts at a time when the state is seeing increasing numbers of HIV cases and greater ADAP need, he adds.

"The epidemic is expanding in North Carolina more than the current distribution system is making an allowance for," Arnold says.

The result is a North Carolina ADAP waiting list that is the nation's largest at close to 500 people.

Appearance and reality

Plus there are a number of states that choose to avoid the bad local publicity associated with ADAP waiting lists, and instead are making ADAP eligibility and other changes that eliminate funding. Although they effectively are cutting people from their ADAP roles, they avoid the transparency of waiting lists by saying these clients no longer are eligible to receive antiretroviral treatment through ADAPs.

"About two months ago, Louisiana stopped taking any new ADAP clients," Arnold says. "People are filling out ADAP forms, but they're not being accepted into the program, and the state's governor is not allowing Louisiana to maintain a waiting list."

In Utah, state officials made the eligibility criteria more stringent for ADAP, and this cut drugs for an unknown number of people, he adds.

"They say these people are not eligible, so of course they're not on the ADAP waiting list," Arnold says.

HIV/AIDS advocates and treatment groups have sent an emergency request for $126 million in ADAP funding in an April 29, 2010 letter to President Barack Obama, asking for supplemental funding to prevent state ADAPs from collapsing under the weight of increased need, reduced state funding.

"ADAP continues to be a crisis situation in so many states," Johnson says. "It's compounded by the budget crisis that states themselves are experiencing and that minimizes their ability to augment their ADAP budgets."

The HIV/AIDS advocacy letter for emergency ADAP funding says states made $167 million in budget cuts to AIDS programs in 2009. The state cuts have had a bigger impact than they would have a decade ago because the federal government's percentage of ADAP expenditures has dropped from 72% in 2000 to 51% in 2009, the letter states.

"This staggering drop in the federal commitment to ADAP in addition to state budget crises has largely been the catalyst for the most recent spike in HIV wait lists," the letter says.

The letter to the president also makes the point that 74% of the people on an ADAP waiting list are in Southern states and that half of the people served by ADAP have annual incomes of below the federal poverty level.

"The currently proposed $20 million increase in appropriation for FY2011 will only be enough to cover 2,307 people, not enough resources to allow Ryan White to continue to act as a safety net for those already in the program and on wait lists, let alone the steadily growing need," the letter states.

"While we expect implemented health reform to provide significant relief to ADAP we must do everything we can to keep the 1-2 million HIV positive Americans alive, working, and well until health reforms are in place in the coming years," the letter says.

AIDS BUDGET AND APPROPRIATIONS COALITION
FY 2011 Appropriations for Federal HIV/AIDS Programs

March 29, 2010
(Increases or decreases from previous fiscal year are shown in parentheses)

PROGRAM

FY 2009
Final

FY 2010
Final

FY 2011
President's
Budget
Request

FY 2011
Coalition
Request

C

D

C

Total - HIV, Hep, STD, TB line

$1,006.4 m
(+$4.2 m)

$1,045.4 m
(+$39 m)

$1,083.3 m
(+$37.9 m)

$2,175.5 m
(+$1,130.1 m)

HIV Prevention & Surveillance

$692 m
(+$0 m)

$728 m
(+ $36 m)

$759 m
(+$31 m)

$1,606 m
(+$878 m)

Viral Hepatitis

$18.3 m
(+$0.7 m)

$19.3 m
(+$1.0 m)

$21.1 m
(+$1.8 m)

$50 m
(+$30.7 m)

STD Prevention

$152.3 m
(+$0 m)

$153.9 m
(+$1.6 m)

$160.6 m
(+$6.7 m)

$367.4 m
(+$213.5 m)

TB Prevention

$143.9 m
(+$3.5 m)

$144.3 m
(+$0.4 m)

$143.1 m
(-$1.2 m)

$220.5 m
(+$76.3 m)

DASH - HIV Prevention Education

$40.2 m
(+$0)

$40.2 m
(+$0)

$40.2 m
(+$0)

$60.2 m
(+$20 m)

H

R

S

A

Ryan White Programs Total

$2,238.4 m
(+$71.6 m)

$2,290.9 m
(+$52.7 m)

$2,330.4 m
(+$39.5 m)

$3,101.5
(+$810.8 m)

Part A

$663.1 m
(+$35.9 m)

$679.1 m
(+$16 m)

$679.1 m
(+$0 m)

$905 m
(+$225.9 m)

Part B: Care

$408.8 m
(+$7.9 m)

$418.8 m
(+ $10.0 m)

$428.8 m
(+$10.0 m)

$474.7 m
( +$55.9 m)

Part B: ADAP

$815 m
(+$20.6 m)

$835 m
(+ $20.0 m)

$855 m
(+ $20.0 m)

$1,205.1 m
(+$370.1 m)

Part C

$201.9 m
(+$3.1 m)

$206.9 m
(+$5.0 m)

$211.9 m
(+$5.0 m)

$337.9 m
(+$131 m)

Part D

$76.9 m
(+$3.2 m)

$77.8 m
(+ $.94 m)

$77.8 m
(+ $0 m)

$84.8 m
(+$7.0 m)

Part F: AETCs

$34.4 m
(+$0.3 m)

$34.8 m
(+ $.42 m)

$37.4 m
(+$2.6 m)

$50 m
(+$15.2m)

Part F: Dental

$13.4 m
(+$0.6 m)

$13.6 m
(+$.17 m)

$15.4 m
(+$1.8 m)

$19 m
(+$5.4 m)

Part F: SPNS

$25 m

$25 m

$25 m

$25 m

Compiled by The AIDS Institute. For questions or comments, please contact AIDS Action Council at (202) 530-8030.

PROGRAM

FY 2009
Final

FY 2010
Final

FY 2011
President's
Budget
Request

FY 2011
Coalition
Request

Community
Health Centers

$2,146 m
(+$125 m)

$2,146 m}
(+$0)

$2,436 m1
(+ $290 m)

$2,553 m
(+$363 m)

Office of

Title X2

$307.5 m
(+$7.5 m)

$317.5 m
(+$10 m)

$327.4 m
(+$9.9 m)

$394 m
(+$76.5 m)

N
I
H

NIH3

$30.32 b
(+$630 m)

$31.0 b
(+$692 m)

$32.09 b
(+ $1.09 b)

$35.0 b
(+$4 b)

[Transfer to
Global AIDS]4

[-$300 m]

[-$300 m]

[-$300 m]

[$0 m]

AIDS Research

$3.02 b
(+$82 m)

$3.09 b
(+$ 90 m)

$3.18 b
(+$ 98.7 m)

$3.5 b

A
C
F

Community-
Based
Abstinence
Education

$99 m
(-$14 m)

$0 m
(-$99 m)

$0 m
(+$0 m)

$0 m
(+$0 m)

Office of
Adolescent
Health

Teen
Pregnancy
Prevention
Initiative5

N/A

$114.5 m
(+$114.5 m)

$133.7 m
(+$19.2 m)

$114.5 m
(+$0 m)

S
A
M
H
S
A

Center for
Substance
Abuse
Treatment

Substance
Abuse Block
Grant

$412 m
(+$12 m)

 

$1,779 m
(+$20 m)

$452.6 m
(+$40.6 m)

 

$1,799 m
(+$20 m)

$486.7 m
(+$34.1 m)

 

$1,799 m
(+$0 m)

$529.6 m
(+$77.0 m)

 

$2,009 m
(+$210 m)

Center for
Substance
Abuse
Prevention

$201 m
(+$7 m)

$202 m
(+$1 m)

$223 m
(+$21 m)

$277.2 m
(+$75.2 m)

Center for
Mental Health
Services
(CMHS)

Subset of
CMHS: Mental
Health Block
Grant

$969 m
(+$59 m)

 

[$421 m]
[(+$0 m)]

$1,005 m
(+$36 m)

 

[$421 m]
[(0 m)]

$1,028 m
(+$23 m)

 

[$421 m]
[(0 m)]

$1152.8m
(+$147.8 m)

 

[$482.7m]
[(+$61.7 m)]

M
A
I

Minority HIV/AIDS
Initiative
(within multiple programs)

[$402.9 m]
[(+$.3 m)]

[$402.9 m]
[(+$0 m)]

[TBD]

[$610 m]
[(+$207.1 m)]

H
U
D

HOPWA

$310 m
(+$9.9 m)

$335 m
(+$25 m)

$340 m
(+$5 m)

$410 m
(+$75 m)

White House

Office of
National AIDS
Policy

$1.4 m
(+$1.4 m)

$1.4 m
(+$0 m)

N/A

$1.4 m
(+$0 m)

Compiled by The AIDS Institute. For questions or comments, please contact AIDS Action Council at (202) 530-8030.

1 Includes $25 million to enhance the availability and quality of substance abuse treatment at community health centers by integrating qualified behavioral health and addiction specialists into this primary care setting.

2 The coalition requests that funding for Title X be increased to $700 million over five years beginning with an increase of $76.5 million in FY11.

3 Labor HHS NIH Discretionary Budget Authority

4 The LHHS appropriation for the Global Fund to Fight AIDS, TB and Malaria comes out of NIH's budget through a pass-through, presenting an inaccurate total amount to the NIH for research. The coalition supports the Global Fund appropriation to come out of Foreign Operations appropriations.

5 ABAC supports the expansion of the Teen Pregnancy Prevention Initiative to be a comprehensive education initiative that includes STD and HIV prevention.