In the aftermath of President Trump’s State of the Union pledge to eliminate new HIV infections by 2030, his newly unveiled budget request for the U.S. government provides additional funds for domestic HIV/AIDS programs in contrast to earlier proposals that sought to cut those programs — but related international programs are facing cuts.
The fiscal year 2020 budget requests a $300 million increase in funds to combat HIV/AIDS, but also seeks to roll back Medicare and Medicaid — programs on which many people with HIV/AIDS rely — and continues the proposed steep cuts to U.S. initiatives seeking to fight the global epidemic.
On March 11 during a conference call with reporters, a senior administration official said the $300 million “would go a long way to being able to end the epidemic through increased testing and the actual provision of life-saving medication to that population.”
The bulk of the $300 million figure is an additional $140 million requested for HIV prevention at the Centers for Disease Control & Prevention, which is a 19 percent increase in its overall budget from fiscal year 2019. According to the Kaiser Family Foundation, the money is the first big increase in funds for the agency in two decades.
The rest of the $300 million includes an additional $70 million for the Ryan White Health Care Program, which provides health care to low-income people with HIV. That’s a 3 percent increase from fiscal year 2019.
Additionally, the request includes $50 million for community health centers at HRSA for expanded PrEP services and $25 million to screen for HIV and treat Hepatitis C.
The $50 million for HRSA is notable because it can provide PrEP services, which Ryan White is barred from providing by statute, according to the Kaiser Family Foundation.
Carl Schmid, deputy director of the AIDS Institute and co-chair of the Presidential Advisory Council on HIV/AIDS, told the Washington Blade the $300 million figure represents a “commitment to end HIV, which is a departure from last year.”
“Instead of seeing budget cuts, we’re seeing increases in several programs,” Schmid said.
In terms of domestic spending, the request stands in contrast to the first two budget requests from the Trump administration, which sought reductions to the initiatives. The first request sought massive cuts in both domestic HIV/AIDS programs, although the cuts in the second request were smaller. Congress ended up disregarding those requests and maintaining funds for the programs.
The Trump administration now seeks increases as opposed to cuts in the aftermath of announcing a plan to end new HIV infections by 2030. The initiative will focus on 48 counties as well as D.C. and San Juan in addition to rural areas in seven states — places where new HIV infections are happening at the highest rates.
Jen Kates, director of global health and HIV policy for the Kaiser Family Foundation, said the increases for CDC and Ryan White would be a good start to implementing the plan.
“Ryan White and CDC have really seen no increases for quite a while, particularly CDC, so in the context of those HIV specific efforts that the federal government has, it could make a difference for those programs,” Kates said. “If targeted appropriately as they say they’re going to do, using the right public health inventions as they say they’re going to do, it could being to sort of catalyze some change.”
But Kates cautioned this budget represents only the first year of proposed funds to end new HIV infections by 2030 and that goal will require a sustained effort.
“This is supposed to be a multi-year initiative, so it’s important to see what will happen in Year Two and Year Three,” Kates said. “Will there be additional funding requested? I think that’s the intention. So, from that more HIV specific and more narrowly focused perspective, it’s important for new investments.”
But while the budget request seeks additional funds for these HIV programs, it also requests cuts in others, including a $63 million cut to the Housing Opportunities for Persons With AIDS (HOPWA) program and a $27 million cut to Housing for Persons with Disabilities.
Moreover, Schmid said the $50 million requested for HRSA for PrEP work isn’t new money for the program and instead is existing funding for community centers.
“That is not new funding,” Schmid said. “That looks like it’s current funding. And that’s something that we will want to change. We don’t want to take existing money from the community health centers. We want new funding, so we’ll be asking Congress for that.”
The budget request also calls for $6 million for the National Institutes of Health to conduct HIV research, but Schmid said that’s not new funding and actually a cut.
The most compromising cuts suggested in the budget for people with HIV/AIDS are not in HIV-specific programs, but general health care programs for the American public on which many people with HIV/AIDS rely.
Despite Trump’s campaign promises not cut to Medicare and Medicaid, the budget calls for a $845 billion reduction in Medicare and seeks major changes to Medicaid by turning it into a block grant program and eliminating the Medicaid expansion under Obamacare.
An estimated 25 percent of people with HIV receive care from Medicare and an estimated 40 percent people of people with HIV receive care under Medicaid.
With respects to the cuts to Medicaid, Schmid said the proposed changes would “hurt people with HIV.”
The modeling to eliminate new infections by 2030, Schmid said, was based on the assumption the Medicaid expansion would remain in place for states that have gone that route, so a rollback of that expansion would change plans.
“This is a change,” Schmid said. “That was not considered in these new cuts…It was not considered in the modeling, and so, that’s another question that we need to ask HHS.”
Also of concern to observers is the proposed cuts for the global programs confronting HIV/AIDS, including PEPFAR, the Bush-era program that seeks to deliver antiretroviral therapy to countries, where the epidemic is raging, such as Africa, and the Global Fund to Fight AIDS, Tuberculosis & Malaria.
For PEPFAR, Trump’s budget would provide $3.35 billion for bilateral efforts, which is $1.35 billion and 29 percent below current levels. For the Global Fund, the budget seeks $958.4 million, which is also 29 percent below current levels.
For the next Global Fund replenishment, the budget proposes $3.3 billion over three years, compared to $4.3 billion in the last round under the Obama administration, according to Kaiser Family Foundation. The proposal will match $1 from the United States for every $3 from other donors. Previously, the ratio was $1 from the United States for every $2 elsewhere.
The cuts are consistent with earlier budget proposals from the Trump administration, which also called for major cuts to HIV programs. But Congress for fiscal year 2019 actually increased funding instead by $50 million, marking the first time in seven years global programs experienced an increase, according to the New York-based Health Global Access Project.
A senior administration official defended the proposed cuts to the global HIV/AIDS programs via an email to the Washington Blade, asserting the administration remains on track to reach goals.
“The Budget fully funds implementation of PEPFAR’s bilateral HIV/AIDS Strategy that maintains all patients currently on antiretroviral treatment and assists 13 countries to achieve epidemic control by 2020,” the official said. “The U.S. will remain the largest donor by far. The reduction reflects FY-2019 funding levels in excess of the strategy’s need. Combined with this carryover, the Budget fully funds the strategy.”
For the Global Fund, the official said the 1 to 3 ratio for donations would encourage other donors to make contributions to the program.
“The budget offers to match $1 for every $3 contributed by other donors to the multilateral Global Fund (which also funds HIV/AIDS), providing a $1.1 billion contribution in 2020 and up to $3.3 billion over the three-year replenishment period, using unmatched funds appropriated by the Congress for 2019 from the last replenishment,” the official said. “This new match will further challenge other donors to make new commitments to fighting the three diseases funded by the Global Fund.”
Kates said whether the United States can maintain global goals under PEPFAR with this funding request remains “an open question.”
“I would want to see the empirical evidence. It doesn’t seem like it would really be possible to do that,” Kates said. “So, just objectively, I haven’t modeled, but an over $1 billion cut from the PEPFAR budget would get to epidemic control in these 13 countries seems like a stretch, honestly.”
For the Global Fund, Kates said the idea the United States can achieve the same goals with a 1 to 3 ratio for donations is also dubious.
“The U.S. has been able to leverage its investment to the Global Fund to get more,” Kates said. “The way the administration is sort of approaching this next pledge period is to actually say it’s going to pledge less money, not more or not even the same. The idea that that’s going to leverage more funds is not clear to me.”
At the end of the day, the budget will have to go through Congress, which controls the purse and has the final say on the funds levels for these programs.
Based on lawmakers’ rejections of cuts proposed in earlier budgets, Schmid was confident Congress would reject them again in addition to providing the additional funds requested by the administration.
“It’s a Republican Senate, but to get anything done on the budget they need Democratic support, and so anything on the budget in the Senate, even though it’s Republican controlled has been bipartisan,” Schmid said. “They’ve done all their spending bills in a bipartisan fashion.”
Schmid said the budget is definitely on track to eliminate new HIV infections by 2030, with the caveat the proposed cuts to HOPWA, Medicaid and Medicare would be harmful.
Kates said the money Trump proposed in the request is “just a start” in meeting the ambitious goal for eliminating new HIV infections by 2030.
“It’s just Year One,” Kates said. “It would really depend on how the resources are actually deployed and what happens in the future years of this initiative. It’s a start. Even if gets approved, it’s a start, but it’s too early to say.”