HIV clinical experts say drastic cuts to the healthcare and social safety net proposed in President Donald Trump’s new budget request would make it less likely that the administration fulfills its pledge to end the epidemic in 10 years despite adding nearly $300 million in new funding toward that effort.
The president’s fiscal 2020 budget, released March 11, included $291 million toward an initiative Trump first announced during his State of the Union address in February to reduce new HIV infections by 90% by 2030.
As part of that plan, the Centers for Disease Control and Prevention would get $140 million for testing and tracking new HIV cases, and to connect those at high risk for infection to pre-exposure prophylaxis, or PrEP.
Other investments include allocating $70 million toward the Ryan White HIV/AIDS Program to increase its capacity to provide healthcare and support services to low-income individuals living with the disease, and $170 million toward programs to target prevention and treatment among minority individuals.
The funding allotment is a mere “drop in the bucket” for what’s needed on the prevention and treatment fronts, said Dr. David Hardy, board chair of the HIV Medical Association. HIV afflicts more 1.1 million Americans and 38,000 more are infected annually.
“The same kind of skepticism that I think was present after the State of the Union has become even more clearly defined because of the fact that the money is just not there,” Hardy said. “There’s bits of money there, but it has not been well thought through about how to best use the healthcare resources in this country.”
Directing the majority of the new funding to the CDC and community health centers is misplaced, according to Hardy, who said more should go toward building up the nation’s HIV specialty-care capacity since those providers have expertise in HIV prevention care, a service the CDC does not directly handle and that is still not offered at many community health centers. Hardy’s organization represents those specialty care providers.
Jennifer Kates, vice president and director of global health and HIV policy at the Kaiser Family Foundation, acknowledged the country’s community health centers, as a whole, have historically been “punching below their weight” when it came to providing HIV care. But she argued HHS has over the past decade increased its focus on encouraging CHCs to do more work in that area.
Concentrating more funding to Ryan White programs, such as HIV clinics, has limitations, she said, noting that the funding only covers care for those already living with HIV and does not provide preventive services for those at risk.
Kates said the funding outlined in the budget request was only the first step in what’s expected to be a multiyear initiative but that it already represented the first significant boost in domestic HIV funding in years.
“If the money is channeled using the right public health know-how and tools and to the places that need it the most, it can begin to catalyze some change in this area,” Kates said.
But experts said the proposed budget’s biggest impact on HIV care would likely be reflected in the cuts in funding for safety-net programs, including a $1.5 trillion reduction in Medicaid spending over the next 10 years and converting the program into a block grant program.
An estimated one-quarter of people living with HIV who receive care get their health insurance coverage through Medicare, while Medicaid provides coverage for 40% of those living with the disease, according to the Kaiser Family Foundation.
Kates said the effect of such proposals if they are pushed forward would change the environment around HIV care services and make it much more difficult to put an end to the epidemic, adding “cutting back on that system would be quite a challenge.”
Funding cuts have also been proposed to social programs, including $220 billion over the next 10 years from food stamps, $21 billion from Temporary Assistance for Needy Families, and a $45 million reduction in the Housing Opportunities for Persons with AIDS program, which provides grants to communities for projects to address housing needs for those living with HIV/AIDS.
Bruce Packett, executive director for the American Academy of HIV Medicine, said the impact of cuts to public insurance programs and more broadly to the safety net would not only negate any of the benefits gained from the addition of the HIV funding that has been proposed but could halt the progress made thus far toward defeating the virus.
“If you start to place restrictions on those payers, then you’ll have a much more significant problem than they are calibrating for right now,” Packett said. “You’re going to have a lot more money that’s going to be needed to fight the epidemic than the relatively small almost $300 million they’ve requested this year.”