March 15, 2019 – The Act Now End AIDS coalition (Act Now End AIDS) expresses deep disappointment with the President’s Fiscal Year 2020 (FY 20) budget proposal for its failure to provide the fiscal resources, policy leadership, and political vision needed to end the HIV epidemic in the United States. Instead, the administration chooses to drastically reduce resources for programs that provide lifesaving support to communities living with and vulnerable to HIV, negating the $291 million increase in Department of Health and Human Services (HHS) resources for HIV prevention and care. This proposed budget fundamentally undermines the ambitions laid out in the federal Ending the HIV Epidemic: A Plan for America (Ending the HIV Epidemic) strategy that was announced in February 2019.1
The administration’s proposed cuts to Medicaid would fuel rather than curb our domestic HIV epidemic. Access to comprehensive healthcare is central to ending the epidemic in the United States, and Medicaid is the single largest domestic payer for HIV care, treatment, and prevention services. Instead of recognizing and building on the strategic importance of this essential program, the administration’s budget proposal seeks to actively dismantle Medicaid coverage by reducing Medicaid funding by $1.5 trillion over 10 years, reversing expansion, instituting work requirements, and block-granting the program. Work requirements have been approved by waiver in some of the very states and counties that were identified as priority areas in Ending the HIV Epidemic (Arkansas, Arizona (Maricopa), Indiana (Marion), Kentucky, and Michigan (Wayne)). In Arkansas, work requirements resulted in the loss of coverage to 18,164 individuals during 2018.2 Act Now End AIDS strongly opposes all items in the proposed budget that create barriers to Medicaid access.
While the community applauds a much-needed funding increase for the safety net HIV health services provided by the Ryan White program, this modest increase cannot begin to address the significant coverage gaps created by reductions to Medicaid that are orders of magnitude larger than total Ryan White funding. Further, the vital HIV-specific Ryan White program is not designed to and cannot meet the complex heath care needs of people with HIV, which necessitate access to comprehensive primary and specialty care. Nor can Ryan White funds be used to pay for PrEP and other HIV prevention services. Without resources to improve healthcare access and active efforts by the administration to facilitate Medicaid expansion, the administration simply cannot realize their stated goal to end the U.S. HIV epidemic by 2030.
These continued and growing gaps in health coverage also drive the worsening syndemics of sexually transmitted infections (STIs), opioid dependence, hepatitis C (HCV) and tuberculosis (TB) that both heighten the risk for HIV infection and worsen health outcomes for persons living with HIV. Like HIV, these syndemics are compounded daily by the lack of access to comprehensive health care, yet the federal Ending the Epidemic strategy fails to acknowledge or respond to these interrelated health issues, and the administration’s budget proposes essentially flat funding for the federal programs responsible for tackling increasing rates of STIs and HCV and the lack of progress in TB elimination. And while the administration’s budget proposal does include a modest $53 million increase in CDC funding to address the country’s opioid crisis, this investment falls far short of the response required by a worsening epidemic of avoidable deaths and infectious disease transmission. There was a record 70,237 overdose deaths in 2017, at least 70 percent of new cases of HCV, and one in ten new HIV infections a direct result of injection drug use. Nor does the federal response to the related opioid, HIV and HCV epidemics reflect or fund widespread adoption of syringe access, and other harm reduction strategies demonstrated to improve drug user health and provide a path to substance use treatment.
Drastic proposed cuts to federal housing programs, food assistance, disability benefits and other critical social protection programs will exacerbate demonstrated barriers to HIV prevention and care, further worsening already stark HIV health disparities. A wealth of research evidence and years of experience demonstrate that it is simply not possible to end HIV without addressing the social and structural factors that drive new infections and poor HIV health outcomes. Any funding increase in HIV programs administered by HHS must be viewed within the context of proposed cuts that would slash the full range of lifesaving programs that support HIV prevention and care among persons made vulnerable by poverty, disability, homelessness and social marginalization. When access to safe housing has been repeatedly proven essential to achieving and maintaining viral suppression, how can the administration propose a $63 million dollar cut to the successful Housing Opportunities for People with HIV/AIDS (HOPWA) program?
The administration continues to fail to provide leadership and vision to address the persistent stigma that continues to be a barrier to outreach, engagement, and care of vulnerable and marginalized communities. Stigma is not alleviated, but rather heightened by the administration’s ongoing attacks on communities of color, women, transgender people, immigrants, and people who use drugs. Without a roll-back of these policies and strong leadership to end stigma through social protection programs, no amount of funding will achieve an end to the epidemic among these priority populations.
We must also note our alarm at the administration’s proposals to cut U.S. support for the Global Fund to Fight AIDS, Tuberculosis and Malaria by 29% and funding for the President’s Emergency Plan for AIDS Relief (PEPFAR) by 30%. It is impossible to understand these drastic cuts, which will affect millions of lives, in light of the President’s State of the Union pledge to “defeat AIDS in America and beyond [emphasis added].”
The Act Now End AIDS Coalition urges the administration to consider the policy and funding recommendations in the community’s Ending the Epidemic Roadmap, so that federal budget and policy priorities are consistent with what is needed to truly end the HIV epidemic. Without additional resources and policy alignment with the community plan, ending the epidemic in those jurisdictions targeted in the initiative will be arduous, and the many communities, cities, and states not targeted by the federal plan are being left behind. We call on our champions in Congress to reject the President’s budget proposal and work with us to catalyze the necessary resources, policies, and political commitment to end AIDS everywhere in the U.S.
1 Ending the HIV Epidemic: A Plan for America, U.S. Department of Health and Human Services, February 5, 2019, accessed at https://www.hhs.gov/blog/2019/02/05/ending-the-hiv-epidemic-a-plan-for-america.html
2 January State Data for Medicaid Work Requirements in Arkansas, Kaiser Family Foundation, February 25, 2019 accessed at https://www.kff.org/medicaid/issue-brief/state-data-for-medicaid-work-requirements-in-arkansas/