With a declared goal of beating HIV/AIDS in the United States by 2030, President Trump this week in his $4.8 trillion budget request for fiscal year 2021 proposed major increases in HIV/AIDS funds, but global programs and social services used by low-income people with the disease face steep cuts.
At first glance, the proposed request Trump unveiled Monday is a major victory for advocates hoping he’d make good on his stated vision to beat HIV/AIDS by 2030, which he renewed in his State of the Union address last week.
But despite $716 million proposed to beat HIV in a PrEP-centric “Ending the HIV Epidemic” initiative, the budget seeks to cut Housing Opportunities for People with AIDS, or HOPWA, by $80 million, halve funding for PEPFAR and reduce the U.S. commitment to the Global Fund to Fight AIDS, Tuberculous & Malaria.
The budget seeks $716 million in discretionary investments for the “Ending the HIV Epidemic” initiative, which is $425 million more than what Congress agreed to appropriate late last year in the omnibus for fiscal year 2020.
That $716 million request breaks down into smaller requests for various U.S. agencies working to fight HIV/AIDS:
- $371 million for the Centers for Disease Control & Prevention for transition activities from planning to implementation, scaling up jurisdictional programs to provide additional testing, linkage to treatment and prevention services, including PrEP; and augmentation of public health staff in local jurisdictions;
- For the Health Resources & Services Administration, $137 million for Community Health Centers for increased access to HIV prevention services, including PrEP, and $165 million for Ryan White HIV/AIDS program to treat HIV rapidly after diagnosis;
- $27 million for Indian Health Services to enhance support for prevention, diagnosis and links to treatment (Congress last year declined to fund this money despite Trump’s request, but gave an additional $25 to the National Institute for Health to support HIV research);
- $16 million for NIH Centers for AIDS Research to evaluate prevention and treatment methods.
Assistant Secretary for Health at the Department of Health & Human Services Rear Adm. Brett Giroir presented the numbers at a meeting of the Presidential Advisory Council on HIV/AIDS on Monday, saying they demonstrate Trump’s commitment to ending HIV/AIDS.
“I don’t run the budget, but you’re going to see cuts in many many many programs proposed by OMB,” Giroir said. “$716 million in new money is a serious investment in this program.”
Carl Schmid, executive director of the HIV & Hepatitis Policy Institute and co-chair of PACHA, told the Washington Blade prior to the meeting on Monday the proposed increases were “really, really good.”
In a joint statement, the Partnership to End HIV, STD & Hepatitis — which comprises the AIDS United, the National Alliance of State & Territorial AIDS Directors, the National Coalition of STD Directors, the National Minority AIDS Coalition and the AIDS Institute — hailed the request for $716 million as “an important scale up of current funding.”
“Coupled with continued HIV funding across HRSA and CDC, these dollars will support the communities that remain vulnerable and disproportionately impacted by this epidemic,” the statement says.
But praise from the partnership comes with a major caveat: Criticism for not increasing funds to fight sexually transmitted diseases generally or hepatitis.
“With STD rates at an all-time high and new cases of viral hepatitis on the rise, it is paramount that we respond to this crisis with the funding necessary to mount a public health response,” the statement says.
These gains are offset by general reductions in social services programs across the board, including many programs used by people with HIV/AIDS, such as Medicare and Medicaid. The budget would cut $451 billion from Medicare and $900 billion from Medicaid over the course of 10 years.
Additionally, the budget calls for Medicaid to become a block grant program, which would give states greater leeway, but make federal resources for the program finite.
An estimated 40 percent of people with HIV/AIDS are on Medicaid, and 25 percent are on Medicare, according to the Kaiser Family Foundation.
House Speaker Nancy Pelosi (D-Calif.) and Senate Minority Leader Charles Schumer (D-N.Y.) laid into Trump in a joint news conference for the proposed cuts to Medicare and Medicaid, which total $1.6 trillion.
“Two-thirds of long-term care is payed for by Medicaid,” Pelosi said. “This is a middle class benefit. Those cuts endanger the health of seniors in long-term care needs for them and their families. And these Medicaid cuts also hurt rural hospitals, people seeking opioid addiction treatment, veterans and their families, more than one million veterans are on Medicaid.”
Defending the proposed cuts was Acting Office of Management & Budget Director Russ Vought, who at a White House briefing on Monday insisted Medicare would grow by 6 percent and Medicaid would grow by 3 percent under Trump’s proposal.
“The budget does propose good government reforms to lower drug prices, to root out improper payments, and to address wasteful and inefficient spending,” Vought said. “For instance, this budget proposes to remove from Medicare certain programs, such as uncompensated care in graduate medical education that are draining the Medicare trust fund and benefit more than just seniors. These costs would still be funded outside of Medicare, but with reforms to moderate their growth.”
Moreover, while the funds for HIV/AIDS programs under the Department of Health & Human Services get a boost, a look at another HIV/AIDS-related item in the budget under the Department of Housing & Urban Development, HOPWA, faces a steep cut.
Lauren Banks Killelea, director of policy and advocacy for the National AIDS Housing Coalition, lambasted the proposed cuts to HOPWA in a statement, estimating the proposed reduction would result in nearly 9,000 families potentially losing their homes.
“Taking away healthcare options and housing options from low-income Americans will only exacerbate the HIV epidemic,” Killelea said. “The proposed increases to the Ending the HIV Epidemic initiatives pales in comparison to the drastic cuts proposed elsewhere.”
Schmid, announcing he had just learned about the proposed HOPWA cut at the AIDS council meeting, said that part of the budget was an “important unfortunate thing” compared to the increases elsewhere and said he’d work with Congress to restore that money.
The Partnership to End, HIV, STD & Hepatitis criticized the Trump budget for its proposed cuts to health programs and HOPWA.
“Proposed cuts to Medicaid, HOPWA, and Medicare (among other safety net programs) will also be devastating to people living with and at risk for HIV. Rolling back these vital safety net programs will have a disproportionate impact on communities prioritized in the EHE initiative, including low-income Black and Latinx populations, and will only deepen existing HIV disparities,” the groups said.
Further, the increased funds Trump seeks to fight HIV/AIDS on the domestic front stands in contrast to the hacksaw the request takes to global programs.
For the Bush-era President’s Emergency Plan AIDS Relief, or PEPFAR, which provides HIV treatment drugs to developing countries, primarily in Africa, Trump seeks $3.2 billion, which is $1.17 billion less than the money Congress appropriated for fiscal year 2020 funding levels. The proposed reduction is even steeper than the cut proposed by Trump in the previous budget request by $200 million.
For the Global Fund, Trump proposed to contribute $1 for every $3 donated to the partnership, which is a reduction from an earlier U.S. commitment to donate $1 for every $2.
Emily Sanderson, national organizer for the New York-based Health GAP and the Student Global AIDS Campaign, tore into Trump in a statement on the proposed cuts and called on Congress to increase funds for global programs.
“Today’s budget request is a chilling reminder that, if he had it his way, President Trump would take a hacksaw to the HIV treatment and healthcare programs that save the lives of millions of people around the world,” Sanderson said. “The president has threatened people living with HIV enough these last three years. It’s time for Congress to roundly reject Trump’s deadly vision for gutting the HIV response and instead rapidly scale up funding and provide an additional $500 million for PEPFAR this year.”
In previous years, Trump has proposed similarly draconian cuts to global programs, but Congress rejected them and reinstated the funds for both PEPFAR and the Global Fund. It’s likely Congress will take the same approach in response to Trump’s proposed cuts in the FY-21 budget.
The Obama administration had also sought a reduction in PEPFAR funds on the basis that it was doing more with less money because of generic drugs, although the proposed cuts were less severe.
Jennifer Kates, director of global health and HIV Policy at the Kaiser Family Foundation, said the increase in domestic funds and the decrease for global initiatives means the Trump budget is “a mixed bag” on HIV/AIDS.
“On the one hand, it proposes a significant increase to the domestic ‘Ending the HIV Epidemic’ initiative – an increase of $450 million over FY 2020 funding levels,” Kates said. “On the other, it seeks to cut PEPFAR’s budget by more than $1.5 billion, a cut that would translate into fewer people on HIV treatment and more new HIV infections, globally.”
Neither the White House nor the Office of Management & Budget responded to multiple requests from the Blade to comment on the cuts to HOPWA or to the global programs.