Issue:  Vol. 48 / No. 7 / 15 February 2018

Federal budget sustains HIV funding, requests more for PrEP


President Barack Obama called for a cancer "moonshot" in last month's State of the Union address. Photo: Rudy K. Lawidjaja
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Funding for domestic HIV services saw a modest increase in President Barack Obama's proposed budget for fiscal year 2017 – including a $20 million allocation for a new PrEP pilot program – but advocates say it does not provide enough for HIV research, global AIDS assistance, or hepatitis C.

"The HIV Medicine Association is pleased that the president's fiscal year 2017 budget proposal largely sustains funding for domestic HIV/AIDS programs," said HIVMA chair Dr. Carlos del Rio. "However, we are disappointed that under his proposal investments in HIV research are flat-funded for the third year in a row, and that funding for the President's Emergency Plan for AIDS Relief once again has not seen an increase since peak funding in 2010. A robust federal response is more critical than ever to effectively respond to the HIV epidemic."

Obama's final budget request comes to $4.1 trillion, a 4.9 percent increase over last year. While the Department of Health and Human Services gets about a quarter of that amount, more than 80 percent is committed to Medicare and Medicaid, leaving $82.8 million in discretionary funds.

The budget allocates $2.3 billion to the Ryan White Treatment Modernization Act, a modest $34 million increase over FY 2016, including $900 million for AIDS Drug Assistance Programs that pay for antiretroviral medications for people living with HIV.

The Centers for Disease Control and Prevention's National Center for HIV/AIDS, Viral Hepatitis, Sexually Transmitted Infections, and Tuberculosis Prevention saw only a small increase, remaining at approximately $1.1 billion (out of a total CDC budget of $7 billion), and the $788 million allocated for domestic HIV prevention and research stays about the same.

New this year is $20 million for a demonstration project to improve access to PrEP for HIV prevention. Up to 30 percent of this amount may be used to pay for medication and associated lab tests.

The only FDA-approved PrEP drug, Truvada (tenofovir/emtricitabine), retails for about $1,200 per month, but most Medicaid and some private insurance plans cover it, and manufacturer Gilead Sciences offers financial assistance programs.

Other domestic HIV funding comes through the Department of Veterans Affairs, which received a $57 million increase for medical care for veterans living with HIV, and the Department of Housing and Urban Development's Housing Opportunities for Persons with AIDS, or HOPWA, program, which is level-funded at $335 million.


HIV research and global funding flat

The National Institutes of Health budget for medical research received a 2.5 percent increase overall – up to $33.1 billion – but HIV research got no additional funding for FY 2017, leaving it at the same level as FY 2015 and FY 2016.

"This is a time of unprecedented promise in AIDS research, and flat-lining the NIH AIDS research budget for three years in a row threatens the many opportunities we have to end the epidemic as quickly as possible," Kenyon Farrow of the Treatment Action Group told the Bay Area Reporter. "There are many new and innovative studies underway in vaccine and cure research."

"Implementation of science research will help us address many of the disparities in prevention, treatment, and care we see in communities still largely impacted by the virus, particularly black gay men," Farrow added.

Funds for global HIV/AIDS efforts come from a variety of sources including DHHS, CDC, the U.S. Agency for International Development, and the Department of State, much of it consolidated under PEPFAR.

The FY 2017 budget provides a total of $8.6 billion to combat HIV/AIDS, malaria, and tuberculosis, and address other global health issues. While this is $73 million more than the 2016 allocation, most of the increase goes to malaria, maternal and child health, family planning, and vaccines, while HIV/AIDS itself saw no increase.

The Global Fund to Fight AIDS, Tuberculosis, and Malaria ($1.3 billion), bilateral HIV/AIDS assistance to individual countries ($4.3 billion), and UNAIDS ($45 million) all received the same amounts as last year.


Hepatitis funding

The CDC's Division of Viral Hepatitis, funded at $39 million, received a small $5 million increase, which advocates say falls short given the large number of people with hepatitis B and C who do not know their status and are not receiving treatment.

"The president's budget fails the more than 5 million Americans living with hepatitis B or hepatitis C and the many more at risk for infection," said National Viral Hepatitis Roundtable Executive Director Ryan Clary. "The lack of funding and commitment to address hepatitis B and hepatitis C in a meaningful way, particularly given the exciting and sorely needed initiatives to combat the overlapping opioid, heroin, and overdose epidemics, is not simply disappointing – it is incredibly short-sighted."

However, the Ryan White budget includes $9 million for a new program to expand hepatitis C screening and treatment for people with HIV. About a quarter of HIV-positive people are estimated to have hepatitis C and co-infection with both viruses leads to more rapid liver disease progression. In addition, a portion of the increase in Veterans Affairs funding for medical care will go toward hepatitis C treatment.

"While we are pleased by the president's requests to invest $9 million to support hepatitis C treatment for people living with HIV through the Ryan White program and $1.5 billion for the VA to treat veterans living with hepatitis C, we need more comprehensive investments," Emalie Huriaux of Project Inform told the B.A.R. "Of the 60 nationally notifiable infectious diseases, hepatitis C-associated deaths are greater than the total number of deaths associated with the other 59 diseases combined."


Other health allocations

The DHHS budget proposal encourages reluctant states to expand their Medicaid programs under the Affordable Care Act by covering the full cost of expansion for three years regardless of when they start. About half of all HIV-positive people receiving medical care are covered by Medicaid, according to the Kaiser Family Foundation, and 16 states have not yet expanded Medicaid to low-income adults up to 133 percent of the federal poverty level.

The budget also includes several provisions to reduce the cost of prescription drugs, including allowing the Centers for Medicare and Medicaid Services to partner with states to negotiate lower prices, reducing the patent period for brand-name biologic drugs from 12 to seven years, increasing discounts for seniors who fall into Medicare's donut hole, or coverage gap, and requiring more price transparency from drug manufacturers.

Other notable health-related items in the FY 2017 budget include $877 million to fight antibiotic resistance and develop new drugs, $500 million to expand access to mental health services, and $755 million for cancer prevention and treatment research – the so-called moonshot proposed in the president's recent State of the Union address. Obama also made a supplemental request for more than $1.8 billion in emergency funding for Zika virus response.

In the area of sexual health for young people, the proposed budget eliminates all funding for "abstinence only until marriage" sex education programs.

Finally, the budget sets aside $1.1 billion over two years to address a growing opioid addiction and overdose epidemic – mostly associated with heroin and prescription pain-killers – which has hit hard in rural areas. The initiative includes expanded medication-assisted addiction treatment using methadone or buprenorphine and increased access to naloxone to prevent overdose deaths.

This new allocation comes on top of $400 million in opioid epidemic funding in a bipartisan budget agreement reached late last year, which also removed language banning the use of federal money for needle exchange programs.

"Expanded access to prevention and treatment of opioid abuse is critical to improving health outcomes for our patients with HIV with co-occurring substance use issues," said HIVMA's del Rio.

Experts consider it unlikely that the Republican Congress will approve Obama's FY 2017 budget request as a whole, but specific pieces could pass – such as the cancer moonshot – and it sets the groundwork if a Democrat is elected as the next president in November.

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