Elections have consequences, and HIV/AIDS advocates are worried about potential cuts as Republicans take over both houses of Congress and the presidency in January.
"They [Congress] have many tools at their disposal to enact powerful budgetary impacts," Ernest Hopkins, senior strategist and adviser at the San Francisco AIDS Foundation, told the Bay Area Reporter. "The reconciliation process takes only a majority vote and, as long as proposals have budgetary impact, they can make them have a lot of negative impacts early."
As the B.A.R. previously reported, House Republicans had proposed cuts to domestic HIV spending in the amount of $767 million for Fiscal Year 2024. The Democratic-controlled Senate didn't agree to the cuts in its own bipartisan budget bill.
Those cuts didn't come to pass in the budget signed by President Joe Biden for Fiscal Year 2025, which saw a $20 million increase in domestic HIV-related funding in two areas — $10 million included for the Ryan White HIV/AIDS Program for care and treatment and $10 million for the Indian Health Service's efforts to combat HIV and hepatitis C.
"There were pretty dramatic cuts proposed in the Fiscal Year 2025 budget," said Lance Toma, a gay man who is the chief executive officer of the San Francisco Community Health Center. "All of this can have a devastating impact to all communities across the country, and definitely for San Francisco's efforts around doing all we can to end our HIV epidemic here in our city."
As the B.A.R. previously reported, San Francisco has made significant progress toward lowering HIV rates, with 133 cases reported for 2023. The city's Getting to Zero initiative aims to reduce new HIV transmissions and HIV deaths by 90% by 2025, in addition to reducing stigma.
"All of these [federal] monies — hundreds of millions of dollars — has enabled all of us across the country to really understand where the epidemic is and where we needed to put more focus and resources," Toma said, adding he is worried "we're just undoing all of what we have built over the last few years."
Toma said that moves that would be detrimental to health care access in general could hamper progress.
"We really are seeing positive impacts toward ending the epidemic here in San Francisco, so changes to the way we are looking at health care access — any changes to Medicaid in our state and across the country — is of concern. A lot of how we provide HIV care is through specific HIV funding sources we are talking about," said Toma.
House GOP proposed cutting all funding to Trump initiative
Further, House Republicans had threatened to cut all funding toward the Ending the HIV Epidemic in the U.S. initiative — in spite of the fact it was launched under former President Donald Trump's first term.
The then-president — now president-elect — touted it in his 2020 State of the Union address, stating, "We will eradicate the AIDS epidemic in America by the end of the decade."
The initiative seeks to reduce the number of new HIV infections in the U.S. by 90% by 2030 for an estimated 250,000 total HIV infections averted — and it seems to be working, with new HIV diagnoses down nationwide 12% in the last five years, according to federal data, including 16% in the South and 30% among young people.
The initiative has four key components: diagnose all people with HIV as early as possible, treat all people with HIV rapidly and effectively, prevent HIV with PrEP in at-risk populations, and respond quickly to potential outbreaks. PrEP, or pre-exposure prophylaxis, refers to the use of antiviral drugs to prevent people exposed to HIV from becoming infected.
The pill Truvada was first approved for PrEP use in 2012 by the U.S. Food and Drug Administration; since then the FDA has also approved the pill Descovy for some groups, and the drug Apretude as an injectable treatment.
Carl Schmid, a gay man who is the executive director of the Washington, D.C.-based HIV+Hepatitis Policy Institute, hopes the federal initiative to end HIV transmissions will be spared.
"It will take the collective action by the HIV community, state, local, and federal governments, businesses, and others to end HIV," he stated. "Now is not the time to retreat. On the contrary, we must sustain and accelerate the progress made under both the Trump and Biden administrations."
Schmid stated that "because of years of research and scientific advancements, we now have the tools to prevent and treat HIV and keep people living healthy and long lives." He reminded Republicans that, "President Trump initiated the Ending the HIV Epidemic initiative in his first term, which was sustained by President Biden and his administration.
"Now we look forward to that same commitment from President Trump as he and his new administration seek to make our country healthier, bolster prevention, and address chronic diseases," Schmid continued.
PrEP coverage for HIV-negative people may be under threat, too. The 5th U.S. Circuit Court of Appeals decided in June that a Patient Protection and Affordable Care Act provision granting a Health and Human Services task force the authority to require private insurers don't impose out-of-pocket costs for preventative care is unconstitutional, though the ruling only applies to the plaintiffs in the case.
In Braidwood Management v. Xavier Becerra, the plaintiffs argue that covering PrEP makes them "complicit in facilitating homosexual behavior, drug use, and sexual activity outside of marriage between one man and one woman."
The decision is expected to be appealed to the U.S. Supreme Court. Schmid's HIV+Hepatitis Policy Institute joined an amicus brief submitted to the appellate court.
"A wholesale invalidation of the coverage requirement for USPSTF's recommendations would strike a critical, unnecessary, and costly blow to the battle to end HIV, hepatitis, and other infectious diseases," the brief states, referring to the U.S. Preventative Services Taskforce. "Removing access to evidence-based preventive measures will have a devastating impact, not only on those living with HIV and hepatitis, but also for those at risk for acquiring HIV and hepatitis and the population at-large."
Proposed House Republican cuts, which passed the House Appropriations Committee on a 31-25 vote July 10 but did not become law, would have also cut nationally $214 million from the Centers for Disease Control and Prevention's HIV prevention programs, $190 million from Ryan White HIV/AIDS Program, and $15 million from the Health and Human Services secretary's Minority HIV/AIDS Fund.
Project 2025
Hopkins, of SFAF, is worried about the policy implications of Project 2025, an initiative of the Heritage Foundation and other conservative groups to consolidate power in the executive branch of the federal government. It was written with an eye toward Trump returning to the White House.
The project seeks to impart government policy with conservative Christian viewpoints and reclassify civil service workers as political appointees loyal to the president. Federal agencies like the FBI and the Justice Department would no longer be independent under the plan. Critics charge the proposal is autocratic and its implementation would undermine the separation of powers and the separation of church and state.
Project 2025 was disavowed by Trump during the election campaign, though he has been close with many people who've worked on it. Since the campaign, some of his appointments to his upcoming administration are those who were involved with the project. Russ Vought, an architect of Project 2025, is expected to return as director of the Office of Management and Budget, according to Axios.
"Project 2025 has essentially laid out a map of the places and kinds of populations that are going to be targeted for retribution, and we are those populations," Hopkins said. "We are ground zero — San Francisco, and the AIDS foundation, and the people who we serve."
Project 2025 has several references to federal HIV and AIDS programs. It proposes withdrawing Ryan White guidance that "provide controversial 'gender transition' procedures or 'gender-affirming care,' which cause irreversible physical and mental harm to those who receive them" and that exceptions allowing HIV-positive people to serve in the military should be removed.
As the B.A.R. previously reported, a federal judge in August struck down the final categorical disqualification preventing people with HIV from joining the military.
"Project 2025 targets many populations we work with on a regular and immediate basis like injection drug users and the LGBT community," Hopkins said. "San Francisco AIDS Foundation, as a key health care provider, will be concerned as we move forward about any policy or legislative actions that undermine our ability to access federal funds or cuts that undermine the social or health care safety net many of our clients rely on."
Hopkins said the AIDS foundation is keeping a particular watch on HOPWA, or Housing Opportunities for People with AIDS. HIV service providers have long pointed out that people living with HIV or AIDS who are not housed have a difficult time maintaining their health care and keeping their viral loads under control.
"That's a very important program, a little over $500 million in the federal budget," Hopkins said. "If it were eliminated, it would cause an already critical housing crisis to become even more critical."
SF in precarious position
Unfortunately, Hopkins noted that considering San Francisco's budget woes, backfilling funds might not be an easy fix. The B.A.R. reported earlier this year that as the city faced a $789 million shortfall over two years, it took weeks before Mayor London Breed would commit to backfilling roughly $200,000 in cuts to one source of its federal HIV/AIDS funding.
"With budgets across the board tied up at the state and local level, this is not the kind of environment they can anticipate state and local budgets to backfill federal cuts," Hopkins said.
Mayor-elect Daniel Lurie told the B.A.R. at the time that "every San Francisco mayor has backfilled Republican-driven cuts to federal HIV funding, and we cannot stop now," but added the proviso that he couldn't commit to supporting backfills in perpetuity if, for example, Republicans in Congress were able to push through cuts to HIV funds in the hundreds of millions of dollars.
The amount in question at that time was only in the hundreds of thousands.
"That's a small sum for important services when the City Hall insiders I'm running against continue to throw money at wasteful, unaccountable programs that fail to deliver results," Lurie had stated.
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