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Trump budget calls for $291 million to fund HIV initiative

The District of Columbia introduced an HIV kit in 2016 to educate black women about using a daily pill that reduces the risks of contracting HIV. (Nikki Kahn/The Washington Post)

The Trump administration is calling for $291 million for its domestic campaign to stop the transmission of HIV in the United States within a decade, proposing significant new resources for programs that have not received major increases in the past few decades.

The administration announced a budget for fiscal 2020 on Monday that follows President Trump’s State of the Union pledge to end the HIV epidemic by 2030. The proposal calls for $140 million in new funding for the Centers for Disease Control and Prevention to reduce new infections through improved testing, prevention and referral to medical care. The money would be used to connect patients to treatment and provide pre-exposure prophylaxis, known as PrEP, to people at risk of infection. PrEP is a once-a-day pill that protects users against HIV infection. The money represents an 18 percent increase over the fiscal 2019 budget.

In 2017, there were nearly 40,000 new HIV diagnoses in the United States, according to the CDC. An estimated 1.1 million people had the virus that causes AIDS, with about 15 percent of them undiagnosed.

The budget also includes $120 million for the Health Resources and Services Administration (HRSA) to deliver additional care and treatment for people living with HIV through the Ryan White HIV/AIDS program, including $50 million in proposed funding for community health centers at HRSA for expanded PrEP services. The Indian Health Services also would receive $25 million to enhance HIV testing and referrals to care.

The total $291 million is for the fiscal 2020 budget. Additional funding is expected as part of the multiyear initiative.

Experts said the increases “are quite significant for those programs, which have essentially had flat funding for the last couple decades,” said Jennifer Kates, director of global health and HIV policy at the Kaiser Family Foundation. “If finalized, the budget request would mark the first time in many years where the key U.S. HIV prevention & safety net care programs would see significant increases,” she said in a tweet.

Carl Schmid, deputy executive director of the AIDS Institute, said: “While the Trump budget includes several budget cuts that we cannot support, ending HIV is something we can all support. This opportunity is too important to squander. Now is the time for Congress to work together and invest the necessary resources to end HIV once and for all.” Schmid is also co-chairman of the Presidential Advisory Council on HIV/AIDS.

But the reach of the HIV initiative would be affected negatively under the administration’s efforts to dismantle the Affordable Care Act and oppose Medicaid expansion, because reducing access to health insurance and medical care reduces access to HIV treatment and prevention. The Trump administration is proposing a sharp slowdown in Medicaid spending in the budget.

“If the larger health-care forces are to cut back on access, that’s going to make it more difficult for people to get in the door or stay in the door, and will affect the reach of the HIV initiative,” Kates said.

In addition, on the global front, the administration is proposing cuts to global AIDS programs. The administration is proposing cuts to the Global Fund to Fight AIDS, Tuberculosis and Malaria, and also to the President’s Emergency Plan for AIDS Relief (PEPFAR), a multibillion-dollar program started by President George W. Bush. This is the administration’s third budget request to reduce global funding. Congress has rejected the cuts each previous year.

On PEPFAR, it would provide $3.35 billion for bilateral efforts at the State Department and the U.S. Agency for International Development, about 30 percent below fiscal 2019 levels. On the Global Fund, the budget proposes $958.4 million, which is 29 percent below the fiscal 2019 level.

“It’s hard to square [the HIV initiative] with these significant cuts,” Kates said, referring to Trump’s promise in his State of the Union speech to “defeat AIDS in America and beyond.”

In the United States, the HIV initiative will focus on the parts of the country that account for more than 50 percent of new HIV diagnoses. They are in 48 hot-spot counties; the District of Columbia; San Juan, Puerto Rico; and the rural areas of seven states, most of them in the South: Alabama, Arkansas, Kentucky, Mississippi, Missouri, Oklahoma and South Carolina.

In many of these places, it is hard for people at risk of contracting HIV to find the medication critical to protecting them from the virus and ending the 38-year-old epidemic. The CDC estimates that the decline in HIV infections has stalled because effective prevention and treatment are not reaching those who could most benefit.

The goal of the domestic initiative is to reduce HIV transmission by 75 percent within five years and by at least 90 percent by 2030, which would prevent 250,000 new infections.

A recent report from the CDC shows the significant decline in annual HIV infections has stalled. The report provides the most recent data on HIV trends in the United States, from 2010 to 2016. It shows that after about five years of substantial declines, the number of HIV infections began to level off in 2013 at about 39,000 per year.

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