AIDS programs enjoy wide bipartisan support in Congress, but funding for them might still be crowded out by other priorities in the budget fights ahead.
A tight spending climate coupled with medical advances that have driven the disease out of the headlines have AIDS experts and advocates concerned that both domestic and international AIDS programs could face sharp cuts in the coming years.
“I’m worried," said Bill Gates, Microsoft's chairman and the co-chairman of the Bill and Melinda Gates Foundation, which has invested more than $15 billion in global health issues, including many programs in HIV/AIDS prevention and treatment.
"Somebody loves every part of the federal budget," he told National Journal. "I think my love of this part is more important than their part, but at the end of the day, you know, there will be budget cuts at some point in time.”
Funding for the President's Emergency Plan For AIDS Relief, which provides money for international treatment and prevention efforts, as well as domestic spending on public health, treatment, and other services, is on the block if automatic spending cuts kick in as planned next year. And perhaps more significant over the long run, both parties have signaled their willingness to sacrifice the programs when considering other priorities.
President Obama this year asked Congress to reduce funding for the international program, though neither the House nor Senate went along. Instead, lawmakers have aimed at domestic AIDS programs. The report attached to the current draft of the House appropriations bill reflects significant cuts to those programs, including a $100 million, or 12 percent, reduction in funding on HIV/AIDS programs run by the Centers for Disease Control and Prevention, according to a Democratic appropriations aide. Most government-funded AIDS programs weren't singled out in the bill, as were women's health programs, but they were included in top-line cuts to health-care spending.
"While HIV and AIDS programs have not been targeted specifically, we know that if you attack Medicaid and the Affordable Care Act, you end up attacking the greatest hope we have for expanding access to HIV programs,” said Rep. Barbara Lee, D-Calif., a longtime leader in AIDS legislation who sits on the appropriations subcommittee on Labor, Health and Human Services, Education, and related agencies.
AIDS is on the front burner this week, as the International AIDS conference draws luminaries from around the world to Washington. It’s the first time the conference has been in the U.S. capital in more than 20 years, and it has focused substantial attention on AIDS issues—The Washington Post ran a special section, public radio has produced a series of stories, and advocacy groups have staged high-profile demonstrations in town.
But overall, observers say that the issue has faded somewhat from the consciousness of lawmakers as treatment and prevention efforts have improved. The domestic epidemic, which appeared to be rocketing out of control in the 1980s and 1990s, has abated as high infection rates have retreated into concentrated risk groups. Polling from the Kaiser Family Foundation has found that the number of people who think of AIDS as a major threat has dropped off in recent years.
“It seems like the pharmaceutical advances really took away some of the political intensity,” said Mike Franc, the vice president of government studies at the Heritage Foundation, who worked to develop some of the early domestic AIDS programs as a staffer for then-Rep. William Dannemeyer, R-Calif. “The political Richter scale kind of came down a lot.”
The international epidemic has suffered a similar fate. President George W. Bush changed the national conversation about global AIDS in 2003 when he called for the $15 billion international fund in 2003. By all measures, that program has been a major success, and has been able to improve efficiencies and outcomes over time, even though the number of new infections internationally continues to outstrip the number of patients entering treatment each year.
“What I worry about is that we’ve done a good job of making this more bipartisan, but if people don’t see and hear HIV on the evening news every night, will they think it’s a less urgent problem at this precise moment when we could make a very big impact?” said Jeffrey Crowley, who recently left his post as the director of the White House Office of Domestic AIDS Policy and is now a senior scholar at the Georgetown Health Policy Institute.
The last few years have racked up significant scientific advances in treatment and prevention. Studies have demonstrated a close link between early treatment and prevention—the partners of infected people on active treatment were much less likely to catch the virus. The Food and Drug Administration recently approved the first drug for HIV prevention: Uninfected but high-risk people who take the daily pill Truvada will be at greatly reduced risk of infection, studies suggest.
And the issue has traditionally enjoyed strong support among congressional Republicans, in part because there is such a clear connection in HIV/AIDS between dollars spent and lives saved.
“It is crucial that we continue to work nationally and internationally to prevent new infections and ensure people living with HIV/AIDS have access to the best treatment and care they need,” said Sen. Michael Enzi, R-Wyo., in a statement last week. Enzi, a strong voice for deficit reduction overall, is the ranking member of the Senate Health, Education, Labor, and Pensions Committee, which oversees the domestic programs.
But that historic support may not be enough to protect programs in the difficult budget climate to come.
“With the budget pressure on all the programs, cuts may be inevitable to programs,” said Jennifer Kates, the vice president and director of global health and HIV policy at the Kaiser Family Foundation. “That’s not about losing bipartisan support. That’s just where we’re headed.”
Ronald Brownstein contributed