Can we Trump HIV/AIDS?

Can we Trump HIV/AIDS?

We are investing so much money in security, but if US residents are dying without healthcare care access then who are we protecting?

Last week, the Trump administration released their proposed budget boasting an 18% cut in funds allocated to the Department of Health, and Human Services.[i] NBC News reported on this, focusing specifically on HIV/AIDS funding. Much to the relief of advocates and public health professionals around the US, Trump’s proposed budget categorized programs like the Ryan White HIV/AIDS Program and the President’s Emergency Plan for AIDS Relief (PEPFAR) program as “high priority.”[ii] While this means that such programs will not be starved of funding, the programs could still face budget cuts in 2018.

The Ryan White HIV/AIDS Program (formally known as the Ryan White Comprehensive AIDS Resources Emergency Act) was enacted in 1990. The US Congress channeled significant funding to the program making it the largest federally funded program in the US for individuals living with HIV/AIDS. In the 2016 fiscal year, the program received US$2.32 billion.[iii] This year, the program was awarded “12% of the government funding for HIV/AIDS care in the US.”[iv] The primary purpose of the national program is to facilitate access to HIV/AIDS care services ranging from primary medical care for uninsured/underinsured individuals living with HIV/AIDS. The Health Resources and Services Administration in the US reported that “52% of all those diagnosed with HIV in the US utilize the Ryan White program.”[v] Additionally, Ryan White provides support services, technical assistance, and clinical training.[vi] For individuals living in the US, Ryan White provides an opportunity to access HIV medications (antiretroviral drugs and therapies) consistently. Furthermore, the program focuses on developing and enhancing innovative models of care. Using a multipronged approach, Ryan White has focused on combatting the epidemic with a five-part strategy:

●      Part A provides funding for “medical and support services among populations most severely affected by HIV/AIDS.”[vii]

●      Part B provides “grant funding to states and territories to improve the quality, availability, and organization of HIV healthcare and support services.”[viii]

●      Part C provides “grant funding to local community-based organizations to support outpatient HIV early intervention services and ambulatory care.”[ix]

●      Part D provides “grant funding to support family-centered, comprehensive care to women, infants, children, and youth living with HIV.”[x]

●      Part F provides “grant funding that supports several research, technical assistance, and access-to-care programs.”[xi]

According to Trump’s budget, there will be “sufficient resources to maintain current commitment and all current patient levels on HIV/AIDS treatment” under PEPFAR.[xii] PEPFAR was a program implemented by former President George W. Bush in 2009. The PEPFAR program aims to “provide AIDS and HIV drugs and funding to millions of people and initiatives across the world.[xiii] Admittedly, a significant portion of PEPFAR funding goes to Sub-Saharan Africa where HIV prevalence is approximately 4.9%.[xiv] Even though the PEPFAR program is the “largest by any nation to combat a single disease internationally,” PEPFAR also contributes investments towards fighting other global diseases.[xv] I can confirm that PEPFAR provides considerable funding that sustains (not supports, but sustains) township community clinics, HIV testing facilities, and men’s clinics. This is due to my research as a public health researcher in South Africa. Through objective determination, the program bridges the gap between the US and the rest of the developing world by contributing to the funding HIV/AIDS eradication.

Knowing these facts, and despite the reality that these programs provide extensive support for individuals (local and international) living with HIV/AIDS, Trump’s administration has reduced the respective federal funding. Some of us deign to ask - why? Well, that is simple: the US military obviously requires more funding for its defense.

The proposed budget calls for an increase of US$ 52 billion for the Defense Department, over and above the US$ 522 billion allocated under the Obama administration.[xvi] In the Energy and State Departments, there will be an additional US$ 2 billion increase in spending.[xvii] New funds will contribute to accelerating programs dedicated to “fighting Islamic State militants, reversing Army troop reductions, building more ships for the Navy, and ramping up the Air Force.”[xviii]

 

This may be a good time to point out that, according to UNAIDS, we could see the end of the HIV/AIDS epidemic in low- and middle-income countries by 2020 with US$ 26.2 billion.[xix] That is not even 50% of the US Defense budget - forget half; the amount required to end HIV/AIDS in developing nations is not even 10% of what is channeled toward Defense and Military in the US.

In isolation, these budgets cuts and increased expenses will not affect HIV/AIDS services in the US. However, by extension the shift in federal funding allocations will greatly impact HIV/AIDS care and prolong the epidemic - not only in the US, but globally. The new budget has reduced foreign aid by 28% - including federal funds allocated to the United Nations and cultural exchange programs.[xx] This will affect relief aid and global programs supporting HIV/AIDS interventions. Reuters, via the New York Times, reports that “healthcare companies such as drug makers and device makers will pay more than twice as much in 2018 to have their medical products reviewed” by the FDA.[xxi] Cuts in drug approval, and potentially drug production will likely have international ramifications given that the US is leading in HIV research with recent trials on PrEP - a pill that prevents HIV infection in high-risk individuals. Furthermore, will budget cuts deter upcoming generations from pursuing public health and infectious disease research?

I acknowledge that military spending has important ramifications for securing a country’s borders. Based on 2013 figures, for nearly two generations less than 0.5% of the US population has served in the military, including “armed forces.”[xxii] Comparatively, also from figures in 2013, 1.2 million people (out of 316.5 million in the US) were living with HIV - that is roughly 0.4% of the population.[xxiii] What I am highlighting is that the same individuals are affected by HIV/AIDS and military spending - US residents. The same sons. The same daughters. In this way, is it fair to channel funding away from one cause and toward another? I aim to point out that these statistics are specific to HIV/AIDS, and exclude other healthcare concerns - such as cancer, diabetes, cardiovascular diseases, and substance abuse. In other words, why does the US military need so much additional funding?

Certainly, no country can survive without a defense force and military presence - that would be unsustainable. I acknowledge that baseline funding for the defense or for healthcare affects the same people. The distinction is that funding affects different kinds of people - people with varying overall spheres of influence. Ultimately, however, we have to choose which group of people require more money to carry out their responsibilities. Yes, the military in the US could be categorized, by some of my critics, as underfunded. To an extent, I agree with this: the military cannot carry out its duties to protect the residents of the continental United States without funds. I am making a greater point, however, that the military will have fewer people to protect if funding for healthcare access is cut. The government aims to protect the US from foreign attacks, but there is a more dangerous threat: HIV/AIDS.

We all know that the US is a major player in the global game. What we do not know (or what Trump’s administration seems to be missing) is that US funding decisions could potentially topple a carefully stacked Jenga tower. Allow me a childish analogy…..Years, no decades, of clinical care and research efforts have been invested in the Jenga tower that consists of multipronged HIV/AIDS care and intervention strategies. These are programs like the International AIDS Society’s “Call to Action to Support Civil Society” whereby financial support is provided to “people who are working at the frontlines of the HIV response.”[xxiv] These are individuals like you and me -  teachers, doctors, nurses, students, counsellors. Even though the US is not removing funding for HIV/AIDS programs specifically - a Jenga block that lies at the top of the tower - the rest of the tower is compromised. If Trump’s administration removes funding for programs that support general community health interventions and foreign assistance, they remove Jenga blocks at the center of the tower - blocks offering structural support to their higher counterparts. Without these central blocks, which seemingly are disconnected from the higher stack, the Jenga tower will crumble. In the same way, without funding for programs around HIV/AIDS care (such as programs offering foreign aid, social support, technical assistance, and healthcare for the un- or underinsured) our efforts to eradicate HIV/AIDS will cease.

Right now, the new administration will likely continue to support costs for significant HIV/AIDS programs in the US and will definitely continue supporting PEPFAR. As for the rest of the prongs supporting our fight against HIV/AIDS, only time will tell.

References:

1.     "About PEPFAR." About PEPFAR. Accessed March 21, 2017. https://www.pepfar.gov/about/index.htm.

2.     "About the Ryan White HIV/AIDS Program." HRSA-HAB. October 01, 2016. Accessed March 21, 2017. https://hab.hrsa.gov/about-ryan-white-hivaids-program/about-ryan-white-hivaids-program.

3.     "Call to Action to Support Civil Society." AIDS 2016. Accessed March 21, 2017. http://www.aids2016.org/Get-Involved/Call-to-Action-for-Civil-Society.

4.     Eikenberry, Karl W., and David. "Americans and Their Military, Drifting Apart." The New York Times. May 26, 2013. Accessed March 21, 2017. http://www.nytimes.com/2013/05/27/opinion/americans-and-their-military-drifting-apart.html.

5.     "Financing the end of AIDS: the window of opportunity." Financing the end of AIDS: the window of opportunity | UNAIDS. Accessed March 21, 2017. http://www.unaids.org/en/resources/presscentre/featurestories/2016/june/20160608_panel2.

6.     "HIV and AIDS in sub-Saharan Africa regional overview." AVERT. May 01, 2015. Accessed March 21, 2017. https://www.avert.org/professionals/hiv-around-world/sub-saharan-africa/overview.

7.     McCausl, Phil. "Amid dramatic cuts, HIV/AIDS funding spared in Trump's proposed budget." NBCNews.com. March 17, 2017. Accessed March 21, 2017. http://www.nbcnews.com/feature/nbc-out/amid-dramatic-cuts-hiv-aids-funding-spared-new-trump-budget-n734711.

8.     "Statistics Overview." Centers for Disease Control and Prevention. March 03, 2017. Accessed March 21, 2017. https://www.cdc.gov/hiv/statistics/overview/.

9.     "Trump Plans 28 Percent Cut in Budget for Diplomacy, Foreign Aid." The New York Times. March 16, 2017. Accessed March 21, 2017. https://www.nytimes.com/reuters/2017/03/16/us/politics/16reuters-usa-trump-budget-state.html?_r=0.

"U.S. and World Population Clock Tell us what you think." Population Clock. Accessed March 21, 2017. https://www.census.gov/popclock/.

[i] McCausland, 2017

[ii] McCausland, 2017

[iii] Ryan White & Global HIV/AIDS Programs, 2017

[iv] McCausland, 2017

[v] McCausland, 2017

[vi] Ryan White & Global HIV/AIDS Programs, 2017

[vii] Ryan White & Global HIV/AIDS Programs, 2017

[viii] Ryan White & Global HIV/AIDS Programs, 2017

[ix] Ryan White & Global HIV/AIDS Programs, 2017

[x] Ryan White & Global HIV/AIDS Programs, 2017

[xi] Ryan White & Global HIV/AIDS Programs, 2017

[xii] McCausland, 2017

[xiii] McCausland, 2017

[xiv] AVERT.org, 2017

[xv] PEPFAR, 2017

[xvi] Reuters, 2017

[xvii] Reuters, 2017

[xviii] Reuters, 2017

[xix] UNAIDS, 2016

[xx] Reuters, 2017

[xxi] Reuters, 2017

[xxii] Eikenberry, K.W., Kennedy, D.M., 2013

[xxiii] Census Bureau, 2013

[xxiv] International AIDS Society, 2016

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