Senate testimony on FY 2024 funding for HIV and hepatitis programs

Testimony for the Record
Senate Appropriations Subcommittee on Labor, HHS, Education, and Related Agencies
Fiscal Year 2024 Appropriations for HIV and Hepatitis Programs

Carl Schmid, Executive Director, HIV+Hepatitis Policy Institute

            On behalf of the HIV+Hepatitis Policy Institute, we respectfully submit this testimony in support of increased funding for domestic HIV and hepatitis programs in the FY 2024 Labor, HHS spending bill.

            Our nation can eliminate both HIV and viral hepatitis, but without an infusion of new resources to accelerate our efforts, we will continue to fall short of these ambitious goals. Current discussions involving budget caps that reduce non-defense discretionary appropriations would have devastating impacts on our nation’s public health system and our ability to respond to these two infectious diseases.

            We must continue to fund the nation’s response to HIV and hepatitis to both make up for diverted attention to COVID-19 and to accelerate our efforts. Increased investment in surveillance, education, prevention, and care and treatment will ensure we continue to address HIV and viral hepatitis, including taking a syndemic approach to achieve maximum impact. The programs and funding increases detailed below are pivotal to our nation’s ability to end both these potentially deadly infectious diseases.

Ending the HIV Epidemic in the U.S.

            Over the past four years, since it was first proposed by President Trump and continued under President Biden, Congress has appropriated funding for the Ending the HIV Epidemic in the U.S. initiative, which sets the goal of reducing new HIV infections 90 percent by 2030. Unfortunately, this funding has fallen far short of what is necessary. The initiative, which is currently focused on jurisdictions representing about 50 percent of HIV diagnoses, has shown success with the money appropriated to date. The Health Resources and Services Administration’s HIV/AIDS Bureau reports that as a result of this funding in FY 2021, the Ryan White Program served 22,400 new or re-engaged clients. Since the initiative began, the CDC has distributed 100,000 free HIV self-test kits and health departments conducted almost 250,000 HIV tests in the first year and 1,000 people received a new diagnosis of HIV. In addition, over 200 clusters of HIV transmission were identified allowing the CDC, along with state and local health departments and community partners, to disrupt transmissions and avert additional infections. The 302 community health centers funded through EHE successfully conducted 1.7 million HIV tests, provided PrEP (HIV prevention medication) to 52,477 patients, and linked 86 percent of newly diagnosed patients to care within 30 days.

            In FY 2024, we urge Congress to fund EHE activities at the levels outlined below to accelerate our efforts to end HIV in the prioritized jurisdictions.

• $495 million for the CDC Division of HIV/AIDS Prevention for testing, linkage to care, and prevention services, including pre-exposure prophylaxis (PrEP) (+$275 million);
• $330 million for the HRSA Ryan White HIV/AIDS Program to expand comprehensive care and treatment for people living with HIV (+$165 million);
• $207 million for the HRSA Community Health Centers to increase access to prevention services, particularly PrEP (+$50 million); and
• $52 million for the Indian Health Service (IHS) to address the disparate impact of HIV and hepatitis C on American Indian/Alaska Native populations (+$47 million).

PrEP

            It is estimated that only 25 percent of people who could benefit from PrEP have received a prescription. PrEP coverage is highest among White people, at 66percent, yet only 9 percent of Black people and 16 percent of Hispanic/Latino people who could benefit from PrEP have a prescription. PrEP coverage among women is only at 10.4 percent. Reducing these disparities must be a priority as we work to expand PrEP use. The president’s FY 2024 budget request includes a proposal for a mandatory funding program to expand PrEP. As the HIV community, relevant stakeholders, and Congress consider this proposal, we urge you to support $495 million, an increase of $275 million, for the CDC’s Division of HIV Prevention EHE efforts, which includes funding to initiate a national PrEP program. Additionally, we urge you to support the $207 million (+$50 m) for PrEP in community health centers, which will increase the number of centers doing PrEP from around 450 to over 600.

HIV

            The success of the EHE initiative and PrEP delivery rests upon our underlying public health prevention, care, and treatment programs at the CDC, HRSA, and other agencies. Congress must ensure that they are also funded to provide services in all areas of the country.

            The Ryan White HIV/AIDS Program at the Health Resources and Services Administration provides medical care, medications, and essential wrap-around services to over 567,000 low-income, uninsured, or underinsured individuals with HIV. Nearly 61 percent of clients live at or below 100 percent of the federal poverty level and nearly three-quarters are from racial and ethnic minority populations. For over 30 years, the Ryan White program has pioneered innovative models of care, which has resulted in over 89 percent of clients achieving viral suppression. The program is facing increased demand as people live longer and as inflation continues to rise, but funding has remained stagnant.

            This program is especially important in many states, particularly in the South, where there are large healthcare coverage gaps because they have not expanded Medicaid. There are approximately 400,000 people living with HIV who are not engaged in care and treatment. The Ryan White Program can play a large role in bringing this population into care and treatment. Successful HIV treatment ensures that the virus is undetectable, which makes it untransmittable (U=U).

            We urge Congress to fund the Ryan White HIV/AIDS Program at a total of $3.058 billion in FY2024, an increase of $487 million over FY2023, of which $165 million is for the EHE initiative and $68 million is for AIDS Drug Assistance Programs.

            There has been incredible progress in the fight against HIV over the last forty years, but that progress has stalled with new infections plateauing since 2013. Increasing funding for high- impact, community-focused HIV prevention services through the CDC’s Division of HIV Prevention has proven to result in a strong return on investment. HIV continues to disproportionately impact Black and Latino gay men, Black heterosexual women, people who inject drugs, and those in the South. There is no single way to prevent HIV, but jurisdictions use a combination of effective evidence-based approaches including testing, linkage to care, condoms, syringe service programs, and PrEP to meet the needs of these populations.

       In 2020, as a result of CDC funding, health departments conducted 1,255,895 HIV tests, which resulted in finding 12,376 people to be living with HIV.  Seventy-five percent of them were linked to care within 30 days.  106,931 of the persons tested for HIV were found to be eligible for PrEP and 44,743 (or 43 percent) were referred to PrEP providers. We urge you to fund the CDC Division of HIV Prevention at $822.7 million in FY2024.

            A holistic response to the HIV epidemic also depends on fully funding other priority programs at HHS, including the CDC’s Eliminating Opioid-Related Infectious Diseases Program and Division of School and Adolescent Health, the Minority HIV/AIDS Initiative, AIDS Research at the NIH, the Title X Family Planning Program, and the Teen Pregnancy Prevention Program (TPPP).

Viral Hepatitis  

            We urge you to provide increased funding for viral hepatitis programs at the CDC. The CDC estimates that nearly 5 million people in the United States live with hepatitis B (HBV) or hepatitis C (HCV), and as many as 65 percent are unaware they are living with the disease. Viral hepatitis kills more Americans than any other infectious disease, and, left untreated, results in significant costs to public programs through liver cancer and liver transplants. The opioid epidemic has significantly increased the number of viral hepatitis cases. There are several curative treatments available for HCV, but individuals must have access to screening and linkage to care. The president’s budget request includes a proposal for a five-year National Hepatitis C Elimination Program. As Congress considers this program, we must shore up public health funding focused on hepatitis. The viral hepatitis programs at the CDC are severely underfunded, receiving only $43 million—far short of what is needed to build and strengthen our public health response to hepatitis.

            The Viral Hepatitis National Strategic Plan for the United States: A Roadmap to Elimination (2021–2025) lays out an ambitious plan to end the hepatitis epidemic. Increased investment would allow the CDC to enhance testing and screening programs, conduct additional provider education, enhance clinical services specific to hepatitis at sites serving vulnerable populations, and increase services related to hepatitis outbreaks and injection drug use. While we are pleased that the president’s budget has prioritized viral hepatitis in its FY23 budget with an increase of $11.5 million, we urge you to provide the CDC Division of Viral Hepatitis with $150 million, an increase of $107 million over FY 2023 enacted levels.

Federal HIV & Hepatitis Coordination      

            Two important offices which coordinate the implementation of the NHAS and EHE activities need resources to bolster their ability to coordinate HIV and viral hepatitis activities across the federal government. We urge you to provide a total of $20 million for the HHS Office of Infectious Disease and HIV/AIDS Policy and $3 million for the White House Office of National AIDS Policy in FY 2024.

SAMHSA HIV Block Grant

            We urge you to include language, as was proposed in the president’s budget, that would modernize the way in which states qualify to be eligible for the HIV set-aside of the Substance Abuse Block Grant (SABG). Instead of using the outdated measurement of AIDS cases in order for a state to qualify for the 5 percent HIV set-aside, the number of HIV cases should be used. Due to the current language, only two states now qualify. With the update, up to twenty would be able to.

          In conclusion, we urge the committee to continue its investment in our nation’s public health infrastructure specifically as it relates to addressing the ongoing HIV and hepatitis epidemics.