Testimony for the Record Senate Labor HHS Appropriations Subcommittee (FY 2021)
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 2021 Labor, HHS spending bill. The HIV+Hepatitis Policy Institute is a leading HIV and hepatitis policy organization promoting quality and affordable healthcare for people living with or at risk of HIV, hepatitis, and other serious and chronic health conditions.
While our nation and the entire world are currently battling COVID-19, where the science is in its infant stage, we have the science to end two other infectious diseases that have been impacting our country for decades: HIV and hepatitis C. While there still is no cure or vaccine for HIV, we have preventive tools along with treatments that suppress the virus and together can bring the number of new infections down to a point that we can end HIV. For hepatitis C, there are curative treatments. However, federal leadership and funding for our public health system is necessary to ramp up efforts to address these two epidemics. The programs and funding increases detailed below are pivotal to our nation’s ability to end both HIV and hepatitis.
The healthcare workers, community-based organizations, and state and local governments who have been on the front line of the COVID-19 response are the same people and organizations that have been responsible for planning and implementing our nation’s response to both HIV and hepatitis and will continue to be once the current crisis subsides. Funding for them to address infectious diseases, such as HIV and hepatitis and others in the future, will particularly be necessary in the year ahead.
Funding Public Health Programs Outside Budget Caps
Our nation’s public health infrastructure has been underfunded for many years. Now is the time to provide increased funding to allow federal agencies, state and local jurisdictions, and community organizations on the ground the resources and capacity to build interconnected and state-of-the-art surveillance, prevention, screening, and educational programs. In order to provide this necessary funding, the HIV+Hepatitis Policy Institute strongly supports funding critical public health programs, including those for ending HIV and hepatitis in the United States, outside of the Budget Control Act spending caps, similar to the creation of the proposed Health Defense Operations (HDO) fund. Without the necessary funding we will never end these infectious diseases or be prepared for future epidemics.
HIV and hepatitis programs across the nation are experts in best practices related to infectious disease prevention, control, and treatment. Jurisdictions across the nation are discussing how to incorporate and bundle screening and testing for COVID-19 infection with the same services for HIV, hepatitis, and sexually transmitted infections. Programs addressing HIV and hepatitis also have significant experience working with populations currently disproportionately affected by COVID-19 including homeless and racial and ethnic minorities.
Ending the HIV Epidemic
Announced in the 2019 State of the Union, the Ending the HIV Epidemic (EHE) initiative is a historic effort to reduce new HIV infections by 75 percent in the next five years and by 90 percent in the next ten years. The initiative focuses on four key areas: diagnosing all individuals with HIV as early as possible after infection; treating the infection rapidly after diagnosis, achieving sustained viral suppression; protecting individuals at risk for HIV using proven prevention approaches such a Pre-exposure Prophylaxis (PrEP); and responding rapidly to detect and respond to growing HIV clusters.
We thank the committee for supporting funding for the first year of this initiative. Funding is being distributed to the fifty-seven target Phase-1 cities and states, which have all developed Ending the HIV Epidemic plans. They are ramping up screening to diagnose people unaware of their HIV status and link them to antiretroviral treatment and providing PrEP to those who are at high risk of HIV. For FY 2021, we ask that you fully fund the second year of the initiative to continue to scale up the EHE initiative by supporting the president’s budget request of $716 million, an increase of $450 million from FY 2020.
With proposed FY 2021 funding of $371 million, an increase of $231 million, the Centers for Disease Control and Prevention (CDC) will transition from planning to implementation and intensify work already begun in the fifty-seven target jurisdictions. CDC grants will drive additional testing with the goal of doubling the number of new HIV diagnoses rapidly treated with antiretroviral therapy to maintain health and prevent additional HIV transmissions. Funded jurisdictions will use pharmacy data, telehealth, mobile testing, and new science-based networks to ensure individuals enter and adhere to care.
An increase of $182 million for a total of $302 million will allow the Health Resources and Services Administration (HRSA) to expand treatment and prevention services through its vast network of providers. With $137 million, an increase of $87 million, the Bureau of Primary Health Care (BPHC) will fund over 300 additional community health centers to expand the provision of PrEP services, bringing the total number of health centers funded by the initiative to over 500. The Ryan White HIV/AIDS Program would receive an increase of $95 million to the amount of $165 million to reach over 43,000 people living with HIV who are not yet in care or who have not yet received an HIV diagnosis. HRSA’s Ryan White Program is a critical safety net program providing care, treatment, and support services to over 500,000 people living with HIV. Almost 86 percent of Ryan White clients are virally suppressed, far exceeding the national average of nearly 60 percent.
The EHE is a critical targeted component of our nation’s response to the HIV epidemic; however, we must continue to invest in ongoing HIV programs throughout the nation. This includes the CDC’s HIV Prevention Programs (including the Division of School and Adolescent Health), HRSA’s Ryan White HIV/AIDS Programs (including the AIDS Drug Assistance Program), the Minority HIV/AIDS Initiative, AIDS Research at the NIH, and the Teen Pregnancy Prevention Program (TPPP).
Each of these programs is necessary to address the HIV epidemic in our nation and each is being negatively impacted by the ongoing COVID-19 pandemic. State and local health departments’ staff is being detailed to deal exclusively with COVID-19 and facing furloughs to make up for budget shortfalls. Programs that rely on in-person visits for assessments and testing are having to purchase new equipment to increase telehealth services and organizations are having to work with clients and their families to ensure access to broadband and mobile devices to ensure consistent access. Increased funding will help our HIV infrastructure be able to provide necessary services in the “new normal.”
Viral Hepatitis
Additionally, we respectfully request that you provide increased funding for viral hepatitis programs at the CDC. The CDC estimates that more than 4.5 million people in the United States live with hepatitis B (HBV) or hepatitis C (HCV), with nearly half unaware they are living with the disease. The opioid epidemic has significantly increased the number of viral hepatitis cases in the United States, with new cases of HCV rising 374 percent between 2010 and 2017. Newly released CDC data show that in 2018 there were an estimated 50,300 new hepatitis C infections, which represents a three-fold increase in the rate of new infections over the last decade. The CDC also found that due to the ongoing opioid epidemic and injection drug use, there are now just as many new infections among Millennials as Baby Boomers, who in the past bore the brunt of all new cases. Therefore, the CDC is now recommending that every adult eighteen and older be tested at least once for hepatitis C, plus all women during each pregnancy, and those at risk.
From 2006 to 2018, increases in reported cases of acute HBV infection range from 56 percent to 457 percent in states most heavily impacted by the opioid crisis. From 2014-2017, the number of reported cases of hepatitis A increased by 271 percent. There are several curative treatments available for HCV, but individuals must have access to screening and linkage to care programs to be able to take advantage of these medications.
CDC Division of VIral Hepatitis
The viral hepatitis programs at the CDC are severely underfunded, receiving only $39 million—far short of what is needed to build and strengthen our public health response to hepatitis. Currently, the CDC is only able to fund fourteen jurisdictions to conduct enhanced hepatitis surveillance, which is harming our nation’s ability to respond to the infectious disease consequences of the opioid epidemic. Additional resources 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. We urge you to provide the CDC Division of Viral Hepatitis with $134 million, an increase of $95 million over FY 2020 enacted levels.
The CDC recently released a Notice of Funding Opportunity announcement to fifty-eight jurisdictions asking them to prepare ending hepatitis plans that focus on education, surveillance, screening, linkage to care, and syringe service programs. Unfortunately, since the state and local jurisdictions are responding to COVID-19, it had to been withdrawn. Later this year, the administration is expected to release an updated national hepatitis strategy with a stated goal to end hepatitis. However, the current level of funding is completely inadequate for these jurisdictions to even begin to discuss ending hepatitis—particularly hepatitis C, which has a cure, and hepatitis B, which has a vaccine and effective treatments.
CDC’s Eliminating Opioid-Related Infectious Diseases Program
This CDC program focuses on addressing the infectious disease consequences of increased rates of injection drug use due to the opioid crisis. Providing full support for this program is another key step in preventing new cases of viral hepatitis and HIV and putting the country on the path towards elimination. We urge the committee to fund this program to eliminate opioid-related infectious diseases at no less than $58 million, an increase of $48 million, and the amount proposed in the president’s budget.
Syringe Service Programs (SSPs)
We also ask that the committee support ending any prohibition on the use of federal funds to purchase sterile needles or syringes for SSPs. A wealth of scientific evidence has shown that SSPs reduce the spread of infectious diseases, such as HIV and hepatitis. Full federal funding for these programs will only serve to make the programs stronger and more effective. 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 HCV epidemics. Fortunately, we have the tools available to end both these epidemics; however, we must provide the necessary resources to achieve these goals.