Testimony on FY 2023 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 2023 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.

Our nation is on a path to eliminating two infectious diseases, HIV and viral hepatitis, in the U.S., but we need increased funding to accelerate our efforts particularly in communities and populations disproportionately impacted. The ongoing COVID-19 pandemic has demonstrated the interconnectedness of communities and health conditions and has allowed innovative service delivery. 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 in order to achieve maximum impact.

The programs and funding increases detailed below are pivotal to our nation’s ability to end both HIV and hepatitis.

Ending the HIV Epidemic in the U.S.
Over the past three years, Congress has appropriated funding for the Ending the HIV Epidemic in the U.S. initiative, which sets the goal of reducing new HIV infections by 75% by 2025, and 90% by 2030. Unfortunately, this funding has been far less than what estimates used in the creation of the EHE initiative deemed necessary and were proposed by both Presidents Trump and Biden. The initiative, which is currently focused on those jurisdictions that represent about 50 percent of diagnoses, has already shown success with the money appropriated to date. The Health Resources and Services Administration’s HIV/AIDS Bureau reports that in 2020, the Ryan White Program served 11,139 new clients and re-engaged an additional 8,282 clients for a total of 19,421 clients during the first year of the COVID-19 pandemic when services often were disrupted. Additionally, community health centers funded by the EHE Initiative were able to increase PrEP (HIV prevention medication) to 389,000 people.

In FY 2023, we urge Congress to fund EHE activities at the level requested in President Biden’s FY23 Budget Request. For FY 2023, we ask that you fully fund the fourth year of the initiative to continue to scale up the EHE initiative by supporting the president’s budget request of $850 million, an increase of $377 million from FY 2021.

• $310 million for the CDC Division of HIV/AIDS Prevention for testing, linkage to care, and prevention services, including pre-exposure prophylaxis (PrEP) (+$115 million);
• $290 million for the HRSA Ryan White HIV/AIDS Program to expand comprehensive care and treatment for people living with HIV (+$165 million);
• $172 million for the HRSA Community Health Centers to increase clinical access to prevention services, particularly PrEP (+$50 million);
• $52 million for the Indian Health Service (IHS) to address the combat the disparate impact of HIV and hepatitis C on American Indian/Alaska Native populations (+$47 million); and
• $26 million for NIH Centers for AIDS Research to expand research on implementation science and best practices in HIV prevention and treatment.

PrEP
It is estimated that only 23.4% of people who could benefit from PrEP have received a prescription. PrEP coverage is highest among white people, at 63.3%, yet only 8.2% of black people and 14% of Hispanic/Latino people who could benefit from PrEP in the U.S. have a prescription. Additionally, PrEP coverage among women is only at 9.7%. Reducing these disparities must be a priority as we work to expand PrEP use.

We are thankful that there has been an increased focus on PrEP both in Congress and from President Biden. In his FY 2023 budget request, President Biden called for a new mandatory funding program to expand PrEP across the United States through providing medication to uninsured and underinsured individuals, as well as supporting and expanding PrEP programs across a variety of agencies. As the HIV community, relevant stakeholders, and Congress consider this proposal along with others, we urge you to support funding for new and innovative grant programs to expand PrEP access, ensure that those who want PrEP can easily access the medication without any costs or barriers, and increase demand for PrEP among people who could benefit from this important medication. This can be accomplished with increased funding for PrEP services for community health centers, CDC’s Division of HIV Prevention, and other programs.

HIV
Additionally, 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 these 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 coverage completion services to over 567,000 low-income, uninsured and/or underinsured individuals with HIV. Nearly 61% of clients live at or below 100%of the federal poverty level and nearly three-quarters of the clients 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% of Ryan White clients achieving viral suppression, a critical marker for decreasing new infections in the U.S. Currently, Ryan White Programs, and particularly the AIDS Drug Assistance Programs (ADAPs) are facing increased demand as people have lost health coverage and incomes due to the ongoing economic impact of COVID-19. Without increased funding some ADAPs may be forced to institute wait lists for medications or other cost containment measures.

This program is especially important in many states where there are large healthcare coverage gaps because of states choosing not to expand 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 these people into care and treatment and ensuring their virus is undetectable, which makes them untransmittable. The Ryan White Program also needs additional support to address the complex challenges of the overdose crisis, mental health crisis, and prevention and treatment of other infectious diseases, including COVID-19, viral hepatitis, and STIs. We urge Congress to fund the Ryan White HIV/AIDS Program at a total of $2.942 billion in FY2023, an increase of $447 million over FY2022, of which $165 million is for the EHE initiative and $68 million is for ADAPs.

There has been incredible progress in the fight against HIV over the last 40 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 gay and bisexual men, Latinx gay and bisexual men, Black heterosexual women, transgender and gender nonconforming women, people who inject drugs, and people who live in the South. HIV prevention tools that meet the special prevention needs of these populations must be expanded.

Through partnerships with state and local public health departments and community-based organizations, the CDC has expanded targeted, high-impact prevention programs that work to address racial and geographic health disparities. Additionally, the CDC’s national surveillance system is a key tool in identifying people and regions most impacted by the epidemic and tailoring prevention efforts to meet the needs of those populations and prevent HIV transmission. 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. We urge you to fund the CDC Division of HIV Prevention at $822.7 million in FY2023, an increase of $67 million over FY2022, in addition to the $310 million for EHE Initiative work at CDC.

A holistic response to the HIV epidemic also depends on fully funding other priority programs at HHS, including the CDC’s Division of School and Adolescent Health and STI prevention, 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
Additionally, we respectfully request that you 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% are unaware they are living with the disease. The opioid epidemic has significantly increased the number of viral hepatitis cases in the United States, with available data suggesting that more than 70 percent of the 57,800 new HCV infections are among people who inject drugs. 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 $41 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; however, health departments and community partners are in desperate need of additional resources. 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. With the treatment of hepatitis D expected to be approved this year, there will be increased needs for testing and linkage to care programs. While we are pleased that the Biden administration has prioritized viral hepatitis in its FY23 budget with an increase of $13.5 million, we urge you to provide the CDC Division of Viral Hepatitis with $140 million, an increase of $99 million over FY 2022 enacted levels.

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. The U.S. is experiencing an ongoing public health emergency crisis with the U.S. surpassing 105,000 annual overdose deaths from opioid overdose in 2020, a more than 45% increase from January 2020. Providing full support for this program is another key step in preventing new cases of viral hepatitis and HIV, addressing overdose prevention, and putting the country on the path towards elimination. We urge the committee to fund this program to eliminate opioid-related infectious diseases at $150 million, an increase of $133 million.

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.

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. The White House Office of National AIDS Policy and the HHS Office of Infectious Disease and HIV/AIDS Policy both play an important role in developing and implementing government-wide HIV strategies, as well as coordinating efforts among the wide range of federal agencies working to end the HIV epidemic and the syndemics of STDs, hepatitis, TB, and overdoses. 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 2023.

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. Fortunately, we have the tools available to end both these epidemics; however, we must provide the necessary resources to accelerate our efforts to achieve these goals.