Federal & State Federal & State HIV/AIDS PolicyHIV/AIDS Policy

UCLA School of Public HealthUCLA School of Public Health

Epidemiology 227Epidemiology 227

April 23, 2010April 23, 2010

Prof. Arleen LeibowitzProf. Arleen Leibowitz

UCLA School of Public AffairsUCLA School of Public Affairs

OutlineOutline Care and TreatmentCare and Treatment

MedicaidMedicaid MedicareMedicare Ryan White CARE ActRyan White CARE Act Private Insurance and Health Reform ChangesPrivate Insurance and Health Reform Changes

Testing and PreventionTesting and Prevention California issuesCalifornia issues

ResearchResearch Income Support and HousingIncome Support and Housing Global ProgramsGlobal Programs

Follow The Funding to Determine Priorities

FY 2010 Federal HIV/AIDS Budget Request

($ Billions)

Prevention, $0.79

Housing/$, $2.45

Research, $2.62

Global, $6.46

Treatment, $13.53

National Treatment Guidelines National Treatment Guidelines Call for Early Access to Call for Early Access to

Treatment and CareTreatment and Care But many PLWH are not in regular careBut many PLWH are not in regular care

About 21% do not know their HIV statusAbout 21% do not know their HIV status Only 55% of those meeting clinical criteria Only 55% of those meeting clinical criteria

for ARV therapy get itfor ARV therapy get it Expanded guidelinesExpanded guidelines

HAART is costlyHAART is costly $12,000/year in ARV costs$12,000/year in ARV costs $20,000/year in total costs$20,000/year in total costs

Insurance Status of HIV Insurance Status of HIV Patients in Care, 1996Patients in Care, 1996

Medicaid29%

Medicare19%

Private32%

Uninsured20%

Federal Support for Care and Federal Support for Care and Treatment (FY2010)Treatment (FY2010)

MedicaidMedicaid (Federal share) (Federal share) $4.7 B $4.7 B 34.6%34.6% MedicareMedicare $5.1 B$5.1 B 37.5%37.5% Ryan WhiteRyan White $2.3 B$2.3 B 16.9%16.9%

(ADAP(ADAP $0.8 B)$0.8 B) Veterans AffairsVeterans Affairs $0.8 B$0.8 B

5.9%5.9% SAMHSASAMHSA $0.2 B $0.2 B 1.5% 1.5% HOPWAHOPWA $0.3 B$0.3 B 2.2% 2.2% FEHBPFEHBP $0.1 B$0.1 B 0.7% 0.7%

TotalTotal $13.5 B$13.5 B

Two Kinds of Federal Two Kinds of Federal SpendingSpending

Mandatory spendingMandatory spending Presumption that Congress must allocate Presumption that Congress must allocate

funding to meet statutory obligation – e.g., funding to meet statutory obligation – e.g., Medicare, Medicaid, SSIMedicare, Medicaid, SSI

““Entitlements”Entitlements” Defined benefitDefined benefit

Discretionary spendingDiscretionary spending Congress decides on spending level each yearCongress decides on spending level each year Defined contribution Defined contribution Block grantsBlock grants Examples: NIH, CDC, Ryan White, VAExamples: NIH, CDC, Ryan White, VA

Problems With Discretionary Problems With Discretionary SpendingSpending

Block grant means that the budget does not Block grant means that the budget does not increase to accommodate increased enrollmentincrease to accommodate increased enrollment

Health care costs rise faster than CPI, so Health care costs rise faster than CPI, so annual increases are “high”annual increases are “high”

Long-term health investments are discouraged Long-term health investments are discouraged by annual budget processby annual budget process Prevention may reduce costs in long run, but not in Prevention may reduce costs in long run, but not in

shortshort Early treatment of HIV may save money in long runEarly treatment of HIV may save money in long run

Share of discretionary spending is fallingShare of discretionary spending is falling

MedicaidMedicaid

Created in 1965Created in 1965 Federal/state health insurance program for low Federal/state health insurance program for low

income and disabledincome and disabled Federal government pays a minimum of 50% of Federal government pays a minimum of 50% of

costs, more in low income states (average 55% of costs, more in low income states (average 55% of HIV $)HIV $)

Jointly administeredJointly administered States set eligibility criteria, subject to Federal minimaStates set eligibility criteria, subject to Federal minima States set benefits, subject to Federal mandated States set benefits, subject to Federal mandated

benefitsbenefits

Current Medicaid EligibilityCurrent Medicaid Eligibility

States must coverStates must cover Certain poor women and childrenCertain poor women and children Disabled who qualify for SSI (unable to Disabled who qualify for SSI (unable to

engage in “substantial gainful activity by engage in “substantial gainful activity by reason of… (a medical condition) ….expected reason of… (a medical condition) ….expected to result in death or that has lasted…up to 12 to result in death or that has lasted…up to 12 months”)months”)

States set income criteriaStates set income criteria State option to cover Medically Needy State option to cover Medically Needy

who “spend down” to income criteriawho “spend down” to income criteria

Medicaid BenefitsMedicaid Benefits

Covers most services with no or minimal Covers most services with no or minimal cost-sharingcost-sharing

Drugs, an optional service, are covered in Drugs, an optional service, are covered in all statesall states

Optional services include case Optional services include case management, hospicemanagement, hospice

Some states limit servicesSome states limit services Number of Rx per month or yearNumber of Rx per month or year Number of MD visitsNumber of MD visits

Medicaid – Current Policy Medicaid – Current Policy IssuesIssues

State variability in Medically Needy income State variability in Medically Needy income eligibility criteria eligibility criteria

VermontVermont 75% FPL75% FPL LouisianaLouisiana 7% FPL 7% FPL

States can impose limits on discretionary services States can impose limits on discretionary services (drugs)(drugs)

Non-citizens can not qualify for MedicaidNon-citizens can not qualify for Medicaid Green-card holders must wait 5 yearsGreen-card holders must wait 5 years

Medicaid provider payment levels are low, making Medicaid provider payment levels are low, making access difficultaccess difficult

Medicaid discount on drugs of 15.1% less than what Medicaid discount on drugs of 15.1% less than what others getothers get

Medicaid –Policy Issues (2)Medicaid –Policy Issues (2) Catch-22Catch-22

Medicaid eligibility depends on being disabled or Medicaid eligibility depends on being disabled or having AIDShaving AIDS

But early treatment of non-disabled could avert But early treatment of non-disabled could avert disabilitydisability

And reduce transmissionAnd reduce transmission Some states have 1115-waivers to provide Some states have 1115-waivers to provide

Medicaid to low income people with HIV prior to Medicaid to low income people with HIV prior to disabilitydisability 1115 waiver requires “budget neutrality” --Medicaid 1115 waiver requires “budget neutrality” --Medicaid

savings >= additional Medicaid costssavings >= additional Medicaid costs But, given fractured system, inpatient savings of ARV But, given fractured system, inpatient savings of ARV

treatment often go to Medicare, SSI or Ryan Whitetreatment often go to Medicare, SSI or Ryan White

Medicaid –Policy Issues (3)Medicaid –Policy Issues (3) Lose Medicaid if earnings exceed threshold, Lose Medicaid if earnings exceed threshold,

however, earnings may not cover the cost of however, earnings may not cover the cost of costly ARV treatment costly ARV treatment Ticket to Work/Work Incentives Improvement Act of Ticket to Work/Work Incentives Improvement Act of

1998 continues Medicaid coverage even if person 1998 continues Medicaid coverage even if person returns to workreturns to work

In recessions, states attempt to cut Medicaid In recessions, states attempt to cut Medicaid benefitsbenefits Gov. Schwarzenegger proposed premiums for Gov. Schwarzenegger proposed premiums for

MedicaidMedicaid Federal government raised its match rate during Federal government raised its match rate during

recessionrecession

Health Care Reform and Health Care Reform and MedicaidMedicaid Persons <133% of FPL are eligible for Medicaid Persons <133% of FPL are eligible for Medicaid

from 2014from 2014 $14,404 for single individual; $29,327 for family of 4$14,404 for single individual; $29,327 for family of 4 Does not depend on disabilityDoes not depend on disability Individuals w/o dependent children now will qualifyIndividuals w/o dependent children now will qualify

Removes eligibility variation by state, but Removes eligibility variation by state, but undocumented still not eligibleundocumented still not eligible

100% federal funding for eligibility expansions in 100% federal funding for eligibility expansions in 2014-16, declining later to 90%2014-16, declining later to 90%

Increases drug 340b rebate to 23.1%, but some Increases drug 340b rebate to 23.1%, but some goes back to federal governmentgoes back to federal government

Provides 100% federal funding to raise Medicaid Provides 100% federal funding to raise Medicaid reimbursement rate to Medicare levels for reimbursement rate to Medicare levels for primary care services in 2013, 2014 primary care services in 2013, 2014

Encourages “medical home” for those with Encourages “medical home” for those with chronic conditionschronic conditions

MedicareMedicare

Created in 1965Created in 1965 Covers persons 65+, persons with ESRD, Covers persons 65+, persons with ESRD,

and long term disabledand long term disabled Funded by payroll tax on earnings, Funded by payroll tax on earnings,

general revenues, beneficiary premiums general revenues, beneficiary premiums for Part B and co-payments (Medicaid can for Part B and co-payments (Medicaid can pay patient cost-sharing)pay patient cost-sharing)

Uniform throughout U.S.Uniform throughout U.S.

Medicare: Eligibility for Medicare: Eligibility for DisabledDisabled

Disabled must have sufficient covered work Disabled must have sufficient covered work history to quality for SSDIhistory to quality for SSDI

29 Month Waiting period29 Month Waiting period Federal law requires 5 month wait after disability Federal law requires 5 month wait after disability

determination before receiving SSDI paymentsdetermination before receiving SSDI payments 24-month waiting period for Medicare, following 24-month waiting period for Medicare, following

SSDI SSDI Medicaid coverage for low income persons Medicaid coverage for low income persons

during the 29 months during the 29 months

Medicare BenefitsMedicare Benefits

HospitalHospital Outpatient (20% cost-sharing)Outpatient (20% cost-sharing) Drugs have been covered since January 1, Drugs have been covered since January 1,

2006 under Part D, private drug 2006 under Part D, private drug insurance plansinsurance plans Plans required to cover all ARVsPlans required to cover all ARVs Low income subsidy needed for “the donut Low income subsidy needed for “the donut

hole”hole”

Medicare – Current Policy Medicare – Current Policy IssuesIssues

Eligibility Eligibility Must have sufficient work history to qualify Must have sufficient work history to qualify

for SSDI, a problem for young, poor persons for SSDI, a problem for young, poor persons with HIVwith HIV

29 month wait for Medicare eligibility29 month wait for Medicare eligibility Catch-22 of disability requirementCatch-22 of disability requirement

Cost-sharingCost-sharing High cost sharing if no supplemental coverageHigh cost sharing if no supplemental coverage No cap on out-of-pocket spendingNo cap on out-of-pocket spending

Medicare “donut hole”Medicare “donut hole” When ADAP pays, doesn’t count as “true out When ADAP pays, doesn’t count as “true out

of pocket cost” (TROOP)of pocket cost” (TROOP)

Health Reform and Health Reform and MedicareMedicare

Medicare “donut” hole will be closedMedicare “donut” hole will be closed 2010--$350 towards cost2010--$350 towards cost Phase-down coinsurance rate in donut hole from Phase-down coinsurance rate in donut hole from

100% to 25%, starting 2011 by requiring 50% 100% to 25%, starting 2011 by requiring 50% rebate from manufacturers plus federal 25% rebate from manufacturers plus federal 25% subsidysubsidy

ADAP payments will count as TROOP in Part DADAP payments will count as TROOP in Part D No cost-sharing for covered preventive No cost-sharing for covered preventive

services (rated A or B by U.S. Preventive services (rated A or B by U.S. Preventive Services Task Force)Services Task Force)

Ryan White Care ActRyan White Care Act

CARE= Comprehensive AIDS Relief EmergencyCARE= Comprehensive AIDS Relief Emergency Enacted 1990Enacted 1990 Administered by Health Resources and Services Administered by Health Resources and Services

Administration (HRSA)Administration (HRSA) Payer of last resort for 553,000 uninsured and Payer of last resort for 553,000 uninsured and

underinsured PLWAunderinsured PLWA Outpatient care, including medical, dental, case Outpatient care, including medical, dental, case

management, home health, hospice, housing, management, home health, hospice, housing, transportation, drugs (through ADAP), transportation, drugs (through ADAP), insurance continuationinsurance continuation

Ryan White Funds Systems Ryan White Funds Systems of Careof Care

Originally designed to provide relief to cities with Originally designed to provide relief to cities with disproportionate burden of caring for HIV/AIDSdisproportionate burden of caring for HIV/AIDS

Part A:Part A: Emergency Relief (EMA, TGA)Emergency Relief (EMA, TGA)Part B:Part B: HIV Care (including ADAP)HIV Care (including ADAP)Part C:Part C: Early InterventionEarly InterventionPart D:Part D: Women, Infants, Children, YouthWomen, Infants, Children, YouthPart FPart F AIDS Education and Training, AIDS Education and Training,

Dental, SPNSDental, SPNS

AIDS Drug Assistance Program AIDS Drug Assistance Program (ADAP)(ADAP)

Funded by Part B of Ryan White Care ActFunded by Part B of Ryan White Care Act Congressional Earmark: $835 M (approx 50%)Congressional Earmark: $835 M (approx 50%) Plus state supplements (approx 25%)Plus state supplements (approx 25%) And rebates from drug manufacturers (approx 25%)And rebates from drug manufacturers (approx 25%) Other Federal fundingOther Federal funding

States set eligibility States set eligibility 5 x FPL in NJ; 4 x FPL in CA; 2 x FPL Texas5 x FPL in NJ; 4 x FPL in CA; 2 x FPL Texas Disability not requiredDisability not required Residency, not citizenship requiredResidency, not citizenship required

ADAP is a block grantADAP is a block grant States have used waiting lists to ration States have used waiting lists to ration

ADAP (2)ADAP (2) Drugs provided to 110,000 PLWH monthly in Drugs provided to 110,000 PLWH monthly in

20082008 Cost/enrollee c. $1000/monthCost/enrollee c. $1000/month

ServicesServices HIV MedicationsHIV Medications Drug monitoring and adherence servicesDrug monitoring and adherence services Can purchase health insurance for eligible clientsCan purchase health insurance for eligible clients

Drug FormulariesDrug Formularies Must include at least one medication w/I each ARV Must include at least one medication w/I each ARV

classclass Louisiana had 28 drugs; New York had 460Louisiana had 28 drugs; New York had 460

Ryan White – Current Policy Ryan White – Current Policy IssuesIssues

Discretionary grant program provides a block Discretionary grant program provides a block grantgrant Growth in PLWHA increases demand for CARE Act Growth in PLWHA increases demand for CARE Act

servicesservices Medical costs increase faster than CPIMedical costs increase faster than CPI States have limited ability to supplement States have limited ability to supplement Resulted in waiting lists for ADAP Resulted in waiting lists for ADAP States set eligibility rules, resulting in variability States set eligibility rules, resulting in variability States with less generous Medicaid programs, need States with less generous Medicaid programs, need

more Ryan White supportmore Ryan White support Provides support for non-citizens Provides support for non-citizens

Ryan White – Policy Issues Ryan White – Policy Issues (2)(2)

2006 Reauthorization of Ryan White Act 2006 Reauthorization of Ryan White Act revised funding formulas for Parts A and Brevised funding formulas for Parts A and B Funding now based on reported HIV cases, Funding now based on reported HIV cases,

not only AIDS casesnot only AIDS cases Directs funding to reflect emerging epidemicDirects funding to reflect emerging epidemic California just began names reporting of HIV California just began names reporting of HIV

casescases Required 75% of funding to be used for Required 75% of funding to be used for

core medical servicescore medical services

ADAP - Policy IssuesADAP - Policy Issues

Coordination with Medicare Part DCoordination with Medicare Part D Payment for Part D co-pays, deductibles, Payment for Part D co-pays, deductibles,

premiumspremiums ADAPs can pay for drugs in “donut hole”ADAPs can pay for drugs in “donut hole”

Increasing demand for ADAP as more Increasing demand for ADAP as more PLWHA are not disabled, but require PLWHA are not disabled, but require medicationmedication Longer bridge to MedicaidLonger bridge to Medicaid New, more costly drugsNew, more costly drugs

ADAP - Policy Issues (2)ADAP - Policy Issues (2)

Continued availability of prescription Continued availability of prescription rebates? rebates?

State fiscal environments challenge states’ State fiscal environments challenge states’ ability to supplement ADAPability to supplement ADAP

States seek to reduce formularies to cut States seek to reduce formularies to cut costscosts

Need to explore cost containment Need to explore cost containment strategies that maintain client access (i.e. strategies that maintain client access (i.e. purchasing options)purchasing options)

Health Reform and ADAPHealth Reform and ADAP

Insurance exchanges should reduce number Insurance exchanges should reduce number of uninsured, and reliance on ADAPof uninsured, and reliance on ADAP Would provide for medical care, not just drugsWould provide for medical care, not just drugs CARE/HIPP could help purchase insuranceCARE/HIPP could help purchase insurance

ADAP will count as TROOPADAP will count as TROOP ADAP costs after donut hole should decreaseADAP costs after donut hole should decrease

Cost of drugs while in donut hole is reduced Cost of drugs while in donut hole is reduced by 50%by 50% Effect on rebates?Effect on rebates?

Effect of health reform on Ryan White Effect of health reform on Ryan White funding?funding? UndocumentedUndocumented

Health Reform and Private Health Reform and Private InsuranceInsurance

Eliminates “medical underwriting” and rescissionsEliminates “medical underwriting” and rescissions Provides subsidies for purchase from exchanges (32 Provides subsidies for purchase from exchanges (32

million people by 2019) with mandated benefitsmillion people by 2019) with mandated benefits Legal immigrants eligible for subsidiesLegal immigrants eligible for subsidies Bronze plan—covers 60% of costBronze plan—covers 60% of cost

Caps out of pocket expenditures for persons<4xFPLCaps out of pocket expenditures for persons<4xFPL Sets up high risk pool—June 2010 to Jan 2014Sets up high risk pool—June 2010 to Jan 2014 Allows children to stay on parents’ policy until age Allows children to stay on parents’ policy until age

2626 May reduce pressure on COBRA for unemployedMay reduce pressure on COBRA for unemployed

OutlineOutline Care and TreatmentCare and Treatment

MedicaidMedicaid MedicareMedicare Ryan White CARE ActRyan White CARE Act Health Reform and private insuranceHealth Reform and private insurance

Testing and PreventionTesting and Prevention California IssuesCalifornia Issues

ResearchResearch Income Support and HousingIncome Support and Housing Global ProgramsGlobal Programs

HIV TestingHIV Testing

21% of PLWH do not know they are HIV+21% of PLWH do not know they are HIV+ CDC “Advancing HIV Prevention” (2004)CDC “Advancing HIV Prevention” (2004)

1.1. Make voluntary HIV testing a part of routine Make voluntary HIV testing a part of routine medical caremedical care

2.2. Test for HIV outside of medical care settingsTest for HIV outside of medical care settings

3.3. Prevent new infections by focusing on HIV+ Prevent new infections by focusing on HIV+ individuals and their partnersindividuals and their partners

4.4. Further decrease perinatal HIV transmissionFurther decrease perinatal HIV transmission

HIV Testing – Policy IssuesHIV Testing – Policy Issues CDC goal to “normalize” HIV testingCDC goal to “normalize” HIV testing

DestigmatizeDestigmatize Opt-out vs. opt-in testing recommended by Opt-out vs. opt-in testing recommended by

CDC in Sept. 2006CDC in Sept. 2006 Default is testing; patient must specifically decline Default is testing; patient must specifically decline

testtest Covered by general consent to treatCovered by general consent to treat CA state law since Jan. 1, 2008 removes CA state law since Jan. 1, 2008 removes

requirement for specific written informed consent requirement for specific written informed consent for testingfor testing

Need prevention counseling accompany testing?Need prevention counseling accompany testing?

Testing—Policy Issues (2)Testing—Policy Issues (2)

Rapid test could increase knowledge of Rapid test could increase knowledge of HIV statusHIV status Results ready in 20 minutes, no need to Results ready in 20 minutes, no need to

return for resultsreturn for results But needs to be confirmed if “preliminarily But needs to be confirmed if “preliminarily

positive”positive” CA state law relating to who can perform CA state law relating to who can perform

finger prick test limited use of rapid testsfinger prick test limited use of rapid tests Just changedJust changed

Prevention Prevention

Centers for Disease Control and Centers for Disease Control and Prevention administers most federal Prevention administers most federal prevention efforts (FY 10 budget: $785.1 prevention efforts (FY 10 budget: $785.1 B) B)

National budget share for prevention National budget share for prevention (4%) is decreasing over time(4%) is decreasing over time

California share for prevention <6%California share for prevention <6%

California Cut 09/10 HIV/AIDS California Cut 09/10 HIV/AIDS Budget by $59MBudget by $59M

State State CutCut

($ ($ million)million)

State State CutCut

(%)(%)

State State ShareShare

(%)(%)

(09/10)/ (09/10)/ (08/09)(08/09)

C&T, HERRC&T, HERR 32.932.9 100100 78.678.6 0.2660.266

Care & Care & SupportSupport

22.822.8 100100 40.040.0 0.6070.607

SOASOA 3.03.0 44.844.8 31.131.1 0.7280.728

ADAPADAP 25.025.0 0-0-funded funded by by rebatesrebates

IncreaseIncreased for d for FY11FY11

1.001.00

Prevention: Policy IssuesPrevention: Policy Issues

Balance efforts targeting HIV- and HIV+ Balance efforts targeting HIV- and HIV+ individualsindividuals

Target increased risk behavior among MSMTarget increased risk behavior among MSM Methamphetamine epidemic in CAMethamphetamine epidemic in CA Internet—prevention challenge or opportunity?Internet—prevention challenge or opportunity?

Reach populations who may not realize their Reach populations who may not realize their risk and may not receive routine medical risk and may not receive routine medical carecare Young men are not in routine medical careYoung men are not in routine medical care STI clinics, EDs, jails?STI clinics, EDs, jails?

Separation between federal treatment and Separation between federal treatment and prevention effortsprevention efforts

Prevention – Policy IssuesPrevention – Policy Issues Federal government promotion of abstinence onlyFederal government promotion of abstinence only

The The Task Force on Community Preventive ServicesTask Force on Community Preventive Services concludes that there is concludes that there is insufficient evidenceinsufficient evidence to determine to determine the effectiveness of group-based abstinence education the effectiveness of group-based abstinence education delivered to adolescents to prevent pregnancy, HIV and delivered to adolescents to prevent pregnancy, HIV and other sexually transmitted infections (STIs). other sexually transmitted infections (STIs).

HIV Federal Materials Review ProcessHIV Federal Materials Review Process Congressionally mandated review of HIV prevention Congressionally mandated review of HIV prevention

education materials supported by CDC fundseducation materials supported by CDC funds Messages must emphasize ways to fully protect against Messages must emphasize ways to fully protect against

acquiring or transmitting the virusacquiring or transmitting the virus Materials can not directly encourage sexual activities or Materials can not directly encourage sexual activities or

drug usedrug use

OutlineOutline

Care and TreatmentCare and Treatment MedicaidMedicaid MedicareMedicare Ryan White CARE ActRyan White CARE Act

Testing and PreventionTesting and Prevention ResearchResearch Income Support and HousingIncome Support and Housing Global ProgramsGlobal Programs

ResearchResearch

NIH Budget for HIV research is $2.62B in NIH Budget for HIV research is $2.62B in FY10FY10 Largest investments are biomedicalLargest investments are biomedical

California HIV Research ProgramCalifornia HIV Research Program FY07 $12MFY07 $12M

Income Support and Income Support and HousingHousing

Cash Assistance (11% of Domestic HIV Cash Assistance (11% of Domestic HIV funding)funding) SSI - $500 M in FY10SSI - $500 M in FY10 SSDI - $1,636 M in FY10SSDI - $1,636 M in FY10 Entitlement programs for the disabledEntitlement programs for the disabled

Housing Opportunities for Persons with Housing Opportunities for Persons with AIDS (HOPWA) $310 M in FY10AIDS (HOPWA) $310 M in FY10 AIDS exceptionalism?AIDS exceptionalism?

Conclusions—Domestic Conclusions—Domestic IssuesIssues

Health Reform has addressed many Health Reform has addressed many HIV/AIDS policy issuesHIV/AIDS policy issues

But, the fragmented system still presents But, the fragmented system still presents challengeschallenges

OutlineOutline

Care and TreatmentCare and Treatment MedicaidMedicaid MedicareMedicare Ryan White CARE ActRyan White CARE Act

Testing and PreventionTesting and Prevention ResearchResearch Income Support and HousingIncome Support and Housing Global ProgramsGlobal Programs

Global ProgramsGlobal Programs President’s Emergency Plan for AIDS Relief President’s Emergency Plan for AIDS Relief

(PEPFAR) (PEPFAR) President Bush proposed $15B commitment over 5 years in President Bush proposed $15B commitment over 5 years in

20032003 Upped to $48 B over 5 yearsUpped to $48 B over 5 years

Most US funding is bilateral, circumvents Global Most US funding is bilateral, circumvents Global Fund Fund But US is still largest single contributor to GFBut US is still largest single contributor to GF

Obama administration changes in May 2009Obama administration changes in May 2009 Funding at $63B over Funding at $63B over 6 years6 years Global Health Initiative (GHI) Global Health Initiative (GHI) Shift from emergency response to sustainable modeShift from emergency response to sustainable mode Recipient country ownership of planning processRecipient country ownership of planning process Rebalance Global Health portfolio from HIV to MCHRebalance Global Health portfolio from HIV to MCH

HIV Is Largest Share of GHIHIV Is Largest Share of GHI

Return to Tutorials

U.S. Global Health Initiative (GHI), FY 2011 Budget Request

HIV$5,739.1

$1,000

$829.2$155

$200

$108

$700 $590

$251

*FY 2011 is President’s Budget Request to Congress. SOURCES: Kaiser Family Foundation analysis of data from the Office of Management and Budget, Agency Congressional Budget Justifications, Congressional Appropriations Bills, and White House Statement by the President on Global Health Initiative, May 5, 2009. Also see: Kates J., The U.S. Global Health Initiative: Overview & Budget Analysis, Menlo Park: Kaiser Family Foundation, December 2009.

In Millions

Total = $9.6 billion

Slide 10

Global Fund

Nutrition

OtherMalaria

MCH

TB

FP/RH NTDs

Global Policy IssuesGlobal Policy Issues

20032003 55% of funding for 55% of funding for

treatment; 20% for treatment; 20% for preventionprevention

33% prevention funding had 33% prevention funding had to be targeted to abstinenceto be targeted to abstinence

In 2005, 2/3 on abstinence, In 2005, 2/3 on abstinence, 1/3 condoms +1/3 condoms +

Condoms only for “high-Condoms only for “high-risk” (prostitutes, risk” (prostitutes, discordant couples, discordant couples, substance abusers)substance abusers)

20102010 Over half of funding for Over half of funding for

treatmenttreatment Target 50% of prevention Target 50% of prevention

funds on abstinence. If funds on abstinence. If less, report to Congress less, report to Congress

AB-C still in place AB-C still in place

Global Policy Issues (2)Global Policy Issues (2)

20032003 ARVs must be approved by ARVs must be approved by

FDA (WHO approval not FDA (WHO approval not sufficient) sufficient)

HIV exempted from “gag HIV exempted from “gag rule” on abortions, but many rule” on abortions, but many misunderstoodmisunderstood

Funded organizations need Funded organizations need “policy explicitly opposing “policy explicitly opposing prostitution and sex prostitution and sex trafficking.” (PL108-25)trafficking.” (PL108-25)

No funding for needle No funding for needle exchangeexchange

20102010 By 2007, 73% of drugs By 2007, 73% of drugs

distributed were generic. distributed were generic. Accelerated FDA Accelerated FDA approval.approval.

Pres. Obama rescinded Pres. Obama rescinded “gag rule” on abortion“gag rule” on abortion

Focus on MTCT, MC and Focus on MTCT, MC and services for IDUsservices for IDUs

Overarching Policy Overarching Policy QuestionsQuestions

Will care and treatment crowd out Will care and treatment crowd out prevention because we adopt a short prevention because we adopt a short term planning horizon?term planning horizon? Why do we spend so little on prevention?Why do we spend so little on prevention?

Fragmented funding makes it difficult toFragmented funding makes it difficult to Know what resources are availableKnow what resources are available Coordinate careCoordinate care

Policy Resources

HRSA http://www.hrsa.gov

CDC http://www.cdc.gov/hiv

NIH http://www.nih.gov

CHRP http://chrp.ucop.edu

CHIPTS http://chipts.ucla.edu

Kaiser Family Foundation http://www.kff.org/hivaids

CAPS http://www.caps.ucsf.edu