Bay Area Reporter - May 14, 2009
Bob Roehr

AIDS advocates praised some changes in policy from the Bush administration but are increasingly frustrated and vocal in expressing the need to change additional policies and substantially increase funding for both domestic and international programs.

"AIDS advocates can't keep giving Obama a pass on his lack of movement in fighting the AIDS epidemic," said Charles King, president of Housing Works, a major service provider in New York City.

San Francisco AIDS officials also said they were less than impressed with Obama's budget for fighting HIV domestically.

The brightest spot in the president's budget was an end to the $99 million abstinence-only program and the creation of a new $110 million program to prevent teen pregnancy. But there was no inclusion of HIV prevention in the new program.

Joseph DiNorcia Jr., president of the Sexuality Information and Education Council of the United States, a leading sex education group, praised the decision to drop funding for abstinence-only programs but questioned the focus of the new program.

"Unfortunately, the exact language of the president's budget for this new initiative remains narrowly focused on the silo of preventing teen pregnancy and fails to embrace programs that also help young people avoid acquiring a sexually transmitted disease, including HIV," he said. "We need a broader approach to help adolescents make good, healthy, and responsible decisions."

CARE Act

The $2.2 billion Ryan White CARE Act will increase by $54 million, a paltry 2.2 percent over the current year. That is substantially less than the $72 million (3.3 percent) increase last year. The greatest portion of the new money, $20 million, will go to the AIDS Drug Assistance Program.

"The president is not proposing the necessary resources," said Carl Schmid with the AIDS Institute. "At a time when state and local budgets are being cut due to the economic downturn, coupled with increased caseloads and health costs, significant added resources are essential."

San Francisco AIDS Foundation CEO Mark Cloutier said he had expected to see the White House propose a bigger increase in Ryan White funding given the program's flat-funding under Bush and price inflation pressures.

"Due to the growing pool of people who are infected with HIV, I was expecting substantially more than what the administration put out," Cloutier told the Bay Area Reporter. "The metaphor I would use is it is like being in a big hole and they are throwing down a ladder that is not tall enough to get us out of the hole."

Dr. Grant Colfax, the city's HIV prevention director, noted that HIV providers at least are not grappling with a reduction in CARE funds. But he shared similar sentiments about the funding request not being large enough to meet the country's needs in treating and preventing HIV and AIDS.

"When you hear about the billions of dollars being put into other sectors, it certainly is a challenge. It would have been nice to see another, larger dollar amount," said Colfax.

While the president's request now must pass through Congress, Dana Van Gorder, executive director of Project Inform, predicted lawmakers would approve it "partly because it is not particularly ambitious."

"We are a little disappointed in not seeing more of an increase," he added.

As for San Francisco seeing an increase in Ryan White dollars, Van Gorder sounded pessimistic about such an outcome and warned the city could still face a decrease in its allocation and would likely need to rely on House Speaker Nancy Pelosi (D-San Francisco) to seek an earmark preserving the city's federal AIDS funding.

"It is not clear if there won't be cuts," he warned. "It certainly will not make the city whole."

Authorization for Ryan White is set to expire at the end of September and the president's budget would extend that. Revision of the safety net program is up in the air as Congress grapples with health reform legislation. Most experts believe it makes sense to hold off on changes to Ryan White until after the broader legislation is enacted.

Prevention

Prevention got a $53 million boost to $745 million. The bulk of the new money will go to increased testing to identify more of the estimated quarter-million Americans who do not know they are carrying the virus. Prevention outreach to communities of color also will increase.

Rebecca Haag, executive director of AIDS Action, called the increase "gratifying." But it does not begin to approach the $1.3 billion a year in prevention spending that Johns Hopkins University HIV prevention researcher David Holtgrave believes is necessary "to make a big difference in the epidemic in the U.S."

There was no increase for the Housing Opportunities for People with AIDS program. With more people learning they are infected with HIV, and a recession where more people are losing their job and often with it their health insurance and housing, that puts enormous additional pressure on the program, advocates said.

"We are looking at this as a decrease in funding," said Nancy Bernstine, executive director of the National Housing Coalition.

Needle exchange

The Obama budget maintains the prohibition on federal funding of syringe exchange programs. Those programs have proven to be successful at reducing the spread of HIV and other infectious diseases by reducing needle sharing, while at the same time not increasing injection drug use.

Once he left office, President Bill Clinton acknowledged that evidence and said his refusal to lift that ban on needle exchange was one of his major regrets.

Candidate Obama said he would lift that ban. The White House Web site once noted that campaign pledge but a recent update to the Web site removed it.

White House spokesman Ben LaBolt told the HuffingtonPost.com, "We have not removed the ban in our budget proposal because we want to work with Congress and the American public to build support for this change. ... We are committed to doing this as part of a national HIV/AIDS strategy."

Last month, White House AIDS director Jeff Crowley said it will take time to develop that strategy; to hire staff, and dialogue with other administration officials to get their buy in to the plan. He offered no timeline for those activities.

"We are disappointed that President Obama has not taken this opportunity to support syringe exchange programs, which have the potential to save thousands of lives and billions of taxpayer dollars," said Joseph Interrante, chairman of the AIDS Action board.

PEPFAR, the international AIDS effort, is scheduled for a $165 million increase to $6.6 billion in 2010. This is far short of the estimated $9 billion required to meet the expanded five-year goals of the program that Congress enacted last year.

"President Obama needs to explain why he is abandoning planned programs on AIDS, TB, and malaria that are desperately needed by millions around the world," said Kaytee Riek, speaking for the international advocacy group Health GAP. She said Obama was breaking his campaign promise to fully fund global AIDS programs.

Analysis

The anger toward the Obama administration expressed by many AIDS advocates, both domestically and internationally, has been growing ever since the president took office. Advocates muted criticism of earlier disappointments because they knew that what really counts is money. And now that hope has been dashed.

Earlier disappointments included elimination of new funding for HIV prevention and services from the economic stimulus package, and the roll out of a prevention campaign targeting African Americans that included no new money.

The appointment of Crowley to coordinate AIDS activities within the administration won broad praise within the community. But his explanation at a recent AIDSWatch forum as to why it is going to take time for the administration to create a national AIDS strategy drew some mutters of discontent.

Now that the administration is using the lack of such a plan, and no timetable for its delivery, as an excuse not to take action on things such as federal support for needle exchange programs, the level of discontent has intensified.

Disappointment on AIDS issues is interwoven with and reinforced by the Obama administration's failure to address other issues of concern to the gay community, such as marriage, the military, and senior level appointments.

Matthew S. Bajko contributed to this report.

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