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Federal HIV/AIDS Funding Formulas Examined

collage of photos from the meeting

Last week, we convened the first in a series of ongoing discussions about the policies, formulas, and other factors that determine how Federal HIV/AIDS resources are allocated across the United States to departments of health, community-based organizations, and other grantees providing HIV/AIDS services. Participating in the discussion were personnel from the Department of Health and Human Services (HHS), Department of Housing and Urban Development (HUD) and the White House’s Office of National AIDS Policy (ONAP), the Office of Management and Budget (OMB), and the Presidential Advisory Council on HIV/AIDS (PACHA). More than 20 HIV community stakeholders representing States, cities, service providers, policy advocates, academia and other perspectives joined in the discussion and offered valuable input. (View a full list of participants [115 KB].)

In pursuit of the National HIV/AIDS Strategy’s goal of reducing new HIV infections, we must intensify HIV prevention efforts in communities where HIV is most heavily concentrated. This requires that governments at all levels – Federal, State, local and tribal – ensure that HIV/AIDS funding is allocated consistent with the latest epidemiological data and is targeted to the highest prevalence populations and communities. Toward this end, the NHAS Federal Implementation Plan tasked HHS with the responsibility of initiating consultations with the Centers for Disease Control and Prevention (CDC), Health Resources and Services Administration (HRSA), Substance Abuse and Mental Health Services Administration (SAMHSA), HUD, and other departments or agencies as appropriate to develop policy recommendations for revising funding formulas and policy guidance in order to ensure that Federal HIV allocations go to the jurisdictions with the greatest need.

In this initial discussion we set out to establish a clear understanding of what policies and formulas are used when resources for HIV/AIDS prevention, care or housing support are allocated to jurisdictions and providers by CDC, HRSA, SAMHSA and HUD’s Housing Opportunities for Persons with AIDS (HOPWA) program. As a result of the thorough presentations by key officials from each agency, we established that a variety of approaches govern these actions. Some are Congressionally mandated and others are based on historical precedent. Also, it is worth noting that the Federal organizations who presented at this meeting represent programs with distinct purposes, that they often have different accountability measures, and that they distribute funds to a variety of entities (State agencies, local health departments, and non-governmental organizations including community-based and faith-based organizations).

During the thoughtful discussion that followed the presentations, we considered a range of issues including:

  • Some merits as well as potential drawbacks to required minimum funding levels and “hold harmless” provisions that limit the size of any reductions in HIV/AIDS funding levels from year to year.
  • Questions of how well the State or local level targeting of HIV/AIDS funds follows the epidemic and methods to enhance measuring and monitoring of this.
  • The need for and benefits of better coordination of both formula-based and competitively awarded programs at the local and State levels to leverage resources, prevent duplication and avoid gaps.
  • The “prevention paradox” – that under some formula models jurisdictions that are effective at reducing new infections through effective prevention efforts could ultimately receive reduced funding to sustain those efforts if funding is based primarily on new HIV/AIDS cases.
  • The epidemiologic and economic consequences of achieving the NHAS goals, examining models for the potential lives and resources saved as well as funds needed.
  • Various perspectives on the characteristics and circumstances of jurisdictions or types of activities that are perceived to be under- or over-funded.
  • Sources of data on which formulas are based and weights or other factors that are or could be considered when calculating formulas.
  • Possible approaches to making better use of existing resources to achieve the Strategy’s goals should new resources be limited or unavailable.
  • Whether or how cost-effectiveness of various interventions should be considered in decisions about resource allocations.
  • How the “12 Cities Project” could be a laboratory for optimization of resources and interventions tailored to local epidemiology, needs and infrastructure.
  • And, of course, challenges and possible consequences (intended and otherwise!) inherent in changing any formulas.

If anyone arrived thinking there were simple solutions, they clearly departed the meeting understanding that there are many unknowns, tensions and complexities inherent in this issue. No specific recommendations were developed as a result of this meeting but the issues raised provide an excellent platform upon which to build future discussions with other sectors, advocates, and community representatives.

What are your thoughts about what should be considered when establishing policies and funding formulas for Federal HIV prevention, care, treatment and housing support programs? Share your thoughts in the comments section below.

Through continued assessment and dialogue, we hope to address any instances where Federal formulas result in resources not following the epidemic as closely as they should. At the same time, for those funds that are following the epidemic, we must ensure that they are ultimately reaching the right people with the right interventions at the right scale. An important responsibility for HHS in the next year is to work with colleagues inside and outside of government to consider any needed changes to funding policies and funding formulas so as to ensure that public funding matches the U.S. epidemic.

Comments

  1. darrell lewis says:

    The extent of under served and unserved in Iowa is far worse than official then waiting lists suggests because large numbers of people have simply given up getting help in iowa. The current formulas clearly are not providing the financial resources so that iowa can provide anything even comprable to the level and quality of services in most states.

  2. The formulas that have been used in the past have fallen far short of addressing the needs of all communities. You can not simply look at the number of cases to determine need as large urban centers will always have higher numbers. In CA the amount of money provided to San Francisco and Los Angeles is far greater than it should be. The number of agencies in these areas that receive federal funding, private funding and individual donor funding far exceeds the amount provided the other counties and community based organizations in the state combined. The need and impact of these funds must be spread evenly to address the needs of all communities. It is unfair to expect people who live in medium sized counties to subsidize those who live in large urban areas. Capacity needs to be increased across the board to effectively address the issue of HIV. The council unfortunately was made up of people from large urban areas. Federal representatives must do a better job at reaching out to communities that have been historically under funded and under represented. All input should not come from people who live in San Francisco, New York, Washington D.C., or other large urban centers. The people in these areas refuse to give up any monies that could be used to help communities that are not represented at the table when these decisions are made. CDC, SAMSHA and other federal agencies must increase the representation at the table of all communities of all sizes.

  3. We need HIV/AIDS education. It’s very important!! CDC has granted CSU $1.9M for HIV/AIDS education. The number of members on the largest HIV dating&support site == pozspaces.com (if I spell the site correctly) has reached 500,000 members

  4. Erise Williams, Jr., MPH says:

    As a community based agency providing both HIV/AIDS prevention and care services, we know to well the lack of transparency that is involved in funding decesions from serveral HHS Offices, many offices, such as CDC fail to even follow their own criteria as outlined in RFPs. I’m glad to see that meetings are taking place to look at the funding process; currently many communities that reflect the need as outlined in the National Strategic Plan are left with the challenge of identifying resources to meet the need.

  5. As the executive director of a CBO in Oklahoma and grantee of HOPWA, CTR, Ryan White Part B funding more than 19 years – RAIN Oklahoma is currently facing a decrease of 15% in our CTR funding from the OK State Dept of Health.
    Is the funding being decreased due to a lack of CDC funding, or failure to offer services? No.
    This action is referred to as “The Prevention Paradox”
    This slash in funding is a direct result of RAIN Oklahoma offering successful prevention education and outreach programs. In other words, people are remaining NEGATIVE in high risk situations.
    It is impossible to continue to provide this service with a funding decrease. Our positivity rate is 0.96% our target was 1%. Yes, this life saving education may be gone for lack of 0.04%!
    How can this action be beneficial to our community, state, and country? RAIN is not the only organization facing this crippling decrease in funding. What will be the result? What will happen without a complete prevention education program?
    I have an answer – I’m sure the 1% (newly diagnosed) positivity rate will be much easier to reach in the future.
    Julie Lovegrove
    Executive Director
    RAIN Oklahoma

  6. Julie Hope says:

    As a rural HIV/AIDS service provider in the Deep South (Alabama)we are begging for the support of all advocates to hear our plea for equitable funding that follows the epidemic of HIV cases not just cumulative AIDS numbers that includes those who are deceased. In the South we are facing a “newer” epidemic with high incidence of HIV infection and the funding is not here! For our AIDS Service Organization and medical clinic in N.E. Alabama, our rural service area of over 9,000 square miles is overwhelming and our clients are not receiving the same level of services provided in other areas of the country, and that is wrong! Please speak out for funding formulas that are uniform and equitable for all, those persons living with HIV in Alabama deserve the same level of service and funding as those in other states.

  7. Marilyn Swyers says:

    As an Executive Director of an AIDS Service Organization in east central Alabama that serves five counties covering over 3000 square miles, we are struggling to get our patients into care in a timely manner. We currently have a waiting list for new clients to receive medical care with a wait time of 16 weeks. I appeal to you to really take a hard look at the south! We need help and no one seems to care! Please rethink the funding distribution formulary. It needs to follow the epidemic based on new HIV cases not people who have already die.

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