HIV Budget Cuts Show Why U.S. Health Care Is Broken

The CDC is redirecting funds to states with high infection rates—and eliminating programs that actually promote health

Want to know why businesses, states, and municipalities are collapsing under the weight of double-digit health care premium increases?

Look no further than the cuts to HIV funding announced yesterday in Massachusetts: one quarter of the state's HIV/AIDS prevention budget ($4.3 million) has been eliminated. What this means is that outreach to gay and bisexual men, black and Latino men and women, and intravenous drug users--the populations most vulnerable to infection--will be cut entirely or dramatically slashed.

These cuts are being driven by two things: steep reductions in federal spending on HIV/AIDS mandated by the budget deal, and new restrictions stipulating that federal prevention dollars must be directed to clinical settings that emphasize HIV testing and prevention in clinical settings rather than in the community.

Our experience at AIDS Action Committee of Massachusetts shows that it is easier and cheaper to do prevention and sexual health counseling with those living with HIV in comfortable community settings, led by peers with whom they identify. Our experience also shows that we cannot ignore people who are HIV-negative--and we are much more likely to reach those people with prevention messaging in community settings rather than clinical ones. We prioritize people at high risk by providing services they need in order to change behaviors and stay negative: clean needles, referrals to housing and substance abuse programs, financial assistance so people will not have to sell sex on the streets. These programs prevent new infections.

Eliminating these counseling and treatment programs seems like a nonsensical strategy, given the large (and frighteningly increasing) number of people affected by HIV in the minority community and the low number of those people now represented in the health care system--not to mention the time pressures under which doctors and nurses must already work. When was the last time your primary care doctor had time to discuss your sexual behavior? Or even asked you about it?

The CDC claims that given its limited resources, it must redirect funds to states with the highest concentration of HIV infections. But if the goal is to save billions of dollars in health care expenditures, then we should be investing in programs that keep people healthy. In Massachusetts, the state's long-term investment in finding ways to reduce the transmission of HIV resulted in a 60 percent drop in new diagnoses from 1998 to 2008. All of which will save the state more than $1.6 billion in health care costs.

In 2008 and 2009, I worked closely with a coalition of AIDS service organizations to help the Obama administration develop its National HIV/AIDS Strategy. That strategy, which marked the first time that any presidential administration had created a national plan to end the domestic AIDS epidemic, called for accountability and measurable outcomes. That's exactly what Massachusetts has been delivering. Our funding strategies demand results: a reduction in new infections, which saves health care costs and lets us direct scarce dollars to care for those who are already HIV-positive.

The Atlanta-based policy advisors for the CDC should spend some time in Massachusetts learning from our success, so they can replicate it in states where the transmission of HIV has stubbornly risen year after year, and where health outcomes for those with HIV/AIDS is poor. They would find that we do three things extremely well:

• Provide early access to health care. Fifteen years ago, Massachusetts provided health-care eligibility to low-income people living with HIV, which meant they had access to the care and treatment needed to manage their disease and reduce the long-term effects of the infection. Most states still provide access to care and treatment under their Medicaid plans only to those with full-blown AIDS. So even if the states test people at risk, they can't treat them until they become very sick--which costs taxpayers millions of dollars in unnecessary health care costs. Six years ago, Massachusetts adopted health care reform and covered lower-income citizens through MassHealth. Others are covered under private insurance plans. Being in treatment and taking medications ensures low viral loads and significantly reduces the chances of passing on the infection to sexual partners.

• Create community-based social support networks. In Massachusetts, health care for HIV and AIDS has been tightly integrated into the state's network of community-based social service providers, who provide housing assistance, mental health counseling, nutritional support, substance abuse counseling, and peer support programs to those at risk for or infected with HIV--all of which help keep people on their medication regime and in control of their chronic disease.

• Enact robust behavioral prevention programs. Access to sterile syringe needles has dramatically cut the transmission of HIV among intravenous drug users. Fifteen years ago, the state approved needle exchange programs, which now exist in Boston, Cambridge, Northampton, and Provincetown. Since 2006, intravenous drug users have been able to buy needles at pharmacies without a prescription. We have also started excellent outreach programs with gay men, women of color, intravenous drug users, the homeless, and others at high risk of infection.

Every one of these crucial, money-saving services will be decimated by the new CDC decision.

This isn't only about saving money. This is about saving lives. The 60-percent drop in HIV diagnoses from 1998 to 2008 represents 4,085 people who are HIV-negative today who might otherwise not be. The federal government is reducing funding to the very programs that have proven successful and at the same time mandating that we approach HIV prevention and treatment just like all other states--none of which has seen our success. It's a short-sighted strategy that will result in an increase in the numbers of people who become HIV-positive.

Those of us who have made previously unimaginable progress to slow the spread of HIV have much to share with those looking to make similar interventions in the fight against type-2 diabetes, hypertension, and cardiovascular disease--which are collectively bankrupting our health care system. Too bad the CDC sees things another way.

Image: Yiorgos Karahalis/Reuters