Fixing HIV spending: leading AIDS advocates agree that a doubling of federal funding could make a dramatic difference in the fight against the disease, though they diverge when asked how they would allocate the additional money.

There is strong consensus among AIDS experts and advocates that Washington isn't allocating nearly enough money to fight the 25-year-old AIDS epidemic in the United States, and that budgetary shortfall makes agreeing on priorities a near impossible challenge when the war against HIV must be fought on so many fronts. Even given ample resources, many experts differ on how additional funds should be spent.

"This is essentially what we've seen since the 1980s. People on one side say what we desperately need is money for care and treatment, and people on the other say we need money to stop the epidemic," says Phil Curtis, director of government affairs at AIDS Project Los Angeles. "The argument has never been resolved, and with inadequate funding, too often we see each side playing off each other."

The Bush administration has proposed spending about $19 billion on prevention, treatment, support, and research programs in fiscal 2007, roughly $5 billion less than what many advocates say is the absolute minimum needed. And the result of that gap, they say, is a competition for limited federal dollars that sometimes pits programs against each other with potentially disastrous results. "What we've seen in this country is that we're barely holding the epidemic at bay," Curtis says.

Where the clash begins

When editors at The Advocate asked several AIDS experts what they would do with $40 billion--about double the funds proposed by the Bush administration--all of them said they would increase spending across the board to levels at or higher than recommended by the AIDS Budget and Appropriations Coalition, a national bloc of policy and advocacy workers. And all also agreed on eliminating spending for abstinence-only education programs, for which Bush is seeking $204 million in fiscal 2007.

When it came to the question of how best to deploy additional funds, differences emerged. Many experts would prioritize public treatment and assistance programs for the estimated 1.1 million HIV-positive Americans, particularly given that the disease is hitting low-income groups disproportionately hard. Others say that the only way to lower the number of new HIV infections occurring annually--currently holding steady at about 40,000--is to dramatically increase spending on prevention programs. And some believe scientific research into finding a preventive vaccine or cure should take funding precedence.

Treatment is key

Damon Dozier, director of government relations and public policy at the Washington, D.C.-based National Minority AIDS Council, would allocate large chunks of his imaginary $40 billion HIV budget to prevention and research programs, but medical treatment and support programs through the Ryan White Act, Medicaid, and Medicare would get slightly more than half of his total funds.

"Ryan White is the nation's safety net, but what we've found is a lot of people are falling through that net," Dozier notes. Advocates say that even more will likely slip through under proposed funding formulas shifting money away from urban centers and mandating that 75% of all grants go to "core medical services," effectively cutting funding for scores of support programs.

"These changes would be devastating," warns Ronald Johnson, associate executive director for public policy at New York City's Gay Men's Health Crisis. "We cannot simply shift funds. We need more money to cover all communities, and we need to fully fund all needed services."

That's precisely what prompted Dozier to devote $6 billion of his budget to Ryan White programs, with $1 billion of that earmarked for the AIDS Drug Assistance Program, which provides free antiretrovirals to uninsured and underinsured HIV patients. "Much of that is simply to ensure that support programs--everything from counseling and case management to transportation services and emergency financial assistance--get the money they need," he explains.

But shouldn't we find a cure?

Gene Copello, MD, executive director of the AIDS Institute, a Washington, D.C.-based advocacy organization, also would significantly boost Ryan White funding if given $40 billion to spend, and he'd double allocations to the National Institutes of Health for HIV-related research, currently funded at slightly less than $3 billion annually. "We have to find a cure," he insists. "The treatment piece is important, and prevention is important, but we really need to cure this disease. The only way to do that is to invest money in research."

Craig E. Thompson, APLA executive director, agrees that finding a cure is a funding priority. He'd earmark billions to establish a "Manhattan Project to Find a Cure," named after and based on the United States' successful program to develop atomic weapons in the 1940s. Thompson envisions a project headquartered in a government division but coordinated by a consortium of university scientists. "With $40 billion, the United States could do it, and given the scale of the global epidemic this would be the way to go," Thompson argues.

The prevention crisis

Others, like Copello, also would prioritize prevention programs, which saw federal funding cuts in fiscal 2005 and 2006. "The CDC's own five-year plan was to cut the number of new HIV infections in half by 2005, from about 40,000 a year to 20,000 a year," he explains. "That didn't happen." In fact, he says, the numbers barely budged. "It's pretty obvious that having cuts in prevention spending, fewer programs, and fewer prevention workers are a big reason for that," he says.

Curtis goes even further, calling for billions to be devoted to a national HIV prevention campaign that includes TV and radio spots, billboards, Web sites, classroom instruction, printed materials, and numerous other outreach efforts. "You have to go back to the 'Understanding AIDS' fact sheet that [then] U.S. surgeon general [C. Everett] Koop sent to every household in 1988 to come to anything even approaching a national campaign, and that was nearly 20 years ago," Curtis says.

And prevention efforts need to once again target gay and bisexual men, advocates say. This administration's clear disdain for gay-related programming has resulted in what some call intimidation tactics against AIDS service groups, including threats of increased government scrutiny and the loss of some funding. Many organizations during the past five years chose to tone down or scale back their prevention outreach for gay men, just at a time when infection rates among gay and bisexual men--particularly young men--began to climb again after posting declines in the 1990s.

New prevention initiatives for often ignored populations are also needed, Dozier adds. From his hypothetical AIDS budget he's earmarked $3 billion each for two new interventions--one to initiate federal support for needle-exchange programs for injection-drug users, and another focusing on prisoners, many of whom become infected in prison and then transmit HIV once released. "Sex happens in prison; we know this," Dozier says. "We also know that condom distribution is prohibited in almost all prisons. As a result, people are seroconverting."

While coming up with the money for these interventions will be daunting, failing to fund them will cause even greater long-term economic harm, researchers say. A 2003 analysis in the Journal of Acquired Immune Deficiency Syndromes calculated that more than $18 billion in medical costs could have been saved by the year 2010 had the CDC invested just $383 million more in prevention programming per year from 2000 to 2005, an amount that theoretically could have cut the annual HIV infection rate in half. Even if prevention spending had risen to $1.8 billion annually during that time frame in order to achieve the CDC's stated goal of reducing annual new infections by 50%, there would still have been a long-term cost savings, the researchers say.

Our view

It's hard to argue with that kind of data. And so when given the same hypothetical $40 billion federal HIV/AIDS budget offered to our panel of experts, we editors at The Advocate chose to make prevention spending our funding priority. (See accompanying budget recommendations.) Not to say that treatment and research should get short shrift. We'd nearly double Ryan White spending to $4 billion--including $1 billion for ADAP--and dramatically expand NIH research binding from the $2.888 billion proposed by President Bush to $10 billion. We'd also fund virtually all other budget categories at or above the levels recommended by the community-based AIDS Budget and Appropriations Coalition.

We strongly believe that with 40,000 Americans contracting HIV every year, the number of people living with HIV in this country having surged past the 1 million mark, and infection rates rising among gays, stopping the spread of this preventable disease should be priority number 1.