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U.S. Federal Funding for HIV/AIDS: The President’s FY 2015 Budget Request

Introduction

President Obama’s Fiscal Year (FY) 2015 federal budget request, released on March 4, 2014, includes an estimated $30.4 billion for combined domestic and global HIV efforts.1  Domestic HIV is funded at $24.2 billion and global at $6.2 billion in the request.2  The FY 2015 request represents a 2.3% increase ($685 million) over FY 2014 levels, which totaled $29.7 billion.  Detailed data for FY 2009-FY 2015 are provided in Tables 1-2.

Federal funding for HIV has increased significantly over the course of the epidemic, including by $5.4 billion (or 22%) since FY 2009 (see Figure 1).  This growth has been driven primarily by increased spending on mandatory domestic care and treatment programs, as more people are living with HIV in the United States and new HIV infections remain at constant levels. Federal funding for HIV, however, represents just a small fraction (<1%) of the overall federal budget of the United States.

Figure 1: Figure 1: U.S. Federal Funding for HIV/AIDS, FY 2009-FY 2015

Figure 1: U.S. Federal Funding for HIV/AIDS, FY 2009-FY 2015

Budget Categories

The federal HIV budget is generally organized into five broad categories: care & treatment; cash & housing assistance; prevention; research; and global/international.  The first four categories are for domestic programs only.  More than half (57%) of the FY 2015 request is for care and treatment programs in the U.S.; 10% is for domestic cash/housing assistance; 3% is for domestic HIV prevention; 9% is for domestic HIV research; and 20% is for the global epidemic, including funding for international research (See Figure 2).  

Mandatory/Discretionary

Federal funding is either mandatory or discretionary.  Discretionary funding levels are determined by Congress each year through the appropriations process.  Mandatory spending, primarily for entitlement programs (such as Medicaid and Medicare), is determined by eligibility rules and cost of services for those who are eligible, and is not dependent on annual Congressional appropriations (e.g., if more people are eligible and/or the cost of services goes up, mandatory spending will also increase).  Mandatory spending accounts for $16.5 billion, or 54%, of the total budget request and includes: Medicaid, Medicare, Social Security Disability Insurance (SSDI), Supplemental Security Income (SSI), and the Federal Employees Health Benefits Plan (FEHB), programs which provide health coverage and cash assistance.

The remaining $13.9 billion (46%) of the federal HIV budget request in FY 2015 is discretionary, and is determined annually by Congress during the appropriations process.  Of this, $7.7 billion (25% of the overall HIV budget request and 55% of the discretionary component of the request) is for domestic programs – prevention research, housing, and non-mandatory care programs (e.g., the Ryan White HIV/AIDS Program).  The remainder of the discretionary budget, $6.2 billion (20% of the overall request and 45% of the discretionary component), is for the global epidemic.

Figure 2: Federal Funding for HIV/AIDS by Category, FY 2015 Budget Request

Figure 2: Federal Funding for HIV/AIDS by Category, FY 2015 Budget Request

The Domestic HIV Budget

In July 2010, the White House released the first comprehensive National HIV/AIDS Strategy (NHAS) to combat the domestic epidemic, with three main goals: to reduce new HIV infections, increase access to HIV care, and reduce HIV-related disparities.3 The FY 2015 budget request includes funding to achieve these goals.

Care

The largest component of the federal HIV budget is health care services and treatment for people living with HIV in the U.S., which totals $17.5 billion in the FY 2015 request (57% of the total and 72% of the domestic share).  This represents a 5.3% increase over FY 2014, due to increased mandatory spending for Medicaid and Medicare.  The Ryan White HIV/AIDS Program, the largest HIV-specific discretionary grant program in the U.S. and third largest source of funding for HIV care, is funded at $2.3 billion in the budget request, just slightly above FY 2014 levels (a $10 million or 0.4% increase).  Ryan White’s AIDS Drug Assistance Program (ADAP), which provides access to HIV-related medications to people with HIV, is funded at $900.3 million in the request, the same level as FY 2014.  Of the $10 million requested increase for the Ryan White budget, $4 million would accompany a proposed consolidation of the Part D Program (Women, Infants, Children and Youth), using the FY 2014 level of funding for Part D, into the Part C Program (Early Intervention Services).

Cash/Housing Assistance

$3.1 billion (10%) of the FY 2015 budget request for HIV is for cash and housing assistance in the U.S.  This includes mandatory spending estimates for SSI and SSDI, which provide cash assistance to disabled individuals with HIV.  Housing assistance, through the Housing Opportunities for Persons with AIDS Program (HOPWA), is discretionary and receives $332 million in the request, $2 million more than the FY 2014 level ($330 million).

Prevention

The smallest category of the federal HIV budget is domestic HIV prevention (3% of the overall budget and 4% of the domestic budget).  The FY 2015 request includes $929 million for domestic HIV prevention across multiple agencies, representing an $11.7 million (1.3%) increase over FY 2014.  Most prevention funding is provided to the CDC’s National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention (NCHHSTP), which receives $796.2 million, a 1.2% increase over FY 2014.

Research

$2.8 billion (9% of the overall request and 11% of the domestic budget) is for domestic HIV research across multiple agencies, similar to FY 2014 levels.  The National Institutes of Health (NIH), which carries out almost all HIV research,4 receives $2.6 billion for domestic HIV research activities (additional amounts used for international HIV research are attributed to the global category).

Minority HIV/AIDS Initiative

The budget request also includes funding for the federal Minority HIV/AIDS Initiative (MAI), created in 1998 to address the disproportionate impact of HIV/AIDS on racial and ethnic minorities in the U.S.  Funding for the MAI includes $57 million requested for the MAI specifically, as well as additional funding to be designated at other agencies within HHS.

Table 1: Federal Funding for HIV/AIDS by Category, FY 2009 – FY 2015 (US$ Billions)

CATEGORY

FY 2009 FY 2010 FY 2011 FY 2012 FY 2013 FY 2014 FY 2015*
Domestic $18.5 $19.6 $20.5 $21.4 $21.9 $23.2 $24.2

Care

$12.5 $13.2 $14.0 $14.8 $15.6 $16.6 $17.5

Cash/Housing

$2.5 $2.6 $2.7 $2.8 $2.9 $3.0 $3.1

Prevention

$0.9 $1.0 $0.9 $1.0 $0.9 $0.9 $0.9

Research

$2.7 $2.7 $2.8 $2.8 $2.7 $2.8 $2.8
Global $6.5 $6.6 $6.5 $6.4 $6.3 $6.5 $6.2
TOTAL $25.0 $26.2 $27.0 $27.8 $28.4 $29.7 $30.4
*FY 2015 is the President’s Budget Request

The Global HIV Budget

The U.S. government first provided funding to address the global HIV epidemic in 1986, and funding has increased significantly over time, particularly in the prior decade. However, it has slowed in recent years, with bilateral funding now flat and even on the decline.  All U.S. funding for global HIV is part of PEPFAR, the President’s Emergency Plan for AIDS Relief, first authorized in FY 2003 and reauthorized in FY 2008 and FY 2013.5 PEPFAR includes funding for both bilateral HIV efforts as well as contributions to multilateral organizations.

The FY 2015 budget for HIV requests $6.2 billion for the global epidemic, 5% less than FY 2014. Bilateral funding overall is slightly below FY 2014 levels. Multilateral support to the Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund) is down by $300 million.  An overview of the global HIV budget request follows:

Bilateral Funding

  • Most bilateral HIV funding is channeled to the State Department which receives $4.020 billion in the request, nearly $600 million below its peak level of funding in FY 2010.  Of this amount, $45 million is slated for UNAIDS (UNAIDS is a multilateral agency but the U.S. provides its support through bilateral funding).
  • USAID would receive $330 million, the same as FY 2014 levels.  This amount includes contributions to the International AIDS Vaccine Initiative (IAVI) ($28.7 million) and microbicide research ($45 million).
  • CDC would receive $128.7 million and NIH estimates that international HIV research would total $375.9 million, approximately the same levels as FY 2014.

Multilateral Funding

  • The request includes $1.35 billion for the Global Fund,6 an independent, public-private, multilateral institution which finances HIV, TB, and malaria programs in low and middle income countries; the U.S. is the Global Fund’s largest contributor.
  • As described above, the FY 2015 request is $300 million below FY 2014 levels.  This $300 million could be provided to the Global Fund through a new “Opportunity, Growth, and Security Initiative” proposed in the President’s budget, which is subject to Congressional approval.  Even if approved, U.S. contributions to the Global Fund are also contingent on the amount of support provided by other donors – as mandated by Congress, U.S. Global Fund contributions cannot exceed 33% of funding from all sources.
Table 2: Federal Funding for HIV/AIDS, FY 2009 – FY 2015a
Program/Account
(US$ Millions)
FY 2009 FY 2010 FY 2011 FY 2012 FY 2013 FY 2014 FY 2015
Request
Change
FY 2014-FY 2015
Domestic Programs & Research $ %
Ryan White Programb,c $2,238.4 $2,312.2 $2,336.7 $2,392.2 $2,248.6 $2,313.0 $2,322.8 $10.0 0.4%
ADAP (non-add)d $815.0 $857.0 $885.0 $933.3 $886.3 $900.3 $900.3 $0.0 0%
CDC Domestic Prevention (& Research)e $731.9 $799.3 $800.4 $822.6 $775.5 $786.7 $796.2 $9.0 1.2%
National Institutes of Health (domestic)f $2,567.6 $2,599.7 $2,683.5 $2,681.6 $2,527.4 $2,609.3 $2,629.1 $20.0 0.8%
SAMHSA $178.2 $178.4 $178.1 $177.4 $169.7 $180.8 $180.9 $0.0 0.1%
Department of Veterans Affairs (VA) $701.0 $783.0 $852.0 $956.0 $987.0 $1,047.0 $1,106.0 $59.0 5.6%
HOPWA $310.0 $335.0 $334.3 $332.0 $331.0 $330.0 $332.0 $2.0 0.6%
Minority HIV/AIDS Initiative (non-add) $395.5 $413.7 $419.9 $426.2 not available not available not available
Other domestic discretionaryg $299.7 $296.5 $316.9 $318.5 $306.3 $339.6 $331.6 ($8.0) -2.4%
Subtotal discretionary $7,026.8 $7,304.1 $7,502.0 $7,680.3 $7,356.4 $7,606.4 $7,698.6 $92.0 1.2%
Medicaid $4,400.0 $4,700.0 $5,100.0 $5,300.0 $5,600.0 $6,200.0 $6,600.0 $400.0 6.5%
Medicare $4,800.0 $5,100.0 $5,400.0 $5,800.0 $6,200.0 $6,600.0 $7,000.0 $400.0 6.1%
Social Security Disability Insurance (SSDI) $1,692.0 $1,763.0 $1,806.0 $1,894.0 $1,971.0 $2,031.4 $2,103.6 $72.0 3.6%
Supplemental Security Income (SSI) $485.0 $530.0 $590.0 $535.0 $590.0 $600.0 $620.0 $20.0 3.3%
Federal Employees Health Benefit (FEHB) $123.0 $143.0 $150.0 $161.0 $169.0 $175.4 $183.0 $8.0 4.6%
CDC PPHF $0.0 $30.4 $0.0 $0.0 $0.0 $0.0 $0.0 $0.0 0%
Subtotal mandatory $11,500.0 $12,266.4 $13,046.0 $13,690.0 $14,530.0 $15,606.8 $16,507.1 $900.0 5.8%
Subtotal Domestic $18,526.8 $19,570.5 $20,548.0 $21,370.3 $22,068.6 $23,213.2 $24,205.7 $992.5 4.3%
Global Programs & Research $ %
USAID (GHP account)h $350.0 $350.0 $349.3 $350.0 $333.0 $330.0 $330.0 $0.0 0%
State Department (GHP account)h $4,559.0 $4,609.0 $4,585.8 $4,242.9 $3,870.8 $4,020.0 $4,020.0 $0.0 0%
CDC Global AIDS Program (GAP) $118.9 $119.0 $118.7 $131.2 $124.3 $128.4 $128.7 $0.3 0%
Department of Defense (DoD) $8.0 $10.0 $10.0 $8.0 $8.0 $8.0 $0.0 ($8.0) -100%
NIH international HIV research $451.7 $485.6 $375.7 $392.5 $372.1 $375.8 $375.9 $0.0 0%
Subtotali $5,487.6 $5,573.6 $5,439.6 $5,124.5 $4,708.2 $4,862.2 $4,854.6 ($7.6) 0%
Global Fundj,k,l $1,000.0 $1,050.0 $1,045.8 $1,300.0 $1,569.0 $1,650.0 $1,350.0 ($300.0) -18%
Global Fund – State (non-add) $600.0 $750.0 $748.5 $1,300.0 $1,569.0 $1,650.0 $1,350.0 ($300.0) -18%
Global Fund – USAID (non-add) $100.0 $0.0 $0.0 $0.0 $0.0 $0.0 $0.0 $0.0 0%
Global Fund – NIH (non-add) $300.0 $300.0 $297.3 $0.0 $0.0 $0.0 $0.0 $0.0 0%
Subtotal Global $6,487.6 $6,623.6 $6,485.4 $6,424.5 $6,277.2 $6,512.2 $6,204.6 ($307.6) -5%
TOTAL $25,014.3 $26,194.1 $27,033.3 $27,794.8 $28,363.2 $29,725.5 $30,410.3 $684.8 2.3%
NOTES: (a) Data are rounded and adjusted to reflect across-the-board rescissions to discretionary programs as required by appropriations bills in some years and some data are still considered preliminary. FY 2015 represents the President’s budget request only and not final, enacted amounts. FY 2013 funding includes across the board rescissions, as well as mandated sequestration as part of the Budget Control Act (BCA) of 2011, to be applied equally at the program, project, and activity level within each budget account (for most but not all accounts). (b) Ryan White totals include $25 million for Special Projects of National Significance (SPNS) in each fiscal year. (c) In FY 2012, the president announced the availability of an additional $15 million for Ryan White Part C grantees, $10 million of which was to be provided from other HHS activities via the HHS Secretary’s transfer authority, and is counted in the Ryan White total for FY 2012 above, and $5 million of which was provided from the federal health center program budget and is counted in “other domestic discretionary” funding. (d) ADAP funding in FY 2010 includes $25 million in emergency funds provided as new, competitive grant funding to address ADAP waiting lists and cost containment measures.  In FY 2011, the ADAP total of $885 million includes $40 million to address ADAP waiting lists and cost containment measures, of which $25 million was provided to those states that had received emergency funding in 2010 and $15 million was provided as new, competitive grant funding. In FY 2012, the ADAP total of $933.3 includes $75 million to address ADAP waiting lists and cost containment measures, of which $40 million was provided to those states that had received emergency funding in 2011 and $35 million was provided as new, competitive grant funding.  The FY 2013 CR did not include the $35 million in new funding that was provided in FY 2012. (e) FY 2012-FY 2015 funding levels at CDC include redistributed Business Services Support (BSS) funding to each CDC programmatic budget line and are therefore not directly comparable to prior year levels. (f) The NIH does not define HIV research as “domestic” given its broad application. However, for purposes of this analysis, all HIV research funding not designated as “global” was considered to be domestic research. (g) “Other domestic funding” includes amounts at: HHS Office of the Secretary; Health Resources and Services Administration; Food and Drug Administration; Indian Health Service; Agency for Healthcare Research and Quality; and the Departments of Defense, Justice, and Labor. (h) GHP is the “Global Health Programs” account, formerly named the Global Health and Child Survival Account (GHCS). (i) Includes funding for UNAIDS; the International AIDS Vaccine Initiative; and Microbicides. (j) Global Fund grants support country projects to fight HIV, tuberculosis, and malaria. Figures used here are not adjusted to represent an estimated “HIV share”. (k) FY 2012 funding for the Global Fund includes $250 million above final FY 2012 appropriations levels, which was transferred from HIV bilateral funding at the State Department to the Global Fund. (l) The FY15 Budget Request includes an additional $300 million in potential funding for the Global Fund that would be made available through the new “Opportunity, Growth, and Security Initiative” (if approved by Congress), but is dependent on additional pledges from other donors.
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SOURCES: Kaiser Family Foundation analysis of data from: FY 2009-FY 2015 Budgets of the United States and Congressional Budget Justifications; Congressional Appropriations Bills and Conference Reports; Agency operational plans; White House; White House Office of Management and Budget; personal communication, May 2014.

Endnotes
  1. Unless otherwise noted, all data sources are listed below Table 2.

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  2. It is difficult to disaggregate federal funding for HIV into discrete domestic and global categories, since some agencies do not report activities along these lines and certain activities may have application in both arenas.

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  3. White House, National HIV/AIDS Strategy; July 2010.

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  4. The NIH does not define HIV research as “domestic” given its broad application. However, for purposes of this analysis, all HIV research funding not designated as “global” is categorized as domestic.

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  5. P.L. 108-25, May 27, 2003; P.L. 110-293, July 30, 2008; P.L. 113-56, December 2, 2013.

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  6. Global Fund grants support country projects to fight HIV, tuberculosis, and malaria. Figures used here are not adjusted to represent an estimated “HIV share”. 

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