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U.S. Federal Funding for HIV/AIDS: Trends Over Time

Introduction

President Obama’s Fiscal Year (FY) 2017 federal budget request, released on February 9, 2016, includes an estimated $34.0 billion for combined domestic and global HIV efforts.1  Domestic HIV is funded at $27.5 billion and global at $6.6 billion in the request.2  The FY 2017 request represents a 3.1% increase ($1.0 billion) over the FY 2016 enacted level, which totaled $33.0 billion.  Detailed data for FY 2011-FY 2017 are provided in Tables 1-2.

Federal funding for HIV has increased significantly over the course of the epidemic, including by $5.7 billion (or 20%) when comparing the FY17 request, which still needs Congressional approval, to the FY 2011 enacted funding level.  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.

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 (61%) of the FY 2017 request is for care and treatment programs in the U.S.; 9% is for domestic cash/housing assistance; 3% is for domestic HIV prevention; 8% is for domestic HIV research; and 19% is for the global epidemic, including funding for international research.

Figure 1: U.S. Federal Funding for HIV/AIDS, by Category, FY 2017 Request

Figure 1: U.S. Federal Funding for HIV/AIDS, by Category, FY 2017 Request

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 for HIV accounts for $19.7 billion, or 58%, of the total budget request and includes estimated spending levels for: 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. When comparing the FY 2017 budget request to the FY 2011 enacted level, mandatory spending has accounted for 94% of the growth in total federal funding for HIV.

The remaining $14.3 billion (42%) of the federal HIV budget request for FY 2017 is discretionary, and is determined annually by Congress during the appropriations process.  Of this, $7.8 billion (23% of the overall HIV budget request and 54% 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, $6.6 billion (19% of the overall request and 46% of the discretionary component), is for the global epidemic.

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, which a 2015 update to The Strategy reaffirmed.3,4 The FY 2017 budget request includes funding to support 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 $20.8 billion in the FY 2017 request (61% of the total and76% of the domestic share).  This represents a 5.2% increase over the FY 2016 enacted level, and is largely due to increased mandatory spending for Medicaid and Medicare.5 Medicare is the largest federal funder of HIV care and treatment, followed by Medicaid. The Ryan White HIV/AIDS Program, the largest HIV-specific discretionary grant program in the U.S. and third largest source of federal funding for HIV care (behind Medicaid and Medicare), is funded at $2.3 billion in the budget request (a $9 million or 0.4% increase over the FY 2016 enacted level).  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, at the same level as the FY 2016 enacted level.  The $9 million increase for the Ryan White Program was all attributed to a proposed funding increase for the Special Projects of National Significance (SPNS) Program to support Hepatitis C treatment for people with HIV. In addition, and as was proposed but not finalized in the previous two Presidential  budgets, a proposal consolidates the Ryan White Part D Program (Women, Infants, Children and Youth) with Part C (Early Intervention Services)of The Program, zeroing out funding for Part D and moving it into Part C.

Cash/Housing Assistance

$3.1 billion of the FY 2017 budget request for HIV is for cash and housing assistance in the U.S. (9% of the overall budget and 11.2% of the domestic budget), an increase of $32 million (1.1%) over the FY 2016 enacted level.  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 $335 million in the request, which is the same as the FY 2016 enacted level.

Prevention

The smallest category of the federal HIV budget is domestic HIV prevention totaling $919 million in the budget request (about 3% of the overall budgets).  The FY 2017 prevention request includes funding for domestic HIV prevention across multiple agencies, representing a $2.9 million (0.3%) decrease over the FY 2016 enacted level.  Most prevention funding is provided to the CDC’s National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention (NCHHSTP), which receives $789 million in the FY 2017 request, which is the same amount as the FY 2016 enacted level.

Research

$2.7 billion (8% of the overall request and 10% of the domestic budget) in the FY 2017 request is for domestic HIV research across multiple agencies, a decrease of $15.5 million (0.6%) below the FY 2016 enacted level.  The National Institutes of Health (NIH), which carries out almost all HIV research6, receives $2.6 billion in the FY 2017 request 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 $54 million requested for the Minority AIDS Initiative (MAI) through the Office of the Secretary MAI Fund, as well as additional funding to be designated at other agencies within HHS.

Table 1: Federal Funding for HIV/AIDS by Category, FY 2011 – FY 2017 Request (US$ Billions)
Category FY 2011 FY 2012 FY 2013a FY 2014 FY 2015 FY 2016
FY 2017
Request
Domestic $21.8 $22.0 $22.5 $23.9 $25.5 $26.4 $27.5
   Care $15.3 $15.5 $16.1 $17.4 $18.9 $19.7 $20.8
   Cash/Housing $2.7 $2.8 $2.9 $3.0 $3.0 $3.0 $3.1
   Prevention $0.9 $1.0 $0.9 $0.9 $0.9 $0.9 $0.9
   Research $2.8 $2.8 $2.7 $2.7 $2.7 $2.7 $2.7
Global $6.5 $6.4 $6.3 $6.6 $6.6 $6.6 $6.6
TOTAL $28.3 $28.5 $28.8 $30.5 $32.1 $33.0 $34.0
NOTES: (a) indicates FY 2013 includes the effects of sequestration.

The Global HIV Budget

The U.S. government first provided funding to address the global HIV epidemic in 1986. Total funding (bilateral and multilateral) has increased significantly over time, particularly in the prior decade. However, since 2010 it has remained essentially flat. 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 2013.7 PEPFAR includes funding for both bilateral HIV efforts as well as contributions to multilateral organizations.

The FY 2017 budget request for HIV includes $6.6 billion for the global epidemic – $5.2 billion for bilateral programs and $1.35 billion for the U.S. contribution to the Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund). If approved by Congress would be essentially flat compared to the FY 2016 enacted level.

Bilateral Funding

  • Most bilateral HIV funding is channeled to the State Department which receives $4.32 billion in the request and is flat compared to the FY 2016 enacted level, but is nearly $300 million below its peak level of funding in FY 2010. Of this amount, $45 million is 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 the FY 2016 enacted level. This amount includes contributions to the International AIDS Vaccine Initiative (IAVI) ($28.7 million) and microbicide research ($45 million).
  •  HIV funding through the CDC is $128.4 million in the request, while funding for international HIV research activities at NIH is $431.9 million, both of which essentially match the FY 2016 enacted level.

Multilateral Funding

  • The request includes $1.35 billion for the Global Fund,8 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.
  • The FY 2017 request for the Global Fund matches the FY 2016 enacted level ($1.35 billion).
Table 2: Federal Funding for HIV/AIDS, FY 2011 – FY 2017a
Program/Account
(US$ Millions)
FY 2011 FY 2012 FY 2013 FY 2014 FY 2015 FY 2016 FY 2017
Request
Change
FY 2016-FY 2017
Domestic Programs & Research $ %
Ryan White Programb,c $2,336.7 $2,392.2 $2,248.6 $2,313.0 $2,318.8 $2,322.8 $2,331.8 $9.0 0.4%
     ADAP (non-add)d $885.0 $933.3 $886.3 $900.3 $900.3 $900.3 $900.3 $0.0 0%
CDC Domestic Prevention (& Research)e $800.4 $822.6 $768.6 $786.7 $786.7 $788.7 $788.7 $0.0 0%
National Institutes of Health (domestic)f $2,683.5 $2,681.6 $2,508.7 $2,524.0 $2,566.2 $2,569.0 $2,568.1 ($0.9) 0%
SAMHSA $178.1 $177.4 $173.1 $180.3 $180.5 $181.8 $197.9 $16.1 8.9%
Department of Veterans Affairs (VA) $852.0 $956.0 $987.0 $1,047.0 $1,093.0 $1,117.0 $1,174.0 $57.0 5.1%
HOPWA $334.3 $332.0 $315.0 $330.0 $330.0 $335.0 $335.0 $0.0 0%
Other domestic discretionaryg $316.9 $318.5 $355.4 $373.6 $381.6 $392.9 $381.8 ($11.1) -2.8%
Subtotal Discretionary $7,501.9 $7,680.3 $7,356.4 $7,554.6 $7,656.8 $7,707.2 $7,777.3 $70.1 0.9%
Medicaid $4,370.0 $3,960.0 $4,190.0 $4,780.0 $5,570.0 $5,860.0 $6,060.0 $200.0 3.4%
Medicare $7,420.0 $7,810.0 $8,260.0 $8,780.0 $9,420.0 $9,950.0 $10,680.0 $730.0 7.3%
Social Security Disability Insurance (SSDI) $1,806.0 $1,893.0 $1,963.2 $2,031.4 $2,083.0 $2,070.0 $2,127.0 $57.0 2.8%
Supplemental Security Income (SSI) $590.0 $525.0 $580.0 $600.0 $605.0 $635.0 $610.0 ($25.0) -3.9%
Federal Employees Health Benefit (FEHB) $150.0 $161.0 $169.0 $175.0 $183.0 $200.0 $211.0 $11.0 5.5%
Subtotal Mandatory $14,336.0 $14,349.0 $15,162.2 $16,366.4 $17,861.0 $18,715.0 $19,688.0 $973.0 5.2%
Total Domestic $21,837.9 $22,029.3 $22,518.6 $23,921.0 $25,517.8 $26,422.2 $27,465.3 $1,043.1 3.9%
Global Programs & Research $ %
USAID (GHP account)h $349.3 $350.0 $333.0 $330.0 $330.0 $330.0 $330.0 $0.0 0%
State Department (GHP account)h $4,585.8 $4,242.9 $3,870.8 $4,020.0 $4,320.0 $4,320.0 $4,320.0 $0.0 0%
CDC Global AIDS Program (GAP) $118.7 $131.2 $125.3 $128.4 $128.4 $128.4 $128.4 $0.0 0%
Department of Defense (DoD) $10.0 $8.0 $7.4 $8.0 $8.0 $8.0 $0.0 ($8.0) -100%
NIH international HIV research $375.7 $392.5 $389.2 $453.6 $433.8 $431.1 $431.9 ($1.9) 0%
Subtotal $5,439.6 $5,124.5 $4,725.6 $4,940.0 $5,220.2 $5,217.5 $5,210.3 ($9.9) 0%
Global Fundj,k,l $1,045.8 $1,300.0 $1,569.0 $1,650.0 $1,350.0 $1,350.0 $1,350.0 $0.0 0%
     Global Fund – State $748.5 $1,300.0 $1,569.0 $1,650.0 $1,350.0 $1,350.0 $1,350.0 $0.0 0%
     Global Fund – NIH $297.3 $0.0 $0.0 $0.0 $0.0 $0.0 $0.0 $0.0
Total Global $6,485.4 $6,424.5 $6,294.6 $6,590.0 $6,570.2 $6,567.5 $6,560.3 ($9.9) -0.1%
TOTAL (Domestic & Global) $28,323.3 $28,453.8 $28,813.2 $30,511.0 $32,088.0 $32,989.7 $34,025.6 $1,033.2 3.1%
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 2017 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 $34 million in the FY17 request (and $25 million in the previous years) 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) 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 2017 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; the DC Fund, 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.

SOURCES: Kaiser Family Foundation analysis of data from: FY 2011-FY 2017 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, 2016.

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. White House, National HIV/AIDS Strategy For The United States: Updated to 2020; July 2015.

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  5. The methodology for estimating Medicare and Medicaid spending on HIV has been revised by the Centers for Medicare & Medicaid Services (CMS), resulting in changes to prior year estimates.  Table 2 reflects these changes starting in FY 2011 and through the FY 2017 budget request.

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  6. 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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  7. 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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  8. 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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