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U.S. Federal Funding for HIV/AIDS: The President’s FY 2014 Budget Request

Introduction

President Obama’s Fiscal Year (FY) 2014 federal budget request, released on April 10, includes an estimated $29.7 billion for combined domestic and global HIV/AIDS activities.1   Domestic HIV/AIDS is funded at $23.2 billion and global at $6.5 billion in the request.2  The FY 2014 request represents a 5.5% increase ($1.5 billion) over FY 2013 levels, which totaled $28.2 billion.  FY 13 funding was finalized through a Continuing Resolution (CR) several months ago, but final funding levels by program, accounting for the effects of sequestration, were only recently made available.3  Final FY 2013 funding levels reflect cuts due to sequestration, which mandated an approximate 5% decrease from enacted levels to most discretionary programs, projects, and activities.4  Some of the increase in discretionary funding in the FY 2014 request over FY 2013 can be attributed to the effects of sequestration. Detailed data for FY 2009-FY 2014 are provided in Tables 1-2.

Federal funding for HIV/AIDS has increased significantly over the course of the epidemic, including by $4.7 billion (or 19%) 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/AIDS in the United States. Federal funding for HIV/AIDS, however, represents a small fraction (<1%) of the overall federal budget of the United States.

Figure 1: U.S. Federal Funding for HIV/AIDS, FY 2009-FY 2014

Figure 1: U.S. Federal Funding for HIV/AIDS, FY 2009-FY 2014

The federal HIV/AIDS budget is generally organized into five broad categories: care; cash & housing assistance; prevention; research; and global/international.  The first four categories are for domestic programs only.  More than half (55%) of the FY 2014 request is for care and treatment programs in the U.S.; 10% is for domestic cash/housing assistance; 3% is for domestic HIV prevention; 10% is for domestic HIV research.  Of the total FY 2014 request for HIV/AIDS, 22% is for the global epidemic, including funding for international research (See Figure 2).

Figure 2: Federal Funding for HIV/AIDS by Category, FY 2014 Budget Request (US$ Billions)

Figure 2: Federal Funding for HIV/AIDS by Category, FY 2014 Budget Request (US$ Billions)

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, 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 $15.3 billion, or 52%, 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 to people with HIV/AIDS.

The remaining $14.4 billion (48%) of the federal HIV/AIDS budget request in FY 2014 is discretionary, and is determined annually by Congress during the appropriations process.  Of this, $7.9 billion (27% of the overall AIDS 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, $6.5 billion (22% of the overall request and 45% 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.5  The FY 2014 budget request includes funding to achieve these goals.

CARE: The largest component of the federal AIDS budget is health care services and treatment for people living with HIV/AIDS in the U.S., which totals $16.4 billion in the FY 2014 request (55% of the total and 71% of the domestic share).  This represents a 6.2% increase over FY 2013, primarily 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 $2.4 billion in the budget request, a $164 million increase (7.3%) over FY 2013 (and an increase even if sequestration were not a factor).  Part of this increase is for the AIDS Drug Assistance Program (ADAP) which provides access to HIV-related medications to people with HIV but has been subject to ongoing waiting lists and other cost containment measures in several states due to shortage of funds and increased demand. To address these shortages, the Administration provided emergency funding to ADAPs in each of fiscal years 2010-2012, including $35 million in 2012.  The FY 2013 CR, however, while continuing ADAP funding at FY 2012 enacted levels, did not carry forward the additional $35 million provided in FY 2012. The FY 2014 budget request for ADAP of $943.3 million includes the $35 million and adds an additional $10 million.

CASH/HOUSING ASSISTANCE: $3 billion (10%) of the FY 2014 budget request for HIV/AIDS 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, similar to the FY 2013 level ($331 million).

Table 1: Federal Funding for HIV/AIDS by Category, FY 2009 – FY 2014 (US$ Billions)
CATEGORY
FY 2009
FY 2010
FY 2011
FY 2012
FY 2013
FY 2014*
Domestic
$18.5
$19.6
$20.5
$21.4
$21.9
$23.2
Care
$12.5
$13.2
$14.0
$14.8
$15.4
$16.4
Cash/Housing
$2.5
$2.6
$2.7
$2.8
$2.9
$3.0
Prevention
$0.9
$1.0
$0.9
$1.0
$0.9
$1.0
Research
$2.7
$2.7
$2.8
$2.8
$2.7
$2.9
Global
$6.5
$6.6
$6.5
$6.4
$6.3
$6.5
TOTAL
$25.0
$26.2
$27.0
$27.8
$28.2
$29.7
*FY 2014 is the President’s Budget Request

PREVENTION: The smallest category of the HIV/AIDS budget is domestic HIV prevention (3% of the overall budget and 4% of the domestic budget).  The FY 2014 request includes $977.8 million for domestic HIV prevention across multiple agencies, representing a $62.6 million (6.8%) increase over FY 2013.  Most prevention funding is provided to the CDC’s National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention (NCHHSTP), which receives $836.1 million, a 7.8% increase over FY 2013.

RESEARCH: $2.9 billion (10% of the overall request and 12% of the domestic budget) is for domestic HIV research across multiple agencies, a 7% increase over FY 2013.  The National Institutes of Health (NIH), which carries out almost all domestic HIV research,6 receives $2.7 billion (additional amounts are used for international HIV research, 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 MAI specifically, as well as additional funding to be designated at other agencies within HHS.

THE GLOBAL HIV BUDGET

The U.S. government first provided funding to address the global HIV/AIDS epidemic in 1986, and funding increased significantly over time, particularly in the last decade. However, it has slowed in recent years, with bilateral funding now on the decline.  The U.S. funds both bilateral HIV efforts in other countries as well as contributions to multilateral organizations. All U.S. funding for global HIV/AIDS is part of PEPFAR, the President’s Emergency Plan for AIDS Relief, first authorized in FY 2003 and reauthorized in FY 2008.7  The FY 2014 budget request for HIV/AIDS includes $6.5 billion for the global epidemic, 4% more than FY 2013. Of this:

  • Most funding ($5.67 billion) is channeled to the State Department. This includes $4.02 billion for bilateral activities (a 4% increase over FY 13, but a decrease if sequestration were not a factor; the FY 2014 request is below FY 2008 levels), of which $45 million is slated for UNAIDS, and $1.65 billion for the Global Fund to Fight AIDS, Tuberculosis and Malaria (a 5% increase over FY 2013), an independent, public-private, multilateral institution which finances HIV/AIDS, TB, and malaria programs in low and middle income countries; the U.S. is its largest contributor.8
  • USAID would receive $330 million, including contributions to the International AIDS Vaccine Initiative ($28.7 million) and for microbicide research ($45 million);
  • CDC would receive $132 million and NIH estimates that international HIV research would total $399.1 million.
Table 2: Federal Funding for HIV/AIDS, FY 2009 – FY 2014a
Program/Account
(US$ Millions)
FY 2009
FY 2010
FY 2011
FY 2012
FY 2013
FY 2014
Request
Change
FY 2013-FY 2014
Domestic Programs & Research
$
%
Ryan White Programb,c           
$2,238.4
$2,312.2
$2,336.7
$2,392.2
$2,248.6
$2,412.2
$164
7.3%
ADAP (non-add)d
$815.0
$857.0
$885.0
$933.3
$886.3
$943.3
$57
6.4%
CDC Domestic Prevention
(& Research)e
$731.9
$799.3
$800.4
$822.6
$775.5
$836.1
$61
7.8%
National Institutes of Health (domestic)f
$2,567.6
$2,599.7
$2,683.5
$2,681.6
$2,527.4
$2,722.6
$195
7.7%
SAMHSA
$178.2
$178.4
$178.1
$177.4
$169.7
$178.1
$8
4.9%
Department of Veterans Affairs (VA)
$701.0
$783.0
$852.0
$956.0
$1,031.0
$1,111.0
$80
7.8%
HOPWA
$310.0
$335.0
$334.3
$332.0
$331.0
$332.0
$1
0.3%
Minority HIV/AIDS Initiative
(non-add)
$395.5
$413.7
$419.9
$426.2
not available
not available
Other domestic discretionaryg
$299.7
$296.5
$316.9
$318.5
$306.3
$297.0
($9)
Subtotal discretionary
$7,026.8
$7,304.1
$7,502.0
$7,680.3
$7,389.5
$7,888.9
$499
6.8%
Medicaid
$4,400.0
$4,700.0
$5,100.0
$5,300.0
$5,600.0
$5,900.0
$300
5.4%
Medicare
$4,800.0
$5,100.0
$5,400.0
$5,800.0
$6,200.0
$6,600.0
$400
6.5%
Social Security Disability Insurance (SSDI)
$1,692.0
$1,763.0
$1,806.0
$1,894.0
$1,971.0
$2,040.0
$69
3.5%
Supplemental Security Income (SSI)
$485.0
$530.0
$590.0
$535.0
$590.0
$605.0
$15
2.5%
Federal Employees Health Benefits (FEHB)
$123.0
$143.0
$150.0
$161.0
$169.0
$178.0
$9
5.3%
CDC PPHF
$0.0
$30.4
$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
$15,323.0
$793
5.5%
Subtotal Domestic
$18,526.8
$19,570.5
$20,548.0
$21,370.3
$21,919.55
$23,211.9
$1,292.4
5.9%
Global Programs & Research
$
%
USAID (GHP account)h
$350.0
$350.0
$349.3
$350.0
$333.0
$330.0
($3.0)
-1%
State Department
(GHP account)
$4,559.0
$4,609.0
$4,585.8
$4,242.9
$3,870.8
$4,020.0
$149.2
4%
CDC Global AIDS Program (GAP)e
$118.9
$119.0
$118.7
$131.2
$124.3
$131.9
$7.6
6%
Department of Defense (DoD)
$8.0
$10.0
$10.0
$8.0
$8.0
$0.0
($8.0)
-100%
NIH international HIV research
$451.7
$485.6
$375.7
$392.5
$372.1
$399.1
$27.0
7%
Subtotali
$5,487.6
$5,573.6
$5,439.6
$5,124.5
$4,708.2
$4,881.0
$172.9
4%
Global Fundj,k
$1,000.0
$1,050.0
$1,045.8
$1,300.0
$1,569.0
$1,650.0
$81.0
5%
Global Fund – State
(non-add)
$600.0
$750.0
$748.5
$1,300.0
$1,569.0
$1,650.0
$81.0
5%
Global Fund – USAID
(non-add)
$100.0
$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
Subtotal Global
$6,487.6
$6,623.6
$6,485.4
$6,424.5
$6,277.2
$6,531.0
$253.9
4.0%
TOTAL
$25,014.3
$26,194.1
$27,033.3
$27,794.8
$28,196.74
$29,743.0
$1,546.3
5.5%
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 2014 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 will 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 2014 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: DHHS 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/AIDS, tuberculosis, and malaria; to date, approximately 52% of approved Global Fund grants have been for HIV.  Figures used here are not adjusted to represent an estimated HIV/AIDS share unless noted. (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 2014 Budget of the United States and Congressional Budget Justifications; Congressional Appropriations Bills and Conference Reports; Agency operational plans; White House, The President’s FY 2014 Budget, April 2013; Office of Management and Budget, personal communication, April, May, and December 2013.

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.  An example is international HIV research at NIH, which can be counted either as “research” or “global” but is generally attributed to the global category.

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  3. The FY 2013 CR continued funding at FY 2012 levels for many programs, although made changes to others, and includes rescissions and a mandated sequestration.

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  4. White House, OMB Report to the Congress on the Joint Committee Sequestration for Fiscal Year 2013, March 1, 2013.

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  5. White House, National HIV/AIDS Strategy, July 2010.

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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.

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  8. Donors make contributions to the Global Fund without specifying disease allocations, and the Global Fund in turn distributes funding to countries.  To date, 52% of approved Global Fund grants have been for HIV.  If this distribution is applied to U.S. Global Fund contributions to determine an estimated HIV/AIDS “share”, the FY 2014 request would be approximately $856 million.

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