LANSING - Over 30 years into the HIV epidemic in the U.S. the number of new infections nationwide and statewide have stabilized. With the advent of powerful anti-HIV drugs, the number of people living with HIV has continued to increase. But the funding streams that keep the state's HIV prevention and care programs running and the doors open are shifting like sands on the Lake Michigan dunes.
From a state level, the news is a combination of good and bad. On the one hand, while the federal portion of the funding for HIV programming has been cut in prevention, the state has been able to shift some funds from other programming to cover short falls. The bad news is that this is not a sustainable model in the Michigan Department of Community Health budgets.
The Funding
HIV programming in Michigan is a series of organizations, funded mostly through federal pass through dollars given to MDCH.
The funding on a federal level is generally authorized via the Ryan White CARE Act and distributed through the Department of Health and Human Services Health Services and Resources Administration (HRSA) or through the Centers for Disease Control and Prevention (CDC). Generally HRSA dollars are directed towards testing and care, while CDC dollars are directed towards prevention programming in the state.
Under CDC rules, 75 percent of all HIV prevention dollars must be spent on people living with HIV who know they are living with HIV, while 25 percent can be spent on high-risk populations who are not infected or unaware of their infections. All the prevention programs must be scientifically proven as effective and approved by CDC to receive funding.
HRSA dollars fund programs such as case management, AIDS Drug Assistance Programs and medical access programming for those living with HIV.
The money comes to the MDCH, where the staff at the HIV/AIDS Prevention and Intervention Section (HAPIS), dole out the funds in grants to local health departments and AIDS Service Organizations (ASOs). The local health departments and ASOs then deliver many of the services that have come to define the HIV response - testing, counseling, linkage to care, access to care and medications, prevention programming and case monitoring and management. Under federal rules, MDCH is allowed to keep 10 percent of the funding for administrative costs, and grantees are allowed to use no more than 10 percent of the funding for administrative costs.
To fully fund Michigan's AIDS Drug Assistance Program, seen as a key tool in fighting the epidemic by creating access to the expensive drugs used to treat and control the virus, the state leverages taxpayer dollars from the Healthy Michigan Initiative. The HMI was created in the late 70s to divert sales tax revenue to health specific programming. Michigan uses over $4 million a year to leverage about $30 million in federal dollars to fund the program, and an additional $20 million or so comes from rebates negotiated with pharmaceutical companies.
With looming sequestration cuts and new funding formulas under federal law, this funding scheme is in jeopardy, says Jane DuFrane, manager of the HAPIS at MDCH.
She tells BTL that stopgap measures implemented over the last two years to avoid cutting funding awards to local AIDS Service Organizations "won't last another five years," and the federal cuts are essentially permanent - the result of a change in funding formulas under the Ryan White CARE Act reauthorization in 2009. Under the new formula, funding was shifted from places like New York and California (and Michigan) to fund programming and responses to the epidemic in 10 southern states that compromise the bulk of new infections nationwide. The new formula for the first time looks at new cases as the basis for funding, rather than the historic tally of cases.
The result has been a 33 percent cut to federal prevention dollars flowing into Michigan by 2014. DuFrane and other health officials on the state level say they have patched this funding shortfall, as well as shortfalls coming down the pike with the sequester, by shifting funding from drug rebates paid back to the state's AIDS Drug Assistance Program by various HIV drug makers and by tapping into the HMI Fund. The HMI fund diverts a small part of Michigan sales tax into a dedicated fund for health programming. That program once faced possible redirection when then state Rep. Dave Agema (R-Greenville) proposed legislation to shift funding from HMI to a new fund to pay for airport upkeep in the state. Those funds are the only state tax revenues leveraged to bring in millions of dollars in federal programming money to fight the epidemic and provide care and drugs for those infected.
DuFrane says she believes that with the full implementation of the Affordable Care Act including the controversial Medicaid expansion the result will be a 60 percent reduction in state spending on HIV drugs and care through the AIDS Drug Assistance Program. But those savings would not see the money shifted from ADAP to prevention programming, because it is restricted. And don't expect to see ADAP begin to offer subsidies for access to HIV drugs to prevent infections, either. Federal rules prohibit using the Ryan White funds for preventative drugs, called non-occupational post exposure prophylaxis for preventing infection after an exposure, and pre-exposure prophylaxis used to prevent infections by taking an HIV drug daily.
The Reorganization
Money woes are not the only concerns for the state's HIV programming. A reorganization shifting the program from the state's department of health wellness and disease control to the department of chronic disease, has resulted in consolidations of office space, cancellation of the department's largest contract and reissuing to another contractor, and rehiring of many of the staff members. This move comes after two years of the HIV programming losing many long-term employees.
The reorganization includes moving HIV programming under the aegis of Division of Chronic Disease and Injury Control, says Linda Scarpeta, acting director of the division. The move comes in order to refocus energy on HIV and some of the common factors shared with other chronic disease, including racial disparities. Scarpeta says a move to consolidate the HAPIS operations in Lansing will have the organization operating like other statewide chronic disease programs.
Despite this, the department has been wracked with internal discord for months before the move to reorganize. Internal documents show management style and conflicts led to the loss of staff. One internal document, a review of complaints against Amna Osman, then director of the Division of Health Wellness and Disease Control of which HIV programming was a section, questioned the use of a contract to Southeast Michigan Health Association (SEMHA).
The report found that the contract was used improperly to circumvent purchasing guidelines in the state, which in turn resulted in purchases of things like computers which remain unaccounted for. Those findings were never referred to the Auditor General's Office for review.
In October the state announced it was closing HIV program offices in Detroit. The epidemiology program was moved to offices in Southfield, while the contract review and technical assistance programs were moved to Lansing.
Angela Minicuci, public information officer for MDCH, says the closing of two Detroit offices will result in a savings of $150,842.
"Other costs of keeping two offices are travel expenses for staff going back and forth to Lansing, and the cost of staff time to travel as some staff have office space in both buildings, computers, phone costs, etc.," Minicuci said in an email in September.
MDCH officials say the reorganization and the loss of long time employees has not resulted in a loss of institutional memory, nor has it harmed ongoing operations. However, county level quarterly analysis of new HIV reports, usually published on the state's website, have not been updated since January of 2013. Reports from county health officials have been filed in April, July and October although they have not been published on the state website.
Trickle Down Crunch Time
Even as state officials struggle with patching the funding holes appearing in federal funding streams, local agencies that rely on that funding - called AIDS Service Organizations, or ASOs - are still feeling the pinch. The organizations are seeing reductions in funding not only from the federal, state and local levels, but also through charitable giving and corporate sponsorships. The result is programs serving more people but operating with fewer financial resources.
To address this problem, a group of nine agencies across the state announced a $25,000 grant from Washington, DC based funding giant AIDS United. The agencies are AIDS Partnership Michigan (APM), Community AIDS Resource and Education Services (CARES), Community Health Awareness Group (CHAG), Grand Rapids Red Project, Health Emergency Lifeline Programs (HELP), HIV/AIDS Resource Center, Lansing Area AIDS Network (LAAN), Michigan AIDS Coalition (MAC), and Wellness AIDS Services.
"The grant will assist participating agencies to plan for the future of HIV/AIDS services in the state by addressing the realities of the Affordable Care Act (ACA) provisions, and continued reductions in both direct care and prevention funds from all sources: federal, state, and local government, corporations, foundations and individual donors," reads an Oct. 29 press release from the nine groups. "Economies of scale, billable services, linkage to care under ACA, program and administrative collaboration, shared services, and many other areas will be explored in CRI [Community Restructuring Initiative] discussions."
Exactly what this CRI conversation will result in is unclear. Directors of the ASOs involved issued a letter to BTL in response to a series of questions. In the letter, the leaders of those ASOs wrote they were "not in a position to provide commentary relative to the AIDS United grant" beyond what was provided in the Oct. 29 press release.
MDCH officials say the grant will most likely lead to administrative cost sharing between the organizations, but that ultimately it was up to the ASOs and not MDCH.
The ASO leaders were also unwilling to discuss the likely impact of the Affordable Care Act, funding cuts from the state and federal level or even the reorganization of HAPIS.
"With the implementation of the ACA, resultant uncertainties relative to the future of the Ryan White Care Act, and restructuring within MDCH (inclusive of HAPIS) there are many unknowns. Because of the tremendous uncertainties on both a federal and state level, any discussion about the resultant impacts on AIDS Service Organizations and other service providers is purely speculative," the leaders wrote in their email to BTL.
