The Bush administration has proposed sweeping changes in the way federal Ryan White Act funds are distributed throughout the United States, with areas seeing rising HIV infection rates getting funding priority while cities with long-established AIDS epidemics face funding cuts. Congress is expected to address the changes when it focuses on reauthorization legislation late this year and into 2006.
The proposal would eliminate the current funding formula that relies on the cumulative number of AIDS cases in a region to determine which areas get the most federal funds. Instead, more weight would be given to parts of the country with rising infection rates and severe shortages in HIV services, including poor and rural areas, particularly in the South.
AIDS treatment advocates say the proposal would cut grants to 51 large urban areas, with San Francisco, for example, slated to lose an estimated $9 million over the next five years. Other major cities with large HIV-positive populations, including New York, Chicago, and Los Angeles, also would see large cuts.
The Administration also recommends that a minimum of 75% of Ryan White dollars be used for medical care, which would reduce funding for such supportive services as case management, housing assistance, legal help, food banks, and transportation programs.
Some AIDS treatment advocates--including members of the HIV Medicine Association, AIDS Healthcare Foundation, and AIDS Institute--have welcomed the proposed changes, stating that more AIDS funds must reach regions of the country where HIV care remains underfunded.
'Talking about that you don't want money to be moved to another area, I think, is just the wrong argument,' says Carl Schmid, director of federal affairs for AIDS Institute, of complaints sounded by urban AIDS groups. 'Every time you say that, it means you believe it's OK to have someone somewhere else go without those lifesaving services.'
Schmid also says that under the current formulas some large states receive more funds than they can spend, pointing out that this year Pennsylvania returned some of its unused money to the federal treasury. 'That's not right,' he says, 'and shows that the formula needs to be fixed.'
But critics of the Bush administration's proposals say treatment and support programs in some parts of the country are lacking because state and local governments have been unwilling to pony up their own money. Shifting more federal funds to those areas essentially rewards communities that have done little to fight the disease--and hurts cities and states that are leaders in HIV services.
Lawmakers from the states set to lose money, which typically have large congressional delegations and wield considerable political clout, would never approve reauthorization legislation that cuts services to their constituents, according to Ernest Hopkins, director of federal affairs for the San Francisco AIDS Foundation. 'I don't envision the proposals being enacted in their current form,' he says. 'They are by definition very broad and open to interpretation. And we plan to interpret the hell out of them.'
What all advocates agree on is that Congress should allocate significantly larger sums to the Ryan White Act when reauthorizing the measure--guaranteeing that all regions of the country receive adequate funding. But whether that Herculean task can be accomplished by a Congress already struggling to pay for relief programs in the wake of two major hurricanes and grappling with a burgeoning federal deficit remains to be seen.
'We've been working really, really hard to send a message as advocates and people living with HIV that we are not interested in a zero-sum conversation where we are pitted against each other for crumbs on the table,' Hopkins says. 'But we've still got a lot of work ahead of us.'