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FY 2017 Budget Sustains HIV Funding, Requests More for PrEP, Opioid Epidemic

President Barack Obama's proposed budget for fiscal year 2017 modestly increases funding for domestic HIV services -- with $20 million allocated for a pre-exposure prophylaxis (PrEP) pilot programand $9 million for HIV/HCV coinfection -- but flat funds HIV research and global AIDS assistance. The budget also address the growing opioid epidemic and includes efforts to expand Medicaid and reduce prescription drug costs.

Experts consider it unlikely that the Republican Congress will approve Obama's budget request as a whole, but specific pieces could pass and it sets the groundwork if a Democrat is elected as the next president in November.

Domestic HIV Services

Obama's final budget request comes to $4.1 trillion, a 4.9% increase over last year. While the Department of Health and Human Services (DHHS) gets about a quarter of this amount, more than 80% of that is committed to Medicare and Medicaid, leaving $82.8 million in discretionary funds.

The proposed budget allocates $2.3 billion to the Ryan White Program, a modest $34 million increase over FY 2016. This includes $900 million for AIDS Drug Assistance Programs (ADAPs) that pay for antiretroviral medications for people living with HIV.

The Centers for Disease Control and Prevention (CDC) National Center for HIV/AIDS, Viral Hepatitis, Sexually Transmitted Infections and Tuberculosis Prevention saw only a small increase, remaining at approximately $1.1 billion (out of a total CDC budget of $7 billion), and the $788 million allocated for domestic HIV prevention and research stayed about the same.

New this year is $20 million for a demonstration project to improve access to PrEP for HIV prevention. Up to 30% of this amount may be used to pay for medication -- currently Truvada (tenofovir/emtricitabine) -- and associated lab tests.

Other domestic HIV funding comes through the Department of Veterans Affairs, which received a $57 million increase for medical care for veterans living with HIV, and the Department of Housing and Urban Development's Housing Opportunities for Persons with AIDS (HOPWA) program, which was level-funded at $335 million.

HIV Research and Global Funding

The National Institutes of Health (NIH) budget for medical research received a $825 million (2.5%) increase overall -- bringing it up to $33.1 billion -- but HIV research got no additional funding for FY 2017, leaving it at the same level as FY 2015 and FY 2016.

Funds for global HIV/AIDS efforts come from a variety of sources including DHHS, CDC, the U.S. Agency for International Development (USAID), and the Department of State, much of it consolidated under the President’s Emergency Plan for AIDS Relief, or PEPFAR.

The FY 2017 budget provides a total of $8.6 billion to combat HIV/AIDS, malaria, and tuberculosis, and address other global health issues. While this is $73 million more than the 2016 allocation, most of the increase goes to malaria, maternal and child health, family planning, and vaccines, while HIV/AIDS itself saw no increase.

The Global Fund to Fight AIDS, Tuberculosis, and Malaria ($1.3 billion), USAID HIV/AIDS funding ($330 million), bilateral HIV/AIDS assistance to individual countries ($4.3 billion), UNAIDS ($45 million), and CDC global HIV funding ($128 million) all received the same amounts as last year. USAID funding for tuberculosis decreased from $236 to $191 million, while funding for the GAVI Vaccine Alliance (which is classified under maternal and child health but includes HIV vaccine research) rose from $235 to $275 million.

"The HIV Medicine Association is pleased that the president’s fiscal year 2017 budget proposal largely sustains funding for domestic HIV/AIDS programs," said HIVMA chair Carlos del Rio. "However, we are disappointed that under his proposal investments in HIV research are flat-funded for the third year in a row, and that funding for the President’s Emergency Plan for AIDS Relief once again has not seen an increase since peak funding in 2010. A robust federal response is more critical than ever to effectively respond to the HIV epidemic."

Hepatitis Funding

The CDC's Division of Viral Hepatitis, funded at $39 million, received only a small $5 million increase, which advocates say falls short given the large number of people with hepatitis B and C who do not know their status and are not receiving treatment.

"The president’s budget fails the more than 5 million Americans living with hepatitis B or hepatitis C and the many more at risk for infection," said National Viral Hepatitis Roundtable executive director Ryan Clary. "The lack of funding and commitment to address hepatitis B and hepatitis C in a meaningful way, particularly given the exciting and sorely needed initiatives to combat the overlapping opioid, heroin, and overdose epidemics, is not simply disappointing -- it is incredibly short-sighted."

However, the Ryan White budget includes $9 million for a new program to expand hepatitis C screening and treatment for people with HIV. About a quarter of HIV-positive people are estimated to have hepatitis C virus and HIV/HCV coinfection leads to more rapid liver disease progression. In addition, a portion of the increase in Veterans Affairs funding for medical care will go towards hepatitis C treatment.

"While we are pleased by the president's requests to invest $9 million to support hepatitis C treatment for people living with HIV through the Ryan White program and $1.5 billion for the VA to treat veterans living with hepatitis C, we need more comprehensive investments," said Emalie Huriaux of Project Inform. "Of the 60 nationally notifiable infectious diseases, hepatitis C-associated deaths are greater than the total number of deaths associated with the other 59 diseases combined."

Other Health Allocations

The DHHS budget proposal encourages the remaining states to expand their Medicaid programs under the Affordable Care Act by covering the full cost of expansion for 3 years regardless of when they start. About half of HIV-positive people receiving medical care rely on Medicaid, according to the Kaiser Family Foundation, and 16 states have not yet expanded Medicaid to low-income adults up to 133%-138% of the federal poverty level.

The budget also includes several provisions to reduce the cost of prescription drugs, including allowing the Centers for Medicare and Medicaid Services to partner with states to form federal-state price negotiating pools, reducing the patent period for brand-name biologic drugs from 12 to 7 years,increasing discounts for seniors who fall into Medicare’s "donut hole" coverage gap, and requiring more price transparency from drug manufacturers.

Other notable health-related items in the FY 2017 budget include:

• $877 million (a $43 million increase) to reduce the spread of antibiotic resistance and develop new antibiotic drugs.
• $755 million for the cancer "moonshot" proposed in the president's recent State of the Union address; $680 million will go to NIH for cancer prevention, diagnosis, and treatment research, while the Food and Drug Administration (FDA) receives $75 million to develop regulatory pathways.
• $500 million over 2 years to improve access to care for mental illness, including
• expanding the behavioral health workforce; NIH will also receive $195 million for its BRAIN initiative to study neurological and psychiatric conditions such as autism, depression, and Alzheimer’s disease.
• $1.8 billion in a supplemental request for emergency funding for Zika virus response, which will include vaccine research, development of diagnostic tests, education for medical providers and pregnant women, and mosquito control.

Addressing the Opioid Epidemic

Finally, the budget sets aside $1.1 billion over 2 years to address the growing opioid addiction and overdose epidemic. As recently reported, the number of drug overdoses -- mostly associated with prescription pain-killers and heroin -- is rising, along with outbreaks of HIV and hepatitis C among people who inject drugs. Increased drug use is occurring in rural areas and many users do not have access to clean syringe programs and other harm reduction services.

The initiative -- a collaborative effort multiple agencies including DHHS and the Department of Justice -- includes $920 million to expand medication-assisted treatment for opioid use disorders (typically using methadone or buprenorphine), $50 million to increase the number of medication-assisted treatment providers, and $500 million for overdose prevention including expanded access to naloxone.

This new allocation comes on top of $400 million in opioid epidemic funding in a bipartisan budget agreement reached late last year, which also removed language banning the use of federal money for needle exchange programs.

"We…applaud the White House’s robust proposal to respond to the growing national public health crisis of opioid abuse with $1.1 billion in mandatory funding over 2 years," said HIVMA's del Rio. "Expanded access to prevention and treatment of opioid abuse is critical to improving health outcomes for our patients with HIV with co-occurring substance use issues."

In related news, on February 4 FDA leaders called for an action plan to reassess the agency’s approach to opioid medications. The plan will focus on policies aimed at reversing the epidemic while still providing effective pain relief for patients.

The agency will develop changes to immediate-release opioid labeling, including additional warnings and safety information, encourage development of abuse-deterrent formulations of opioid products, improve access to naloxone and medication-assisted treatment, and support better pain management options including alternative therapies.

2/17/16

Sources

Office of Management and Budget. Budget of the U.S. Government: Fiscal Year 2017. February 2016.

Department of Health and Human Services. Fiscal Year 2017 Budget in Brief. February 2016.

Department of Health and Human Services. President’s HHS FY 2017 Budget Factsheet. February 9, 2016.

CDC. CDC FY 2017 Budget Request Summary Domestic HIV Prevention. Fact sheet. February 2016.

The White House. Enhancing the Lives of Americans Living With HIV/AIDS, and Fighting the HIV/AIDS Epidemic. Fact sheet. February 2016.

Kaiser Family Foundation. White House Releases FY17 Budget Request. Kaiser Daily Global Health Policy Report. February 9, 2016.

HIV Medical Association. Funding for Domestic HIV Programs Sustained, Promise of HIV Research and PEPFAR Stagnated in President’s Budget. Press release. February 10, 2016.

National Viral Hepatitis Roundtable. President Obama’s Budget Fails to Address Severity of Viral Hepatitis Epidemic.Press release. February 10, 2016.

The White House. President Obama Proposes $1.1 Billion in New Funding to Address the Prescription Opioid Abuse and Heroin Use Epidemic. Fact sheet. February 2, 2016.

Food and Drug Administration. Califf, FDA top officials call for sweeping review of agency opioids policies. Press release. February 4, 2016.