U.S. Federal Funding for HIV/AIDS: Trends Over Time
Federal funding for HIV has increased significantly over the course of the epidemic, rising from just a few hundred thousand in FY 1982 to more than $32 billion in FY 2017. 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, as well as by greater investments to combat HIV in low and middle-income countries. Still, federal funding for HIV represents just a small fraction (<1%) of the overall federal budget of the United States.
In May of this year, President Trump released his first federal budget request, for FY 2018, which includes an estimated $32.0 billion for combined domestic and global HIV efforts. If enacted by Congress, it would mark a decrease in funding for HIV of $839.7 million, or 2.6%,1 compared to current levels ($32.9 billion). Most of this decline would be in the global portfolio (a $1.2 billion or 18% decline), although domestic discretionary programs would decline by $794 million or 10%; mandatory funding would continue to increase. The 2018 fiscal year began on October 1st. However, since Congress has not yet finalized the appropriations bills, the current fiscal year is operating under a continuing resolution that essentially maintains funding at the FY 2017 levels until December 8th. This fact sheet provides an overview of trends in federal funding for HIV and compares the budget request to current funding levels. Detailed data for FY 2012-FY 2018 are provided in Tables 1-2.
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. Nearly two-thirds (65%) of the FY 2018 request is for care and treatment programs in the U.S.; 9% is for domestic cash/housing assistance; 2% is for domestic HIV prevention; 7% is for domestic HIV research; and 17% is for the global epidemic, including funding for international research.
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 62%, 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. Largely due to the growth in Medicare and Medicaid spending, mandatory spending has accounted for an increasing share of federal funding for HIV, rising from 50% of total HIV funding in 2012 to 62% in the FY18 request).
The remaining $12.3 billion (38%) of the federal HIV budget request for FY 2018 is discretionary, and is determined annually by Congress during the appropriations process. If enacted by Congress, discretionary HIV funding in the FY18 budget request would decrease by $2.0 billion (-14%) compared to the FY17 omnibus level ($14.3 billion) and would mark only the second time when overall discretionary funding declined from the preceding year. Of this year’s discretionary request, $6.9 billion (22% of the overall HIV budget request and 56% 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, $5.4 billion (17% of the overall request and 44% of the discretionary component), is for the global epidemic.
The Domestic HIV Budget
The domestic HIV budget includes funding for care, cash/housing assistance, prevention, research, and the Minority HIV/AIDS Initiative (MAI) as follows:
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 $20.7 billion in the FY 2018 request (65% of the total and 78% of the domestic share). This represents a 5.2% increase over the FY 2017 omnibus level, and is largely due to increased mandatory spending for Medicaid and Medicare.2 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 $58.8 million or 2.5% decrease over the FY 2017 omnibus level). Ryan White’s AIDS Drug Assistance Program (ADAP), which provides access to HIV-related medications to people with HIV, was essentially flat funded at $898.6 million in the request.3 The President’s budget proposes defunding the Ryan White Program’s Special Projects of National Significance (SPNS) Program and the Part F AIDS Education and Training Centers (AETC) program.
$3.0 billion of the FY 2018 budget request for HIV is for cash and housing assistance in the U.S. (9% of the overall budget and 11% of the domestic budget), a decrease of $7 million (0.2%) over the FY 2017 omnibus 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 $330 million in the request, a $26 million (7.3%) decrease over the FY 2017 omnibus level.
The smallest category of the federal HIV budget is domestic HIV prevention totaling $721.1 million in the budget request (about 2% of the overall budget). The FY 2018 prevention request includes funding for domestic HIV prevention across multiple agencies, representing a $199.2 million (22%) decrease over the FY 2017 omnibus level. Most prevention funding is provided to the CDC’s National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention (NCHHSTP), which receives $640.1 million in the FY 2018 request, which is $148.6 million (19%) lower than the FY 2017 omnibus level.
$2.2 billion (7% of the overall request and 8% of the domestic budget) in the FY 2018 request is for domestic HIV research across multiple agencies, $491.8 million (18%) below the FY 2017 omnibus level. The National Institutes of Health (NIH), which carries out almost all HIV research, receives $2.1 billion in the FY 2018 request for domestic HIV research activities (additional amounts used for international HIV research are attributed to the global category), a decline of 19% compared to the 2017 omnibus.4
|Table 1: Federal Funding for HIV/AIDS by Category, FY 2012 – FY 2018 Request (US$ Billions)|
|Category||FY 2012||FY 2013a||FY 2014||FY 2015||FY 2016||FY 2017||FY 2018 Request|
|NOTES: (a) indicates FY 2013 includes the effects of sequestration.|
Minority HIV/AIDS Initiative
For the first time since it was founded in 1989, the budget request defunds the federal Minority HIV/AIDS Initiative (MAI), which addresses the disproportionate impact of HIV/AIDS on racial and ethnic minorities in the U.S. In the past the MAI was funded at about $50 million through the Office of the Secretary MAI Fund, 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 epidemic in 1986. Total funding (bilateral and multilateral) has increased significantly over time, particularly since the launch of the President’s Emergency Plan for AIDS Relief (PEPFAR) in 2003 (add note to indicated that it was reauthorized in 2008 and 2013).5 However, since 2010 it has remained essentially flat. All U.S. funding for global HIV is part of PEPFAR, including both bilateral HIV efforts as well as contributions to multilateral organizations.
The FY 2018 budget request for HIV includes $5.4 billion for the global epidemic – $4.3 billion for bilateral programs and $1.13 billion for the U.S. contribution to the Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund). If approved by Congress, this would be a $1.2 billion decrease (-18%) compared to the FY 2017 enacted level.
- Most bilateral HIV funding is channeled to the State Department which receives $3.85 billion in the request, a $470 million (-11%) decline compared to the FY 2017 omnibus level ($4.32 billion) and nearly $759 million (-16%) below its peak level of funding in FY 2010 ($4.61 billion).
- The President’s FY 2108 budget request proposes to eliminate bilateral HIV funding provided through USAID, which totaled $330 million in FY17. Historically, USAID funding included contributions to the International AIDS Vaccine Initiative (IAVI) ($28.7 million in FY17) and microbicide research ($45 million in FY17).
- HIV funding through the CDC is $69.5 million in the request, a cut of $58.9 million (46%) compared to the FY17 omnibus amount, while funding for international HIV research activities at NIH is $346.2 million, a cut of $74.4 million (18%) compared to the FY17 omnibus.
- The request includes $1.13 billion for the Global Fund,6 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 2018 request for the Global Fund is $225 million (17%) lower than the FY 2017 omnibus level ($1.35 billion).
|Table 2: Federal Funding for HIV/AIDS, FY 2012 – FY 2018a|
|FY 2012||FY 2013||FY 2014||FY 2015||FY 2016||FY 2017||FY 2018
FY 2017-FY 2018 Request
|Domestic Programs & Research||$||%|
|Ryan White Programb,c||$2,392.2||$2,248.6||$2,313.0||$2,318.8||$2,322.8||$2,318.8||$2,260.0||($58.8)||-2.5%|
|CDC Domestic Prevention (& Research)||$822.6||$768.6||$786.7||$786.7||$788.7||$788.7||$640.1||($148.6)||-19%|
|National Institutes of Health (domestic)f||$2,681.6||$2,508.7||$2,524.0||$2,566.2||$2,579.4||$2,579.4||$2,093.9||($485.5)||-19%|
|Department of Veterans Affairs (VA)l||$956.0||$987.0||$1,047.0||$1,093.0||$1,117.0||$1,117.0||$1,117.0||$0.0||0.0%|
|Other domestic discretionaryg||$318.5||$355.4||$373.6||$381.6||$416.0||$418.9||$361.0||($57.9)||-13.8%|
|Social Security Disability Insurance (SSDI)||$1,893.0||$1,963.2||$2,031.4||$2,083.0||$2,070.0||$2,055.0||$2,099.0||$44.0||2.1%|
|Supplemental Security Income (SSI)||$525.0||$580.0||$600.0||$605.0||$635.0||$605.0||$580.0||($25.0)||-4.1%|
|Federal Employees Health Benefit (FEHB)||$161.0||$169.0||$175.0||$183.0||$200.0||$211.0||$223.0||$12.0||5.7%|
|Global Programs & Research|
|USAID (GHP account)h||$350.0||$333.0||$330.0||$330.0||$330.0||$330.0||$0.0||($330.0)||-100%|
|State Department (GHP account)h||$4,242.9||$3,870.8||$4,020.0||$4,320.0||$4,320.0||$4,320.0||$3,850.0||($470.0)||-11%|
|CDC Global AIDS Program (GAP)||$131.2||$125.3||$128.4||$128.4||$128.4||$128.4||$69.5||($58.9)||-46%|
|Department of Defense (DoD)||$8.0||$7.4||$8.0||$8.0||$8.0||$8.0||$0.0||($8.0)||-100%|
|NIH international HIV research||$392.5||$389.2||$453.6||$433.8||$420.7||$420.7||$346.2||($74.5)||-18%|
|TOTAL (Domestic & Global)||$28,453.8||$28,813.2||$30,511.0||$32,088.0||$32,947.0||$32,852.9||$32,013.2||($839.7)||-2.6%|
|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 2018 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 in the for Special Projects of National Significance (SPNS) in fiscal years 2012-2017; SPNS funding was eliminated under the budget proposal. (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, 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 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. (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. (l) For the period between FY12 – FY18, the entire Global Fund contribution was provided through the State Department. Prior to FY12, a portion of the contribution was provided through USAID and NIH.
SOURCES: Kaiser Family Foundation analysis of data from: FY 2012-FY 2018 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, 2018.
Unless otherwise noted, all data sources are listed below Table 2.
The methodology for estimating Medicare and Medicaid spending on HIV was revised in 2016 by the Centers for Medicare & Medicaid Services (CMS), resulting in changes to prior year estimates. Table 2 reflects these changes starting in FY 2012 and through the FY 2018 budget request.
While the FY18 Budget Request appears to propose a $1.7m cut to ADAP, this amount was based on an FY17 annualized CR amount in place prior to the budget release.
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.
The President’s Emergency Plan for AIDS Relief (PEPFAR) was first authorized in FY 2003 and reauthorized in FY 2008 and FY 2013 (see P.L. 108-25, May 27, 2003; P.L. 110-293, July 30, 2008; P.L. 113-56, December 2, 2013).
Global Fund grants support country projects to fight HIV, tuberculosis, and malaria. Figures used here are not adjusted to represent an estimated “HIV share.”