U.S. Federal Funding for HIV/AIDS: Trends Over Time

Introduction

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 $34.8 billion in FY 2019, for combined domestic and global efforts. This growth has been driven primarily by increased spending on mandatory domestic care and treatment programs (largely through Medicaid and Medicare), 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, and discretionary funding by Congress has been relatively flat in recent years. This fact sheet provides an overview of trends in federal funding for HIV and an update on current funding levels. Detailed data for FY 2013-FY 2019 are provided in Tables 1-2.1

Budget Categories

The federal HIV budget is generally organized into five broad categories: care & treatment; cash & housing assistance; prevention; research; and global/international. Nearly two-thirds (62%) of the FY 2019 budget is for domestic care and treatment programs in the U.S.; 9% is for domestic cash/housing assistance; 3% is for domestic HIV prevention; 7% is for domestic HIV research; and 19% is for the global HIV efforts, including funding for international research.

U.S. Federal Funding for HIV/AIDS, by Category, FY 2019

Mandatory/Discretionary

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 $20.3 billion, or 58%, of the total HIV budget 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. Mandatory spending has accounted for an increasing share of federal funding for HIV, rising from 50% of total HIV funding in 2012 to 58% in the FY19), largely due to growth in Medicare and Medicaid spending.

The remaining $14.5 billion (42%) of the federal HIV budget for FY 2019 is discretionary, and is determined annually by Congress during the appropriations process. Discretionary HIV funding in FY19 is similar to the FY18 level ($14.4 billion). Of this, $7.8 billion (22% of the overall HIV budget and 53% of discretionary funding) is for domestic programs – prevention research, housing, and non-mandatory care programs (e.g., the Ryan White HIV/AIDS Program). The remainder, $6.8 billion (19% of the overall budget and 47% 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:

Care

The largest component of the federal HIV budget is health care services and treatment for people living with HIV in the U.S., which totaled $21.5 billion in FY 2019 (62% of the total HIV budget and 77% of the domestic share). This represents a 5% increase over the FY 2018 level, primarily 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, the same as the FY18 level. Ryan White’s AIDS Drug Assistance Program (ADAP), which provides access to HIV-related medications to people with HIV, was flat funded at $900.3 million.

Cash/Housing Assistance

$3.1 billion of the FY 2019 budget for HIV is for cash and housing assistance in the U.S. (9% of the overall budget and 11% of the domestic budget), a slight increase over the FY 2018 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 received $393 million in FY 2019, an $18 million (5%) increase over the FY 2018 level.

Prevention

The smallest category of the federal HIV budget is domestic HIV prevention, which totaled $900.8 million in FY19 (about 3% of the overall HIV budget). This includes funding for domestic HIV prevention across multiple agencies, representing a small ($1.9 million) increase over the FY 2018 level. Most prevention funding is provided to the CDC’s National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention (NCHHSTP), which receives $788.7 million in FY 2019, the same as the FY 2018 level.

Research

$2.6 billion (7% of the overall FY 2019 amount and 9% of the domestic budget) in the FY 2019 HIV budget is for domestic HIV research across multiple agencies, essentially the same as the FY 2018 level. The National Institutes of Health (NIH), which carries out almost all HIV research, receives $2.5 billion in FY 2019 for domestic HIV research activities (additional amounts used for international HIV research are attributed to the global category), the same as in FY 2018.3

Table 1: Federal Funding for HIV/AIDS by Category, FY 2013 – FY 2019
(US$ Billions)
Category FY 2013a FY 2014 FY 2015 FY 2016 FY 2017 FY 2018 FY 2019
Domestic $21.85 $23.31 $25.05 $25.69 $26.11 $26.98 $28.03
    Care $15.45 $16.77 $18.40 $19.02 $19.60 $20.43 $21.46
    Cash/Housing $2.86 $2.96 $3.02 $3.04 $3.02 $3.06 $3.07
    Prevention $0.89 $0.90 $0.92 $0.90 $0.90 $0.90 $0.90
    Research $2.66 $2.67 $2.71 $2.72 $2.60 $2.60 $2.60
Global $6.29 $6.59 $6.57 $6.56 $6.67 $6.70 $6.78
TOTAL $28.15 $29.90 $31.62 $32.25 $32.78 $33.65 $34.80
NOTES: (a) indicates FY 2013 includes the effects of sequestration. Amounts may not sum exactly due to rounding.

Minority HIV/AIDS Initiative

The Minority HIV/AIDS Initiative (MAI), which addresses the disproportionate impact of HIV/AIDS on racial and ethnic minorities in the U.S, was funded at about $54 million through the Office of the Secretary MAI Fund. Additional MAI funding is designated at other agencies within HHS (e.g. within SAMHSA, HRSA, CDC).

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 2003.4 However, since 2010, funding for PEPFAR has remained essentially flat. All U.S. funding for global HIV is considered to be part of PEPFAR, including both bilateral HIV efforts as well as contributions to multilateral organizations.

The FY 2019 budget for HIV includes $6.8 billion for the global epidemic – $5.4 billion for bilateral programs and $1.35 billion for the U.S. contribution to the Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund). Congress provided a slight increase in funding for global HIV activities in FY 2019 (approximately $75 million above the FY 2018 level) compared to the FY 2018 level. Global HIV funding amounts to 19% of the overall FY 2019 HIV budget amount and 47% of discretionary funding.

Bilateral Funding

  • Most bilateral HIV funding is channeled to the State Department which receives $4.37 billion in FY 2019, a $50 million (1%) increase compared to the FY 2018 level ($4.32 billion), but still almost $250 million (-5%) below its peak level of funding in FY 2010 ($4.61 billion).
  • HIV funding through USAID ($330 million) and the CDC ($128 million) is all flat in FY 2019 compared to the FY18 level. Funding for international HIV research activities at NIH is $590 million in FY 2019, an increase of $25 million above the FY 2018 level.

The Global Fund

  • The FY 2019 budget includes $1.35 billion for the Global Fund,5 an independent, public-private, multilateral institution which finances HIV, TB, and malaria programs in low- and middle-income countries; the U.S. is the Global Fund’s largest contributor. The FY 2019 budget for the Global Fund is flat compared to the FY 2018 level.
Table 2: Federal Funding for HIV/AIDS, FY 2013 – FY 2019 (a)
(US$ Millions)
Program/Account FY 2013 (b) FY 2014 FY 2015 FY 2016 FY 2017 FY 2018 FY 2019
Domestic Programs & Research
Ryan White Program (c) $2,248.6 $2,313.0 $2,318.8 $2,322.8 $2,313.2 $2,318.8 $2,318.8
     ADAP (non-add) $886.3 $900.3 $900.3 $900.3 $900.3 $900.3 $900.3
CDC Domestic Prevention (& Research) $768.6 $786.7 $786.7 $788.7 $786.7 $788.7 $788.7
National Institutes of Health (domestic) (d) $2,508.7 $2,524.0 $2,566.2 $2,579.4 $2,466.7 $2,430.7 $2,455.0
SAMHSA $173.1 $180.3 $180.5 $181.0 $180.2 $181.0 $181.0
Department of Veterans Affairs (VA) $739.7 $772.8 $1,093.0 $1,030.4 $1,088.4 $1,160.4 $1,204.1
HOPWA $315.0 $330.0 $330.0 $335.0 $356.0 $375.0 $393.0
Other domestic discretionary (e) $355.4 $373.6 $381.6 $416.0 $411.4 $410.8 $410.8
Subtotal Discretionary $7,109.1 $7,280.4 $7,656.8 $7,653.3 $7,602.6 $7,665.4 $7,751.4
Medicaid $3,970.0 $4,540.0 $5,290.0 $5,570.0 $5,690.0 $6,070.0 $6,340.0
Medicare $8,060.0 $8,680.0 $9,230.0 $9,560.0 $9,950.0 $10,320.0 $11,040.0
Social Security Disability Insurance (SSDI) $1,963.2 $2,031.4 $2,083.0 $2,070.0 $2,055.0 $2,099.0 $2,099.0
Supplemental Security Income (SSI) $580.0 $600.0 $605.0 $635.0 $605.0 $580.0 $580.0
Federal Employees Health Benefit (FEHB) $169.0 $175.0 $183.0 $200.0 $211.0 $211.0 $211.0
Subtotal Mandatory $14,742.2 $16,026.4 $17,391.0 $18,035.0 $18,511.0 $19,280.0 $20,270.0
Total Domestic $21,851.3 $23,306.8 $25,047.8 $25,688.3 $26,113.6 $26,945.4 $28,021.4
Global Programs & Research
USAID (GHP account) (f) $333.0 $330.0 $330.0 $330.0 $330.2 $330.2 $330.2
State Department (GHP account) (f),(g) $3,870.8 $4,020.0 $4,320.0 $4,320.0 $4,320.0 $4,320.0 $4,370.0
CDC Global AIDS Program (GAP) $125.3 $128.4 $128.4 $128.4 $128.4 $128.4 $128.4
Department of Defense (DoD) $7.4 $8.0 $8.0 $8.0 $8.0 $8.0 $8.0
NIH international HIV research $389.2 $453.6 $433.8 $420.7 $533.4 $564.7 $590.1
Subtotal $4,725.6 $4,940.0 $5,220.2 $5,207.1 $5,320.0 $5,351.3 $5,426.7
Global Fund (h) $1,569.0 $1,650.0 $1,350.0 $1,350.0 $1,350.0 $1,350.0 $1,350.0
Total Global $6,294.6 $6,590.0 $6,570.2 $6,557.1 $6,670.0 $6,701.3 $6,776.7
TOTAL (DOMESTIC & GLOBAL) $28,145.9 $29,896.8 $31,618.0 $32,245.4 $32,783.6 $33,646.7 $34,798.1
NOTES:
(a) Data are rounded and some data are still considered preliminary. FY 2019 funding levels for SSDI, SSI, some USAID funding, and some accounts included in “other domestic discretionary,” are not yet known; for comparison purposes, these amounts are estimated using prior year levels.
(b) 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).
(c) Ryan White totals include $25 million in the for Special Projects of National Significance (SPNS)
(d) 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.
(e) “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.
(f) GHP is the “Global Health Programs” account, formerly named the Global Health and Child Survival Account (GHCS).
(g) Includes funding for UNAIDS; the International AIDS Vaccine Initiative; and Microbicides.
(h) Global Fund grants support country projects to fight HIV, tuberculosis, and malaria. Figures used here are not adjusted to represent an estimated “HIV share.”
SOURCES: Kaiser Family Foundation analysis of data from: FY 2013-FY 2019 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, 2019.
Endnotes
  1. FY19 funding levels for SSDI, SSI, some USAID funding, and some accounts included in “other domestic discretionary,” are not yet known; for comparison purposes, these amounts are estimated using prior year levels.

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  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 throughout the period shown.

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  3. 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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  4. The President’s Emergency Plan for AIDS Relief (PEPFAR) was first authorized in FY 2003 and reauthorized in FY 2008, FY 2013, and FY 2018 (see P.L. 108-25, May 27, 2003; P.L. 110-293, July 30, 2008; P.L. 113-56, December 2, 2013; P.L. 115-305, December 11, 2018).

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  5. Global Fund grants support country projects to fight HIV, tuberculosis, and malaria. Figures used here are not adjusted to represent an estimated “HIV share.”

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