(NOTE: This article is the 4th segment in a collaboration between IowaWatch and Iowa Public Radio on HIV/AIDS: Medical Advances, Prevention and Criminalization of HIV Transmission)
Chances that more Iowans and people in some 12 other states could become infected with the human immune deficiency virus that causes AIDS could increase.
Iowa Department of Health officials will have to make do with less than half the money they once had to prevent the spread of HIV, partly because of some major financial setbacks, including one that occurred just recently under a new national policy by President Barack Obama.
With the state health department’s disease prevention budget being slashed from $1.6 million to as low as $750,000, health officials were hoping to cushion the blow over the next four years with two HIV prevention grants totaling $2 million that an official said would have "greatly changed the picture of funding for Iowa." Iowa was going to use the money to test people for possible HIV and to identify undiagnosed carriers.
But the federal Centers for Disease Control and Prevention announced the rejection of those applications on March 5th under a policy that, in effect, penalized Iowa and the other 12 states that have been successful in holding down the prevalence of HIV/AIDS within their borders.
Iowa is one of 17 states whose HIV prevention programs rely solely on direct funding from the CDC.
Cuts Blamed on Success
Because Iowa and other “low prevalence” states did not get funding under the policy, health officials fear reduced prevention efforts could reverse years of success in protecting their citizens.
Randy Mayer, bureau chief of HIV, STD, and Hepatitis at the Iowa Department of Public Health, said he expects the numbers to rise.
“We’re very disappointed,” he said.
HIV prevention administrators are also worried.
Rhea Van Brocklin, executive director for the AIDS Project of Central Iowa, said, “HIV prevention in our state is going to look very, very different I fear.”
For HIV/AIDS, funding for prevention is especially critical to efforts to stem the spread of the virus and the disease.
“Care is prevention and prevention is care,” said Holly Hanson, a manager at the Iowa Department of Public Health.
Federal officials argue that the cuts represent a change in national policy to funnel money to cities that have the highest prevalence of HIV/AIDS.
But Iowa health officials say the key to preventing Iowa from becoming one of those high prevalence states is identifying the thousands who may have HIV but don’t know it and engage in risky behavior.
One in Five Don’t Know
CDC estimates that one out of every five persons with HIV is unaware of it, which means they could be unknowingly exposing their partners. In Iowa, the state health department already knows of 1,828 carriers of HIV/AIDS who had been diagnosed as of December 31, 2010, with over half living in Polk, Linn, Johnson, Black Hawk, Scott, Woodbury and Pottawattamie counties.
What worries them are the ones they don’t know about. Mayer's bureau estimated there are over 500 undiagnosed and unreported persons living with HIV/AIDS.
One of the most effective strategies for preventing the kind of epidemic that spread AIDS hysteria across the country in the 1980s has been to find infected patients and get them into treatment and care.
Mayer’s bureau identifies an average of 114 new HIV infections annually. Without money to continue that and to educate HIV carriers, the prevalence of the disease may rise again, making federal funding necessary again. Iowa will be caught in what Mayer calls “funding cycles.”
“Tuberculosis is good example of this,” he said. “It was a disease that at least on a national level, they put lot of money into fighting, and so the numbers [diagnoses] went down. Then they thought, we did a good job here so we can move the money around. But then TB started coming back.”
HIV Prevention Efforts Will Slow
“What I’m most concerned about is we already see very late diagnoses, or people who get tested at a very late stage of the disease…I am most afraid that we will fall further behind,” Mayer said. “I expect to see that number increase, and I think it’s going to be our best marker if we’re seeing these kinds of consequences from funding changes.”
This change comes as part of a new national strategy by the Obama Administration to reduce new HIV infections by reprioritizing its budget and funneling money towards twelve municipalities that have a high number of people living with HIV in 2008.
Almost half of the new grantees are health departments in one of these municipalities or its respective state health department. Some low-prevalence states like Nebraska did receive funding, however.
“It’s high risk for potentially high gain, which is what they’re [CDC] betting on,” Mayer said. “The CDC tries so hard to be evidence-based, and I don’t see any evidence for this redistribution.”
Mayer says there has been no studies or modeling done to show that plugging in the number of HIV diagnoses per jurisdiction is the proper way to quell the spread of this virus. “That’s almost like treating it like an entitlement program,” he said
CDC Mum on Evidence Behind Methods
According to CDC spokesperson Scott Bryan, funding was based on the number of people reported to be living with an HIV diagnosis in 2008. The CDC has promised to offer site visits and in-depth assistance for health departments where funds were cut.
The CDC has not responded to a request for scientific evidence and disease models that prove their new funding formula is the best option to quell the spread of HIV.
What is HIV Prevention?
States have a three-pronged funding approach to controlling the spread of HIV:
* HIV medication;
* Surveillance or diagnoses count;
* Prevention, which include safe sex behavior education for HIV carriers or at-risk HIV persons.
The CDC requires health departments to use 75 percent of prevention funding for condom distribution, testing, health policy development and prevention with HIV-positives and their partners.
Bryan said the center realizes prevention funding was no longer proportionate to the epidemic and coupled with the release of the national strategy, took the opportunity to initiate “a process of readjusting its funding to eliminate resource inequities.”
Last year, Iowa had 12 HIV health education and risk reduction projects. Now it has one.
“It has a huge impact,” said Van Brocklin, the AIDS Project director, which is the last existing project. “Even the year prior, our prevention programs were able to reach a lot more people. Everything is up in the air right now. We’re not really sure what low-incidence states are supposed to do with this magnitude of cut.”
The AIDS Project is a non-profit HIV prevention service and isn’t connected to any hospital or clinic. That makes it harder to know what their jobs are going to look like in the future, Van Brocklin said. Ultimately, they’re just going to have to get creative, she said.
Iowa conducted 40 percent of its HIV testing outside of the clinic setting, but that was before the cuts, according to a 2009 Kaiser Family Foundation comprehensive study of HIV prevention nationwide.
“We’ve reached out to hundreds if not thousands of HIV at-risk people. How can we make sure they have access to testing and other services? What will that look like in the state?” she said.
Black Hawk County Health Department in Waterloo, Iowa, lost its $63,561 grant this year for their Sister to Sister program, which is conducted in a clinic setting and is directed towards black women ages 18 to 45. So far, none of the employees have lost their jobs.
Sister to Sister is a twenty-minute, one-on-one discussion session, in which health educators talk about safe-sex practices.
Judy Lindsey is one of the two health educators at Black Hawk County Health Department’s STD and HIV Clinic. She says they show videos, have condom use demonstrations and talk with women about risky sexual behavior.
The CDC reports that African Americans are the ethnic group most affected by HIV. Although they represent only 14 percent of the U.S. population, they accounted for 44 percent of new HIV infections in 2009.
Women Should Demand Condom Use
“A lot of women are dealing with guys who discourage them from using condoms,” Lindsey said. “A lot of women feel it’s the man’s responsibility to carry a condom, but I tell them hey, it’s alright to make sure you have your own condoms; you can always come back and get more.”
What the program has lost is marketing capabilities. Lindsey says the program previously made public service announcements at the local radio station and passed out flyers and brochures in public locales like bars.
She says the church is best way to reach out to the black community in Black Hawk County.
“The biggest challenge was getting into a church,” she says. “Ministers, black men especially, don’t want to acknowledge the fact that their congregation is engaging in sexual activity. It’s hard to convince a minister to announce that this service is available.”
Sister to Sister had success in the past working with the mission departments and praise groups at churches.
But the budget cut means Sister to Sister will have a difficult time continuing to reach out to the community of women who have not already been to their clinic.
“If anything happens to one component, it really affects the whole system,” said Hanson. “Iowa got severely cut, so we’re really having to take a step back and refocus.”
Hanson manages the department’s Ryan White Part B funding. The Ryan White Care Act gives states multiple levels of federal funding for antiretroviral, or HIV, medication. Iowa’s part B and C collectively provide services and financial assistance to help HIV patients pay for their expensive medications through the AIDS Drug Assistance Program.
ATRIPLA, one of the more popular drugs, costs $1,700 a month. Patients have a variety of coverage options so the drugs can average around $9,000 a year. Currently, HIV positive patients do not qualify for Medicaid coverage because the virus is not considered a disability until it has progressed into full-blown AIDS. In 2014, the Affordable Care Act will eliminate disability as a Medicaid qualification altogether.
“The drugs are very effective if you take them,” said Dr. Jeffery Meier, an HIV specialist at University of Iowa Hospitals and Clinics. “HIV is more of a chronic, manageable infection, and it doesn’t carry death sentence overtone that we had known many years ago.”
Clarification: To clarify a sentence in an earlier version of this story, the Affordable Care Act of 2014 will no longer include disabilities as one of the criteria for people to be eligible for Medicaid, because eligibility will be based only on income level. The story may have suggested that the act will continue using disabilities as a criteria, but qualify HIV as a disability.