DC’s plan has three sources of funding: (1) grants dedicated to ending the HIV epidemic; (2) core public HIV funding from federal and local sources, including health insurance and Veterans Health Administration estimates and other direct funding; and (3) nongovernment funds, through public-private partnerships and foundations.
The federal government has allocated three funding sources to its “Ending the HIVEpidemic: A Plan for America” initiative for planning and implementation. The funding is available for only 57 jurisdictions (48 counties, seven rural states, and Washington, DC, and San Juan, Puerto Rico). Here are brief descriptions of the funds with DC allocations, duration of funding, and program plans.
DC receives core HIV funding through the Ryan White program and CDC’s HIV programs, as well as certain targeted HIV programs from other federal agencies. The Milken Institute School of Public Health at The George Washington University prepares an inventory of HIV funding as part of the Washington, DC Regional Planning Commission on Health and HIV’s priority-setting and resource-allocation process. The following section is based on that analysis.
The national Ryan White program, administered at the federal level by the Health Resources and Services Administration (HRSA), supports HIV care and treatment. Ryan White Part A funds metropolitan areas substantially affected by HIV; Part B funds states (and DC). DC Health coordinates, and receives a portion of, the Washington Eligible Metropolitan Area (EMA) Ryan White Part A funds. For fiscal 2020, the District received $16,936,720 out of the EMA’s Part A allocation for the full range of Ryan White service categories; this included $1,254,545 in Minority AIDS Initiative funds. An additional $4,083,000 was allocated for unit-cost reimbursement of a set of Ryan White services across the EMA; the portion that reimburses services in the District will depend on the share of services provided by different agencies across the region.
Under Ryan White Part B, DC received $15,150,846 for FY20, including $11,499,140 for the AIDS Drug Assistance Program to fund medications and insurance support; and $195,519 of Minority AIDS Initiative funds.
Both Part A and Part B funds went to a broad range of agencies in the District to serve clients across all Ryan White core medical and support service categories:
Several DC organizations also receive Ryan White funding directly from HRSA. In fiscal 2020, four organizations received a total of $2,217,815 in Ryan White Part C funding for early intervention services, and one received $129,261 in Part C funding for capacity building. Another agency received $352,885 in Ryan White Part D funds to serve women, infants, children, and youths.
In fiscal 2020, DC received $6,830,917 in HIV prevention and surveillance funds from the CDC. The bulk was for integrated surveillance and prevention programs; $508,084 was allocated to HIV behavioral surveillance. Prevention efforts conducted by DC agencies using these funds include condom distribution; HIV prevention for high-risk negative individuals; full-range clinical support for HIV-positive individuals (treatment adherence, HIV screening, and linkages to care); HIV screening and linkages to care; and surveillance.
Community-based organizations in DC received a total of $2,092,593 in direct CDC grants for HIV prevention. These funds included:
The DC Office of the State Superintendent of Education received a total of $467,500 in fiscal 2020 for promoting adolescent health through school-based HIV/STD prevention and for school-based surveillance.
DC receives HIV-focused support through several funding streams from the federal Substance Abuse and Mental Health Services Administration (SAMHSA).
One agency has received $225,000 in fiscal 2020 for Proyecto ENLACE ‒ HIV, hepatitis, and substance misuse prevention and navigation for Latino young adult men who have sex with men; as well as $525,000 for a project titled Targeted Capacity Expansion – HIV Program: Substance Use Disorder Treatment for Racial/Ethnic Minority Populations at High Risk for HIV/AIDS. Howard University received $484,985 for the Howard University Minority AIDS Network Effort (HUMANE) Project.
SAMHSA’s block grants to states include a set-aside for HIV-focused services in those states with prevalence over a certain threshold. In fiscal 2020, DC received $174,214 in SAMHSA HIV set-aside funds; these were used for HIV testing and testing supplies.
The US Department of Housing and Urban Development administers the Housing Opportunities for Persons With AIDS Program (HOPWA), a housing assistance program for people living with HIV and for their families. In fiscal 2019 (the most recent year for which full data is available), five DC agencies received a total of $7,394,435 in HOPWA funding to provide the following services:
This funding included $716,350 from the Violence Against Women Act/HOPWA Program, which addresses the housing needs of women living with HIV who have experienced domestic violence, sexual assault, dating violence, or stalking.
Eight federally qualified health centers in DC receive grant funding from HRSA to provide comprehensive primary health care, regardless of clients’ ability to pay. While these funds are not targeted to HIV, a number of the health centers in DC serve a significant number of people living with HIV. Multiplying these health centers’ fiscal 2019 awards by the percentage of each of their patient populations living with HIV yields a total of $1,745,743, a very rough estimate of the proportion of these funds that may be supporting care for people living with HIV.
Insurance, both public and private, represents a major portion of expenditures for care and treatment for people living with HIV. While it is difficult to obtain claims data from private insurance issuers in the District, analyses and estimates have been completed for Medicaid, Medicare, and Veterans Health Administration funding.
The DC Department of Health Care Finance (DHCF) analyzed fiscal 2017 data to provide estimates of Medicaid expenditures for care for enrollees living with HIV. It found that more than $265 million in claims was paid for services for enrollees living with HIV, with slightly more than half of the expenditures in the fee-for-service program, and the rest for managed care enrollees. The expenditures were for all services for these enrollees, not only for HIV-specific care.
DHCF also found that in fiscal 2017, $2,847,301 in expenditures was made for people living with HIV enrolled in the DC Healthcare Alliance — a local health insurance program for people ineligible for Medicaid — and the DC Immigrant Children’s Program.
Specific Medicare claims data for people living with HIV in DC is not available. However, the Kaiser Family Foundation estimates that in fiscal 2019, more than $11billion of Medicare funds was spent for enrollees living with HIV across the U.S. For the purposes of this estimate calculation, it is based on a CDC report of 14,067 people diagnosed with HIV residing in DC at the end of 2018, out of a total of 1,012,040 people nationally. Using this ratio, a very rough estimate can be made that $153 million of Medicare funds were spent on care in 2019 for people living with HIV in DC.
The Veterans Health Administration (VHA) is an important source of HIV services, but, as with Medicare, specific VHA claims data is not available. A 2013 analysis identified 1,103 veterans receiving HIV care at VHA facilities in DC, out of 6,784 receiving HIV care at VHA facilities nationally. Multiplying this ratio by the estimated national expenditure for veterans receiving HIV care at VHA facilities across the country — $1,204,100,000 for fiscal 2019 — yields a very rough estimate of $50 million in VHA expenditures for HIV care in DC.
DC’s fiscal 2021 budget includes $4,164,000 in local funds for DC Health HIV programs, a figure that reflects local funds allocated minus TB- and STD-specific budget lines. These funds reflect both agency support and $965,000 for services provided by agencies.
DC also received $4 million in fiscal 2020 for HIV prevention and treatment as a component of the “federal payment” of congressional appropriations made to the District.
DC has a long history of philanthropic, corporate, and individual giving to support HIV programs. DC Health has leveraged income from its Ryan White Part B program in the form of pharmaceutical rebates to support core HIV staffing and related expenses. DC Health budgeted $2.6 million for FY21. DC Health has also sought funding for innovative projects on HIV testing from corporate sources, including Gilead Sciences.
DC Health has a longstanding collaboration with the Washington AIDS Partnership (WAP) on public-private projects over multiple years, including HIV testing, female condoms, and PrEP for Women. The latter project continues with support from corporate sources.
The Washington AIDS Partnership will award grants in 2021 totaling at least $500,000 in support of the revised DC plan to end the HIV epidemic. These grants will be responsive to the needs of the community and support implementation of key strategies outlined in the plan. The Washington AIDS Partnership has experience with grant-making in the areas of testing, rapid antiretroviral therapy (ART), PrEP, PEP, harm reduction, and wellness, all of which are included as key strategies.