HIV Prevention in the U.S.: The National HIV Prevention Inventory

Represents the nation’s chief health agency HIV/AIDS and viral hepatitis staff in all 50 states, the District of Columbia, Puerto Rico, the U.S. Virgin Islands and the U.S. Pacific Islands Provides technical assistance and other support to health department HIV/AIDS and viral hepatitis programs Provides national leadership on HIV/AIDS and viral hepatitis policy and programs Educates about and advocates for necessary federal funding National Alliance of State and Territorial AIDS Directors (NASTAD)

Represents the nation’s chief health agency HIV/AIDS and viral hepatitis staff in all 50 states, the District of Columbia, Puerto Rico, the U.S. Virgin Islands and the U.S. Pacific Islands

Provides technical assistance and other support to health department HIV/AIDS and viral hepatitis programs

Provides national leadership on HIV/AIDS and viral hepatitis policy and programs

Educates about and advocates for necessary federal funding

The Role of Health Departments Entrusted through U.S. law as the “central authorities of the nation’s public health system” and as such, bear the primary public sector responsibility for health ( “The Future of Public Health.” Institute of Medicine, January 1, 1988) Responsible for protecting and guaranteeing the health of constituents within jurisdictions’ borders Responsible for more than half of CDC’s domestic HIV prevention budget and a third of CDC’s domestic viral hepatitis prevention budget Responsible for significant HIV/AIDS and viral hepatitis funding from jurisdictional governments Responsible for implementing a comprehensive HIV/AIDS and viral hepatitis response in every jurisdiction in the U.S.

Entrusted through U.S. law as the “central authorities of the nation’s public health system” and as such, bear the primary public sector responsibility for health ( “The Future of Public Health.” Institute of Medicine, January 1, 1988)

Responsible for protecting and guaranteeing the health of constituents within jurisdictions’ borders

Responsible for more than half of CDC’s domestic HIV prevention budget and a third of CDC’s domestic viral hepatitis prevention budget

Responsible for significant HIV/AIDS and viral hepatitis funding from jurisdictional governments

Responsible for implementing a comprehensive HIV/AIDS and viral hepatitis response in every jurisdiction in the U.S.

National HIV Prevention Inventory (NHPI) Background and Methodology Partnership between NASTAD and the Henry J. Kaiser Family Foundation Survey of all 65 CDC-funded health department HIV prevention programs in February / March 2008 58 respondents All 50 states 6 directly-funded localities Washington D.C. and Puerto Rico

Partnership between NASTAD and the Henry J. Kaiser Family Foundation

Survey of all 65 CDC-funded health department HIV prevention programs in February / March 2008

58 respondents

All 50 states

6 directly-funded localities

Washington D.C. and Puerto Rico

NHPI Background and Methodology Data collection categories Funding and resource allocation HIV prevention community planning HIV testing HIV partner services Health education / risk reduction Other HIV prevention strategies Public information / media Collaboration and integration Challenges and the future of HIV prevention

Data collection categories

Funding and resource allocation

HIV prevention community planning

HIV testing

HIV partner services

Health education / risk reduction

Other HIV prevention strategies

Public information / media

Collaboration and integration

Challenges and the future of HIV prevention

NHPI Key Findings Funding for HIV prevention has been relatively flat in recent years; while funding from CDC represents just over half the nation’s prevention budget, states provide key share. Jurisdictions with greater numbers of people living with HIV/AIDS have the largest prevention budgets, but do not rank at the top in funding per person with HIV/AIDS. An array of HIV prevention services is provided across the country, including health education and risk reduction activities, partner services, and HIV testing. Health departments are increasingly moving to routine population-based HIV screening, while continuing more targeted efforts to reach those at higher risk. Health departments face numerous challenges, primarily due to funding shortages, which affect their prevention capacity and have resulted in some scaling back.

Funding for HIV prevention has been relatively flat in recent years; while funding from CDC represents just over half the nation’s prevention budget, states provide key share.

Jurisdictions with greater numbers of people living with HIV/AIDS have the largest prevention budgets, but do not rank at the top in funding per person with HIV/AIDS.

An array of HIV prevention services is provided across the country, including health education and risk reduction activities, partner services, and HIV testing.

Health departments are increasingly moving to routine population-based HIV screening, while continuing more targeted efforts to reach those at higher risk.

Health departments face numerous challenges, primarily due to funding shortages, which affect their prevention capacity and have resulted in some scaling back.

NHPI Analysis—Jurisdictions by HIV/AIDS Prevalence AL AR GA ID IN KY MO MT NV OH SC SD TX VA WY OK ME AK CO LA UT CA KS MS FL NM AZ ND MN IA WI MI NE WA PA NC TN WV OR Low Prevalence Moderate Prevalence High-to-Mod Prevalence High Prevalence Directly-funded localities (Chicago, Houston, LA County, New York City, Philadelphia and San Francisco) IL NY HI NH VT RI MA CT NJ DE MD DC

NHPI Domestic HIV Prevention Funding

NHPI Domestic HIV Prevention Funding 38 jurisdictions provide funding in addition to federal government funds: $205,265,640 (35% of FY2007 total) 5 provided more funding than received from the federal government (CA, IL, MA, NYS and PA) 19 provided no funding Funding Range: $642,291 – $87,882,244 Average Award (Mean) : $10,585,862 Average Award (Median): $3,127,962

38 jurisdictions provide funding in addition to federal government funds: $205,265,640 (35% of FY2007 total)

5 provided more funding than received from the federal government (CA, IL, MA, NYS and PA)

19 provided no funding

Funding Range: $642,291 – $87,882,244

Average Award (Mean) : $10,585,862

Average Award (Median): $3,127,962

NHPI Domestic HIV Prevention Funding

NHPI Domestic HIV Prevention Funding Funding per HIV/AIDS case Funding Range: $250.00 – $4,799.00 Average Per HIV/AIDS Case Funding: $802.00 Funding per capita Highest Per Capita Funding: $0.41 – $11.30 Average Per Capita Funding: $1.93

Funding per HIV/AIDS case

Funding Range: $250.00 – $4,799.00

Average Per HIV/AIDS Case Funding: $802.00

Funding per capita

Highest Per Capita Funding: $0.41 – $11.30

Average Per Capita Funding: $1.93

NHPI Domestic HIV Prevention Allocation and Trends Funding allocation 60% to external entities ($350 million) 34% to health education/risk reduction ($198 million) 26% to HIV testing and partner services ($152 million) Funding trends FY2004-FY2005: $9.7 million increase 29 jurisdictions had decreases FY2005-FY2006: $1.3 million increase 36 jurisdictions had decreases FY2006-FY2007: $34.5 million increase 22/30 jurisdictions with increases were part of the CDC Expanded HIV Testing Initiative (PS07-768)

Funding allocation

60% to external entities ($350 million)

34% to health education/risk reduction ($198 million)

26% to HIV testing and partner services ($152 million)

Funding trends

FY2004-FY2005: $9.7 million increase

29 jurisdictions had decreases

FY2005-FY2006: $1.3 million increase

36 jurisdictions had decreases

FY2006-FY2007: $34.5 million increase

22/30 jurisdictions with increases were part of the CDC Expanded HIV Testing Initiative (PS07-768)

NHPI Community Planning

NHPI HIV Testing *All states implement targeted HIVCTR

NHPI HIV Testing Comparison of NHPI data and 2006 NASTAD HIV testing data; “Increased” = initiated and/or expanded testing.

NHPI HIV Testing Focus of Changes Removal of requirements for separate written informed consent Requirement of HIV testing for pregnant women and/or newborns

Focus of Changes

Removal of requirements for separate written informed consent

Requirement of HIV testing for pregnant women and/or newborns

NHPI Partner Services

NHPI Partner Services Partner Notification Partner Elicitation

NHPI Partner Services

NHPI Health Education / Risk Reduction

NHPI Health Education / Risk Reduction

NHPI Other HIV Prevention Strategies

NHPI Public Information Message Themes Target Audiences

NHPI Collaboration and Integration “ Purview” = AIDS director has oversight of program.

NHPI Collaboration and Integration

NHPI Collaboration and Integration

NHPI Challenges and Consequences CLIENT LEVEL CONSEQUENCES Top Ranked Challenges Faced by Health Department HIV Prevention Programs (n=57) Rank Funding 1 Capacity of community / clinical partners to access target population 2 Capacity of community / clinical partners to provide services 3 Workforce 4 Data collection and reporting requirements 5 Top Ranked Consequences Faced by Health Department HIV Prevention Programs (n varies) Rank Appropriate prevention interventions are not available for high-risk populations 1 Clients are not able to be proactively recruited into prevention programs 2 Clients are not able to be retained in prevention programs 3 Fewer community based partners are currently funded 4 Targeted high-risk individuals are not be tested 5 Resources are diverted from actual programming to meet the needs of other requirements 6 Relationships with non-traditional partners have not been established 7 Fewer community based partners are in existence 8 Inability to fill prevention staff positions due to lack of qualified technical expertise 9 Inability to fill prevention staff positions due to lack of resources 10

NHPI Challenges and Consequences

NHPI The Future Scale Up Scale Back

NHPI take away messages While CDC plays a central, national role, HIV prevention is actually “decentralized” to jurisdictions who have the primary responsibility for coordinating and delivering services and activities. A core set of HIV prevention services and activities are provided in all jurisdictions, though to varying degrees and in different ways. Funding for HIV prevention programs varies greatly across the U.S. Funding was cited as THE greatest challenged faced by health departments.

While CDC plays a central, national role, HIV prevention is actually “decentralized” to jurisdictions who have the primary responsibility for coordinating and delivering services and activities.

A core set of HIV prevention services and activities are provided in all jurisdictions, though to varying degrees and in different ways.

Funding for HIV prevention programs varies greatly across the U.S.

Funding was cited as THE greatest challenged faced by health departments.

New Realities— State General Revenue Cuts in HIV/AIDS and Viral Hepatitis Programs (09.2009) 45% of state HIV/AIDS programs have experienced a decrease in state funding in FY2009 (Anticipated total: $167,000,000 74% experienced cuts to HIV prevention programs 64% of states anticipate a decrease in state funding in FY2010 153 open FTEs (Full Time Equivalents) within state HIV/AIDS programs; 66 positions have been eliminated California’s HIV prevention FY2009-2010 budget was cut by more than $30 million, effectively removing more than 20 percent of the total funding we report.

45% of state HIV/AIDS programs have experienced a decrease in state funding in FY2009 (Anticipated total: $167,000,000

74% experienced cuts to HIV prevention programs

64% of states anticipate a decrease in state funding in FY2010

153 open FTEs (Full Time Equivalents) within state HIV/AIDS programs; 66 positions have been eliminated

California’s HIV prevention FY2009-2010 budget was cut by more than $30 million, effectively removing more than 20 percent of the total funding we report.