How the debt ceiling deal with affect HIV programs and people living with HIV

In early June, President Biden and Democrats and Republicans in Congress reached a compromise deal to raise the ceiling on the national debt only days before the government would have run out of money, which likely would have triggered an economic crisis. Democrats wanted to preserve spending on social programs; Republicans saw slashing domestic spending as the way to reduce the deficit. The compromise, Biden said, meant “no one got everything they wanted.” With its limits on federal spending for the next two years, what does the Fiscal Responsibility Act of 2023 mean for HIV programs, and how will it affect people living with HIV?

The budget deal keeps non-defense spending flat in fiscal year 2024, with a 1% increase in FY 2025. Defense spending would get a 3% raise. Adjusted for inflation, this means everyone’s budget will in effect see a net loss.

“The two things that have the biggest chance of impacting people living with and affected by HIV are the overall non-defense discretionary spending cap and the smaller pool of money that we will have to fight for,” says Drew Gibson, director of advocacy at AIDS United.

How much smaller is that pool of money? Creative accounting, vague wording and political maneuvering make the answer anything but clear. One of the biggest uncertainties surrounds roughly $30 billion in unspent COVID-19 funding intended to pay for a variety of programs, and not all of them are related to public health. Republicans clawed back the money, claiming a win for their side in the budget battle. Included in that unspent money was $400 million for the CDC’s disease intervention specialists program intended in part to help build up public health infrastructure, including STI prevention. Public health leaders have expressed concern that the loss of COVID money could set back STI efforts by years.

“We don't know if that money's been cut or not,” Gibson says. “The White House released a list of things that had been or were going to be rescinded, but it's not specific enough to know whether or not those funds are actually impacted.”

The budget cap comes just as the CDC reported a continued decrease in the incidence of HIV and a higher uptake of PrEP—while communities of color continue to see deepening disparities. Gibson believes that advocates can point to the overall progress to make the case for why HIV funding needs to be preserved to address the disparities.

“There is still horrible racial inequity in both new transmissions and in PrEP usage which needs to be addressed” Gibson says, “but where progress is being made, we can go to Republican offices and Democratic offices and say, we did this, we need to continue.”

One hope is that Biden could still submit a FY 2024 budget that includes funding for this and other public health priorities, but it would have to be passed by a Republican-controlled House and a Senate in which Democrats hold a tenuous lead. Making things even more complicated is a provision within the debt ceiling deal that would institute a an across the board 1% cut on all appropriations bills that are not passed by New Year’s Day 2024.

Another prevention program facing an uncertain future is Biden’s announced national PrEP program. The FY 2024 budget proposal called for an initial $237 million investment in what would eventually be a $9.8 billion, 10-year plan that would provide access to HIV prevention medication and laboratory services at no cost for uninsured and underinsured people and greatly expand the network of PrEP providers supporting underserved communities.

“Even before this debt ceiling agreement was signed, the way that the Biden administration put it forward as a mandatory program, and with the amount of money that was going to be dedicated to it, this was always going to be incredibly hard to get done,” concedes Gibson. 

A similar mandatory program to eliminate hepatitis C in the U.S. proposed spending $11.3 billion over five years. Gibson says getting that money is more difficult now, but explains why it’s not impossible.

“The White House favors mandatory programs because they're able to use offsets and budgetary sleight of hand to show these as cost savings, as opposed to spending on discretionary programs,” he said. “That's a large part of why the White House has done mandatory programs; it allows them to support big programs and at the same time say, look at all the money that we’re saving.”

Whether Republicans will buy that remains to be seen. Selling these proposals has become more challenging with the changing makeup of Congress—on both sides of the aisle.

“We've lost a lot of Republicans who were at least quiet champions for us in recent times, and we're losing Democrats,” Gibson says. “David Price [a Democrat] retired last Congress; he had been the chair of Transportation, Housing and Urban Development [and Related Agencies] Subcommittee for years and was a tremendous HOPWA [Housing Opportunities for Persons with AIDS] advocate. Barbara Lee [Democrat, 12th District, California], is running for Senate. If she doesn't win, there goes arguably the biggest HIV advocate we've ever had in Congress. And Pelosi is going to retire eventually. Those are big shoes to fill.”

Not every federal dollar that gets budgeted, though, is counted against the budget. Congress often passes emergency supplemental funding bills that are not subject to budget caps—disaster relief for hurricanes or tornadoes and aid to Ukraine, for example. COVID-19 was one of the few exceptions, but emergency supplemental bills for public health can have a hard time gaining traction.

That makes advocacy in the halls of Congress—and in state legislatures across the country, which often determine how the money is distributed at the state and local levels—essential to push back against budget cutbacks, Gibson says.

“It's easy for politicians to get caught up in culture wars,” he says. “The farther removed they are from the reality of people's lives—their constituents’ lives—the easier it is to cut funding for things that don't directly impact them. I really believe that with the breadth and diversity of folks that are living with and affect by HIV in this country, there's tremendous work we can be doing to sway legislators away from making really harmful decisions.”