by Kim Krisberg
Just a few years ago in Butte County, Calif., it wasn't unusual for public health workers to administer more than 1,000 free HIV tests every year. In true public health fashion, they'd bring screening services to the people, setting up in neighborhoods, parks and bars, at special community events and visiting the local drug treatment facility and jail. The goal was prevention and education, and no one got turned away.
That was before 2009, which is when California state legislators cut millions in HIV prevention and education funds from the state budget. The cut meant that Butte County Public Health had to completely shutter is HIV screening and education program. A quick visit to the department's HIV/AIDS web page reads:
"Due to recent state budget cuts the state sponsored counseling and testing program has been eliminated in Butte County. These services continue only in select California counties with high HIV incidence.
Anonymous and confidential HIV testing and counseling used to be a free service under this program. Due to the cuts we will no longer be able to provide free HIV testing at outreach testing and alternative anonymous test sites."
Today, the department does about 50 HIV screenings a year, most of them related to partner testing as part of HIV treatment and case management services, said Kiyomi Bird, program manager in Butte County Public Health's Communicable Disease and Emergency Response Division.
"Bringing services to the people and giving them the education and saying 'we can test you for free right now' is a huge incentive for a lot of people to get tested," Bird explains. "It would be fair to say that a good portion of those folks probably would not have been tested had we not gone and reached out to the them.
"What we're seeing in our county — and I'm confident that this is reflected throughout the state — is that the number of cases of HIV being detected has gone down since funding has been reduced, and it's not because there's less disease out there,” Bird said.
For Butte County, in particular, the HIV case detection rate has dropped by at least half since funding was cut and Bird noted that it's not because of a drop in transmission, but because of a drop in screening.
Despite the funding setback, Bird said Butte County Public Health is determined to observe National HIV Testing Day on Wednesday, June 27.
"This is one day we all really try to recognize and participate in," she said. "It's an opportunity to reinvigorate the community in regard to responding to the HIV epidemic and remind people not to forget the importance of testing."
Time to get tested
In 1995, the National Association of People with AIDS (NAPWA) founded National HIV Testing Day, which takes place every June 27. The observance was the very first AIDS awareness day in history, according to Frank Oldham Jr., president and CEO of NAPWA. This year, the association has a number of events planned for the observance, including an invitation to all members of Congress to get tested at a mobile HIV testing van that will be parked just blocks from the U.S. Capitol building in Washington, D.C., on June 26.
Oldham said he's "extraordinarily worried" about the impact that state budget cuts are having on screening services, noting that health departments are major players in the efforts to get people screened and linked to treatment.
"Cutting budgets and reducing the amount of care that people can access is detrimental not only to people living with AIDS, but for all of us," he said. "This is wrong and it shouldn't happen...these cuts cost lives."
The National Coalition of STD Directors reports that 69 percent of states cut sexually transmitted disease funding in 2009. The coalition noted that such cuts cost more in the long run: For every HIV infection that is prevented, an estimated $360,000 is saved in the cost of providing a lifetime of HIV treatment.
According to the Centers for Disease Control and Prevention, the United States was home to about 50,000 new HIV infections annually from 2006 to 2009. Since the first cases of AIDS appeared in the United States, 1.7 million people are estimated to have been infected, including more than 619,000 who have died. As of 2008 — the most recent year for which data is available — about 1.2 million U.S. residents were living with HIV, according to AIDS.gov. Still, about one in five residents who have HIV are unaware of it. Knowing HIV status dramatically reduces the risk that people will transmit the disease.
Natalie Cramer, director of prevention at the National Alliance of State and Territorial AIDS Directors, said federal funding for HIV prevention and screening has remained about level in recent years, however the way it's being distributed has changed. As of this year, CDC is using a new funding methodology that shifts more funding to regions that are home to the highest HIV burdens. The funding shift coupled with state budget cuts means that some states and communities are experiencing severe funding reductions.
"While certainly there's been shifts in funding and while there have been cuts at the state level, I would say that testing is really an area that continues to be prioritized as a first line of defense," Cramer told me. "Health departments are absolutely on the frontline of a coordinated response to the HIV epidemic. And while we're increasingly seeing people getting tested as part of routine (primary) care, many of the people who health departments see are more marginalized, people who may not have a medical home, who are really on the periphery...public health programs are well equipped to find people where they are and find folks who are most in need."
'A short-sighted approach'
In Memphis, Tenn., a short-lived suspension of free HIV testing services wasn't the result of HIV funding cuts per se, but a collateral effect of a larger legislative assault on Planned Parenthood. Early this year, Tennessee legislators cut off Planned Parenthood's access to HIV prevention funds. The move meant that the Memphis Gay & Lesbian Community Center had to shutter its free HIV screening services — the only after-hours HIV screening service in the area.
For three years, the center had partnered with Planned Parenthood to provide free HIV testing and education on site four times a month. They typically tested about eight to 10 people every week, said Will Batts, the center's executive director. Luckily, Planned Parenthood promptly sued and a judge reinstated the funds, so the center's screening services were only down for a week. Still, "we had 10 people that week that we had to turn away...it was very frustrating," Batts told me. Today, Batts said the center is in the process of building the capacity to do HIV screening completely on its own.
"It's so important for our community to have access to testing," he said. "If we have a community where HIV rates are rising, which is what's happening in the gay community, screening will give people the tools to protect themselves."
In Illinois, HIV prevention took a huge hit when lawmakers recently enacted a budget that cuts funding for HIV prevention, care and related housing programs by 42 percent. The cut, which goes into effect in July, will result in an estimated 6,500 fewer HIV tests being administered and "will undoubtedly result in new HIV infections," said Ramon Gardenhire, director of government relations at the AIDS Foundation of Chicago.
While it's too early to say for sure, Gardenhire said the cuts will likely mean some organizations will have to eliminate free testing, begin charging a fee or possibly shut their doors altogether. He noted that communities already hardest hit by the epidemic would be most impacted by the budget cuts.
"We acknowledge the fact that Illinois was in a dire fiscal situation, but we should make public policy decisions based on being cost-effective," Gardenhire told me. "We have done a tremendous job in the state of educating people on the importance of knowing their HIV status...these cuts just undermine that work. It's a short-sighted approach to save some money."
Kim Krisberg is a freelance public health writer living in Austin, Texas, and has been writing about public health for a decade.