An alert went out to health agencies in late summer: the number of Coloradans diagnosed with HIV was on the rise, especially women.
The state health department is now predicting 455 people will receive HIV diagnoses by the end of 2019, up from 409 last year. And this comes after more than a decade of promise in HIV prevention, including a breakthrough drug that was a game-changer for public health.
At the same time, Colorado clinics that provide HIV testing and PrEP, the once-a-day preventative pill, are seeing their budgets slashed, and with little notice.
The Colorado Department of Public Health and Environment informed the agencies this month of funding reductions from 25% to 87% beginning in January, igniting a clash between state officials and a community group that for decades has advised the state about HIV and AIDS prevention.
The cuts are the result of a calamitous trifecta of expiring grants, a new legal interpretation of how dollars are spent and past mismanagement of funds that meant the state had to return almost $8 million to the federal government, according to a Colorado Sun review of health department memos.
The U.S. Health Services and Resources Administration, HRSA, awarded Colorado $13.1 million in 2017 under the national Ryan White program aimed at helping people living with HIV and AIDS. But since the state failed to spend at least 75% of the funds per year – the threshold set by the federal government – Colorado had to return $7.9 million over four years.
The state gave back $757,000 in 2015, $4.3 million in 2016, $2.5 million in 2017 and $357,000 in 2018.
Wasting the funds seems even more reckless now, HIV alliance members say, as clinics that work to prevent the spread of HIV are taking big hits to their budgets. It’s not yet clear if the cuts will mean loss of jobs or inability to provide care.
More than 14,000 Coloradans are living with HIV, according to the state health department.
Barb Cardell, who has been living with HIV since 1991 and is a member of the Colorado Alliance for HIV Prevention, Care and Treatment, said the alliance has long had a respectful relationship with state public health officials — but that relationship has been damaged in recent months.
The alliance is calling for more transparency about state spending and an explanation for why funds intended to support HIV and AIDS work were reverted to the federal government.
“As activists and members of the community, we are very concerned about these irrational activities within the division and the significant negative impact this will have on those living with and at risk of acquiring HIV,” Cardell said. “I’m talking about my friends, some of whom have died.”
In addition to returning the federal dollars, the Colorado Attorney General’s Office advised the health department in September that it should no longer use supplemental rebate dollars for HIV prevention. Instead, the state should spend the funds under the same guidelines used in the Ryan White program, which is for people who already have HIV or AIDS – not for prevention. The program is named after an Indiana boy who contracted AIDS through a blood transfusion in 1984.
Colorado had been using the rebate money for prevention, but state officials said it now will go only toward treatment.
And on top of that news, a four-year, $1 million-per year grant flowing to Colorado from the Centers for Disease Control and Prevention ends this year.
Jill Hunsaker Ryan, executive director of CDPHE, has asked her staff for a review of financial controls to make sure the state is following all of its grant guidelines and getting contracts out on time to community agencies that provide various services.
“Are we making sure that funds aren’t being reverted?” she said, noting that the accounting failure dates back a few years and before she was appointed by Gov. Jared Polis. “I have a pretty good comfort level of where we are today, but I just want complete assurance that the problems we’ve had in the past don’t occur in the future.”
She also vowed to look for other dollars the department could use to shore up funds for community clinics working on HIV prevention until the state can figure out sustainable funding. Support for the clinics comes from a dozen sources, including grants with varying timeframes and pharmaceutical rebates.
As for the new legal advice that Colorado should follow the Ryan White program guidelines and not spend those dollars on prevention, Hunsaker Ryan said she is not finished with that conversation. It came to her attention only recently that other states are continuing to use the money to pay for pre-exposure prophylaxis (called PrEP) to prevent HIV in communities that are at risk.
“In my mind, the issue isn’t quite settled yet and it’s something I want to look further into,” she said. “The more discretion that programs have to use these dollars, the easier it is for us to respond to the needs of the community.”
The daily antiviral became available in 2012 and is sold under the brand name Truvada. Without insurance, PrEP can cost up to $2,000 per month.
The prevention pill was not on the radar when Congress wrote the rules for the Ryan White program. Public health officials have questioned whether it’s time for policymakers to update the law.
Tony Cappello, director of the department’s Division of Disease Control and Public Health Response, warned the alliance about the looming budget issues in September. But details about how drastic the cuts were did not come until this month.
The 14 clinics involved in HIV prevention and testing — which include Denver Health, Planned Parenthood and It Takes a Village — will see a combined loss of more than $2 million this year for prevention and an additional $737,000 loss for HIV testing.
“We recognize that this will cause difficulties for our partners,” Cappello wrote to the Alliance on Nov. 12. “We are committed to helping ensure that program and service delivery remains as stable as possible given the circumstances and appreciate continued partnership and collaboration.”
Hunsaker Ryan said HIV prevention remains one of the top priorities of the state health department.
“It’s just critical that we are able to keep up our prevention response and keep people from acquiring this disease, because it’s possible,” she said.