Last week, we convened the first in a series of ongoing discussions about the policies, formulas, and other factors that determine how Federal HIV/AIDS resources are allocated across the United States to departments of health, community-based organizations, and other grantees providing HIV/AIDS services. Participating in the discussion were personnel from the Department of Health and Human Services (HHS), Department of Housing and Urban Development (HUD) and the White House’s Office of National AIDS Policy (ONAP), the Office of Management and Budget (OMB), and the Presidential Advisory Council on HIV/AIDS (PACHA). More than 20 HIV community stakeholders representing States, cities, service providers, policy advocates, academia and other perspectives joined in the discussion and offered valuable input. (View a full list of participants .)

In pursuit of the National HIV/AIDS Strategy’s goal of reducing new HIV infections, we must intensify HIV prevention efforts in communities where HIV is most heavily concentrated. This requires that governments at all levels – Federal, State, local and tribal – ensure that HIV/AIDS funding is allocated consistent with the latest epidemiological data and is targeted to the highest prevalence populations and communities. Toward this end, the NHAS Federal Implementation Plan tasked HHS with the responsibility of initiating consultations with the Centers for Disease Control and Prevention (CDC), Health Resources and Services Administration (HRSA), Substance Abuse and Mental Health Services Administration (SAMHSA), HUD, and other departments or agencies as appropriate to develop policy recommendations for revising funding formulas and policy guidance in order to ensure that Federal HIV allocations go to the jurisdictions with the greatest need.

In this initial discussion we set out to establish a clear understanding of what policies and formulas are used when resources for HIV/AIDS prevention, care or housing support are allocated to jurisdictions and providers by CDC, HRSA, SAMHSA and HUD’s Housing Opportunities for Persons with AIDS (HOPWA) program. As a result of the thorough presentations by key officials from each agency, we established that a variety of approaches govern these actions. Some are Congressionally mandated and others are based on historical precedent. Also, it is worth noting that the Federal organizations who presented at this meeting represent programs with distinct purposes, that they often have different accountability measures, and that they distribute funds to a variety of entities (State agencies, local health departments, and non-governmental organizations including community-based and faith-based organizations).

During the thoughtful discussion that followed the presentations, we considered a range of issues including:

• Some merits as well as potential drawbacks to required minimum funding levels and “hold harmless” provisions that limit the size of any reductions in HIV/AIDS funding levels from year to year.
• Questions of how well the State or local level targeting of HIV/AIDS funds follows the epidemic and methods to enhance measuring and monitoring of this.
• The need for and benefits of better coordination of both formula-based and competitively awarded programs at the local and State levels to leverage resources, prevent duplication and avoid gaps.
• The “prevention paradox” – that under some formula models jurisdictions that are effective at reducing new infections through effective prevention efforts could ultimately receive reduced funding to sustain those efforts if funding is based primarily on new HIV/AIDS cases.
• The epidemiologic and economic consequences of achieving the NHAS goals, examining models for the potential lives and resources saved as well as funds needed.
• Various perspectives on the characteristics and circumstances of jurisdictions or types of activities that are perceived to be under- or over-funded.
• Sources of data on which formulas are based and weights or other factors that are or could be considered when calculating formulas.
• Possible approaches to making better use of existing resources to achieve the Strategy’s goals should new resources be limited or unavailable.
• Whether or how cost-effectiveness of various interventions should be considered in decisions about resource allocations.
• How the “12 Cities Project” could be a laboratory for optimization of resources and interventions tailored to local epidemiology, needs and infrastructure.
• And, of course, challenges and possible consequences (intended and otherwise!) inherent in changing any formulas.

If anyone arrived thinking there were simple solutions, they clearly departed the meeting understanding that there are many unknowns, tensions and complexities inherent in this issue. No specific recommendations were developed as a result of this meeting but the issues raised provide an excellent platform upon which to build future discussions with other sectors, advocates, and community representatives.

What are your thoughts about what should be considered when establishing policies and funding formulas for Federal HIV prevention, care, treatment and housing support programs? Share your thoughts in the comments section below.

Through continued assessment and dialogue, we hope to address any instances where Federal formulas result in resources not following the epidemic as closely as they should. At the same time, for those funds that are following the epidemic, we must ensure that they are ultimately reaching the right people with the right interventions at the right scale. An important responsibility for HHS in the next year is to work with colleagues inside and outside of government to consider any needed changes to funding policies and funding formulas so as to ensure that public funding matches the U.S. epidemic.