Putting Politics Ahead of Public Health is Spelling Trouble for Tennessee

By: Ranier Simons, ADAP Blog Guest Contributor

In 2023, Tennessee Governor Bill Lee, rejected nine million dollars in federal HIV funding from the Centers for Disease Control & Prevention (CDC). This meant that the pass-through grant contracts associated with the Integrated HIV Programs for Health Departments to Support Ending the Epidemic in the United States CDC-RFA-PS20-2010 grant and the Tennessee Integrated HIV Surveillance and Prevention Programs for Health Departments CDC-RFA-PS18-1802 grant ended in May of 2023.[1] The decision meant a significant cut in funding for HIV prevention, education, and treatment for public health centers and many community-based organizations. The adverse effects of the decision are materializing, and experts continue to sound the alarm about how devastating the outcomes will impact the state.

Photo Source: The Tennessee Conservative

The governor stated he refused the funds to decrease dependence on federal funds and be more independent as a state. He also expressed that the move was to make it easier for organizations and public health departments to access funding without having to deal with bureaucratic red tape.[2] However, analysis shows that the decision was politically motivated. Lee is on public record expressing disapproval of two organizations that were HIV grant recipients, Planned Parenthood and a task force on transgender health issues.[3] Refusing CDC funding means that the state is no longer required to distribute funding based on science, evidence-based data, and research. The goal of the state was to replace the CDC funds with state funding.

In response to Tennessee’s refusal of funding, the CDC decided to try and circumvent the legislature. It decided to directly provide four million dollars in funding to United Way of Greater Nashville.[4] This would allow United Way to distribute funds to nonprofit organizations, such as Planned Parenthood, to continue their HIV prevention efforts. However, four million dollars is only half of the nine million dollars refused.

When the state government replaced the lost CDC funding with state funding, it was mainly local health departments that were guaranteed funding to make up for the cuts.[4] This meant the state health departments could make decisions concerning funding distribution that did not require alignment with CDC requirements. This was eventually followed by an announcement to reallocate funding away from the most at-risk priority communities, such as men who have sex with men, to new groups. The new groups are first responders, pregnant women, and survivors of sex trafficking. Studies are showing that this will result in unnecessary deaths and poor health outcomes because this group is not where the need resides.

Photo Source: Clinical Infectious Diseases

A study published in July of this year in the journal Clinical Infectious Diseases spells out the negative ramifications of Tennessee’s state resource allocation. Men who have sex with men, transgender women, and heterosexual Black women are the evidenced-based identified priority demographic most affected by HIV in Tennessee.[5] The study projected conservative estimates the Tennessee decision would mean 166 preventable HIV transmissions, 190 additional deaths, and 843 life-years lost over 10 years. The study’s more pessimistic or worst-case scenario projections were 1359 preventable HIV transmissions, 712 additional deaths, and 2,778 life-years lost over 10 years.[5] 

Comparatively, this means the reallocation in funding would be prohibitively damaging to the original priority group with negligible benefit for the new priority pivot. “Under Reallocation, MSM would comprise most of the HIV transmissions (77%), followed by TGW (8.6%) and HSBW (6.8%). First responders would contribute 0.5%, pregnant people 0.2%, and SST 6.9% to the total HIV transmissions over 10 years.”[5] The newly suggested priority populations only comprise %1 of all Tennesseans living with HIV compared to the CDC-defined priority populations, which comprise %99 percent.[6]

Funding losses have already begun to negatively affect agencies serving vulnerable populations. Before the change, CDC grant money provided stability for HIV programming for five years at a time. The new state-provided funds happen on a one-year cycle. The one-year budget rides on the auspices of the state legislature, which votes on it each year.[7] Reduced funding means loss of staff for many organizations. According to Amna Osman, CEO of Nashville CARES, “There’s no sustainable grant funding to support these positions…Employees really want some stability.”[7]

Moreover, the new funding plan routes money mainly to metro state health departments and groups associated with them. This translates into a drastic cut to resources for those in rural areas in addition to groups who, under the new reallocation priorities, would not be able to garner funding from the state. 

Photo Source: The New York Times

The motivation behind the original CDC funding was to concentrate efforts on HIV prevention, education, and treatment for those most in need in Tennessee. Prevention requires testing, surveillance, access to PrEP, and more. Before the funding reallocation, a third of those most in need of PrEP did not know where they could access it. Now, issues of access have worsened. Osman states she has heard from community members who say, “Well, I’m hearing there’s no dollars for prevention education for HIV. Then, that means ‘I think there’s no money for me to get a service,”[7] Memphis, Tennessee is second in the nation regarding the rate of new HIV cases. Over 7,500 people in Shelby County alone are living with HIV or AIDS.[8] That number is second only to Miami, Florida.[8]

HIV prevention and testing is not just about HIV. Testing involves STI testing. STI testing benefits the entire community as a public health safeguard as well as a tool in the fight to prevent HIV transmission. People living with HIV do not live in a vacuum, nor do those living with STIs. Effectively focusing funding and infrastructure on the populations that science and health professionals have identified as significantly at risk is the only way to reverse the tide in all of Tennessee’s communities. Only time will tell if voting and continued public and professional outcry, in combination with pressure from the medical community, will result in the legislature changing its course.

[1] Talley, P. (2023, January 17). Dear Colleagues Letter. Retrieved from https://wpln.org/wp-content/uploads/sites/7/2023/01/Notification-HIV-Funding-Changes.pdf

[2] Stillman, J. (2023, April 22). Tennessee Rejected HIV Funds From Feds, But The State Was Just Outsmarted. Retrieved from https://www.hivplusmag.com/politics/tennessee-rejected-hiv-funds-from-feds-but-the-state-was-just-outsmarted

[3] Cha, A., Nirallil, F. (2023, Januery 26). HIV at center of latest culture war after Tennessee rejects federal funds. Retrieved from https://www.washingtonpost.com/health/2023/01/26/tennessee-federal-hiv-funding/

[4] Watts, M. (2023, April 17). Federal HIV funding rerouted to nonprofits, bypasses Tennessee health department entirely. Retrieved from https://www.tennessean.com/story/news/local/2023/04/17/hiv-federal-funds-will-reroute-to-tennessee-nonprofits-state-cut-out/70116510007/

[5] Borre, E. D., Ahonkhai, A. A., Chi, K. K., Osman, A., Thayer, K., Person, A. K., Weddle, A., Flanagan, C. F., Pettit, A. C., Closs, D., Cotton, M., Agwu, A. L., Cespedes, M. S., Ciaranello, A. L., Gonsalves, G., Hyle, E. P., Paltiel, A. D., Freedberg, K. A., & Neilan, A. M. (2024). Projecting the potential clinical and economic impact of human immunodeficiency virus prevention resource reallocation in Tennessee. Clinical Infectious Diseases. https://doi.org/10.1093/cid/ciae243

[6] Ridings, M. (2024, July 11). Study Finds That Tennessee’s Shift in HIV Prevention Funding Will Lead to Poorer Health Outcomes for its Residents. Retrieved from https://www.massgeneral.org/news/press-release/tennessee-shift-in-hiv-policy-will-lead-to-poorer-outcomes

[7] Sweeney, C. (2024, October 22). Tennessee replaced its federal HIV funding with state money. Public health experts say the change is causing damage. Retrieved from https://www.wkms.org/health/2024-10-22/tennessee-replaced-its-federal-hiv-funding-with-state-money-public-health-experts-say-the-change-is-causing-damage

[8] Paul, A. (2024, August 13). Memphis ranks second in the nation in highest number of new HIV cases. Retrieved from https://wreg.com/news/memphis-ranks-second-in-the-nation-in-highest-number-of-new-hiv-cases/l

Disclaimer: Guest blogs do not necessarily reflect the views of the ADAP Advocacy Association, but rather they provide a neutral platform whereby the author serves to promote open, honest discussion about public health-related issues and updates. 

HIV Communities Face Challenges in Blue States & Red States

By: Ranier Simons, ADAP Blog Guest Contributor

Funding is the backbone of most healthcare initiatives, including navigating the landscape of HIV/AIDS. The fight against HIV includes testing, surveillance, treatment, education, and supporting basic life needs. Community centers provide many of these services to vulnerable populations, getting their funding from federal dollars through states. Budgetary decisions that adversely affect such funding can set back strides made through successful initiatives. Two states, New York, and Tennessee are in the spotlight due to controversial proposed decisions.

Photo Source: City & State New York

One such questionable budgetary decision comes from the governor of New York, Kathy Hochul. In the past, the governor has expressed dedication to ending the HIV/AIDS epidemic in New York state. In December 2022, she signed legislation requiring insurance companies to cover PrEP and PEP.[1] However, many view her present proposal to end a current Medicaid drug plan as being damaging. The program, known as the 340B Drug Pricing Program, allows safety net providers to purchase discounted life-saving HIV-related drugs and use the savings to provide essential services.[2] Operationally, the program enables centers to buy the drugs at cost but get reimbursed at the high rate that health insurance company plans pay for the medications. As a result, they can use the difference to pay for other services that are instrumental in supporting the needs of the populations being served.

In addition to supplying medications, many facilities use the extra funds to help with housing, food, and transportation. Losing the funding would result in many centers losing large parts of their budgets, which would be detrimental to the vulnerable populations that depend on their services. Losing the ability to continue to help the PLWHA with affordable housing could mean that some could become homeless. Unstable housing results in poor HIV/AIDS outcomes resulting from issues such as poor medication adherence. 

Hochul’s budget proposal is a continuation of Governor Andrew Cuomo’s Medicaid Pharmacy Carve-Out. The Medicaid Pharmacy Carve-Out is an attempt to boost the state’s revenue. Advocates argue that it adversely affects the 340B program because it gives the money directly to the state instead of directly to the facilities, as is the current status quo. The funds from the program help 2.3 million New York residents, 90 percent of who are low-income and 70 percent are people of color.[2] The New York State Department of Health states that Hochul plans to transition to the Medicaid Pharmacy Benefit of the Medicaid Pharmacy Carve-Out on April 1, 2023, but remains dedicated to ensuring facilities still get needed funds. Many health centers say that the proposed changes do not include enough money to replace the millions of dollars they would lose and have proposed legislative compromise that would give Hochul the savings she wants without destroying the pipeline of funding in place that is the lifeline for other services.[3] 

Photo Source: Rolling Stone

Another budgetary decision receiving push-back comes from Tennessee. Governor Bill Lee announced, in January 2022, that the state would start refusing federal funds for HIV-related programming. The funding being cut is for HIV prevention, detection, and treatment programs that are not affiliated with metro health departments.[4] The funding pots specifically identified to be rejected are P.S.18-1802 and P.S.20-2010. One is for HIV surveillance and prevention, with the other supporting state health departments in ending the HIV epidemic.[5] Currently, Tennessee receives about $8.3 million in total from the two funding sources. 

Parts of Tennessee are hotspots for HIV transmission, with Memphis being among the top 50 communities nationwide for HIV transmission rates.[6] Shelby County, which contains several cities, including Memphis, is one of the areas targeted by the CDC’s EHE (Ending the HIV Epidemic in the U.S.) initiative. The EHE focuses first on 50 local areas that account for more than half of the nation’s new HIV diagnoses and seven states with a substantial rural burden.[7] Additionally, the CDC’s 2020 analysis included forty-two counties in Tennessee among the top two hundred and twenty counties nationwide most vulnerable to an HIV outbreak.[7] 

State officials and the Governor state that they will start refusing the $8.3 million in funding to be more independent and less reliant on federal dollars. Governor Lee has also stated that he can ensure HIV funding is spent in ways that best serve Tennessee better than what he feels are strings attached to federal funding.[8] The Tennessee Department of Health also expressed that priorities in HIV prevention funding would be shifted to focus on first responders, victims of human trafficking, and pregnant women. Data from amfAR, The Foundation for AIDS Research, shows that it is not evidence-based decision-making as such a shift would only prevent about nine cases of HIV transmission annually. The most at-risk populations in the state include transgender individuals, people who inject drugs, cisgender women, and men who have sex with men. According to amfAR, focusing on these at-risk groups would prevent more than 500 new infections yearly.[9]

Photo Source: KevinMD.com

Moreover, the state has not indicated how it will make up for the $8.3 million lost and has suggested that funding will go through state-funded metro health centers. This does not address the needs of rural areas. Without the funding, much evidence-based community programs will end. Testing, a keystone of HIV prevention, will be drastically reduced, access to services will decrease, and some clinics and community centers that do the most work will close.[10]

It is imperative that funding structures stay in place that allow trusted community centers to continue to do the work that they do prevent HIV, treat HIV, and wholistically support the lives of PLWH. People’s lives are at stake, and funding decisions should only be based on scientific data, not political and ideological paradigms. HIV advocates and healthcare providers are closely watching the activities in New York and Tennessee, and many are also hoping that harmful legislation does not spread to other states.

[1] Reisman, N. (2022, December 22). Hochul approves law meant to reduce HIV infections. Retrieved from https://spectrumlocalnews.com/nys/central-ny/ny-state-of-politics/2022/12/22/hochul-approves-law-meant-to-reduce-hiv-infections-

[2] PRivas, S. (2022, February 7). HIV/AIDS activists urge Hochul to repeal Medicaid carve-out. Retrieved from https://www.news10.com/news/hiv-aids-activists-urge-hochul-to-repeal-medicaid-carve-out/

[3] DeWitt, K. (2023, February 14). HIV/AIDS health centers say Hochul's proposal could gut services for most vulnerable. Retrieved from https://www.wamc.org/2023-02-14/hiv-aids-health-centers-say-hochuls-proposal-could-gut-services-for-most-vulnerable

[4] Kennedy, C., Watts, M. (2023, January 2023) Tennessee to cut off funding to nonprofits for HIV prevention, testing, treatment. Retrieved from https://www.commercialappeal.com/story/news/health/2023/01/18/tennessee-cuts-funding-hiv-treatment-testing-prevention/69820175007/

[5] Laws, J. (2023, January 30). Tension in Tennessee: HIV Crisis Looms. Retrieved from https://www.hiv-hcv-watch.com/blog/jan-30-23

[6] Farmer, B. (2023, February 3). Why Tennessee is turning down millions of federal dollars for HIV prevention. Retrieved from https://www.marketplace.org/2023/02/03/why-tennessee-is-turning-down-millions-of-federal-dollars-for-hiv-prevention/

[7] CDC. 2022. Ending the HIV Epidemic in the U.S. (EHE).Retrieved from https://www.cdc.gov/endhiv/jurisdictions.html

[8] Straube, T. (2023, January 24). Tennessee Rejects “Free Money” From U.S. Government to Prevent HIV. Retrieved from https://www.poz.com/article/tennessee-rejects-free-money-us-government-prevent-hiv

[9] Kennedy, C. (2023, February 14). 'A public health crisis': What state's rejection of HIV funds could mean for Shelby County. Retrieved from https://news.yahoo.com/public-health-crisis-states-rejection-110047477.html?soc_src=social-sh&soc_trk=tw&tsrc=twtr&guccounter=1

[10] King, P. (2023, February 14). Shelby County leaders urge the state to keep federal HIV prevention funding. Retrieved from https://www.msn.com/en-us/news/us/shelby-county-leaders-urge-the-state-to-keep-federal-hiv-prevention-funding/ar-AA17uEkN

Disclaimer: Guest blogs do not necessarily reflect the views of the ADAP Advocacy Association, but rather they provide a neutral platform whereby the author serves to promote open, honest discussion about public health-related issues and updates.