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2009 NASTAD Prevention Bulletin Series Focus 2009: Are the nation’s HIV/AIDS programs in peril? Meeting and Planning Calendar

2009 NASTAD Prevention Bulletin Series In 2009, NASTAD will revamp its Prevention Bulletin series and begin to explore new ways to communicate important information, including Web 2.0 media and web-based applications. NASTAD will also refine the content focus of the Bulletin to explore topics in greater depth, featuring multiple issues on a single topic. We are always looking for more effective ways to share important information and messages with the broader HIV/AIDS community. We invite all readers to explore this new direction with us and provide your feedback. back to top > Focus 2009: Are the nation’s HIV/AIDS programs in peril? The final NASTAD Prevention Bulletin in 2008 offered a year in review, highlighting key events that helped shape HIV prevention in the United States (U.S.). We heralded the successes we achieved, reflected on the challenges we faced and looked toward 2009 as a year promising great progress in domestic HIV prevention efforts. While we maintain our belief that this year holds countless opportunities for advancing the important work of the HIV/AIDS community, we must counterbalance the hope with which we framed our belief with the reality of the current shape of the national and states’ economic conditions. The current economic crisis is having devastating consequences on most state and local governments. Amid current year budget cuts, many state and local governments are preparing for even deeper cuts to next year’s budgets, resulting from shortfalls of billions of dollars that face the nation’s governors and mayors. In many jurisdictions, HIV and other public health programs and services that were once held harmless from across-the-board and targeted funding cuts are now finding themselves at risk of losing millions of dollars in critical resources. Among these programs, many state and local health departments are preparing for the consequences of a dismal funding scenario next year. Surveys conducted by the Association of State and Territorial Health Officials (ASTHO) and the National Association of County and City Health Officials (NACCHO) found that significant cuts are being made to health agency budgets and their workforces. ASTHO reported that 100 percent of state and territorial health departments who responded to a December 2008 survey experienced budget cuts during FY2008 and that 62 percent anticipate additional cuts in FY2009. The FY2008 cuts led to grave responses, including loss of staff through attrition or layoffs, a reduction in public health services and/or the elimination of entire public health programs (ASTHO findings were unpublished at the time of release). NACCHO found that among local health departments, 53 percent lost staff during FY2008 and 32 percent expect to layoff additional staff in FY2009. More than a quarter of local health departments reported declining budgets between FY2008 and FY2009 and 44 percent anticipate additional declines in FY2010. Already struggling in the face of inadequate funding, restrictive policies, a troubled workforce and inflexible bureaucratic systems, the current U.S. economy is crippling health departments’ capacity to provide core public health services—those they are entrusted to provide under U.S. law. Essential functions of public health, including prevention; infection disease screening, testing and treatment; immunizations; providing medication for uninsured and underinsured individuals; and critical public health policy development, are at risk for a significant scale back or elimination in the coming year. The absence of core public health services threatens to have a devastating impact on individuals, communities and entire populations across the U.S. In the long term, the impact of a neglected domestic public health system could be dire in both social and economic terms. Relying on significant funding from state and local governments, health department HIV/AIDS programs are faced with responding to the economic crisis while trying to maintain their role as coordinators of state and local responses to the domestic HIV/AIDS epidemic. With millions of dollars of cuts to their prevention, surveillance and care and treatment programs, health departments have been forced to make critical decisions, in some cases with little ability to influence the targets or the outcomes. Chief among the concerns facing health departments are issues related to the public health workforce. Already facing a workforce shortage brought on by attrition and layoffs from past years, early retirement initiatives and constraining bureaucratic processes, health departments are now facing an expanding crisis as they work to staff their programs. In some jurisdictions, health departments are laying off staff to address budget deficits, causing a redistribution of the workload to a fewer number of staff. Many health departments continue to experience hiring freezes, which leave open positions in programs, often despite the availability of federal grant funding to fill them. Existing vacancies are at risk of being eliminated or re-assigned to other programs within the governmental system; once positions are gone, they are difficult to reclaim. When hiring is allowed, programs now experience serious delays because decisions often require internal approval through several layers of bureaucracy. The burden also extends beyond workforce shortages to circumstances that impact existing staff. Many health departments are unable to provide raises or incentives to employees, are forced to implement pay cuts, and/or are required to institute furloughs, resulting in decreased morale and performance. Staff travel is also restricted in many jurisdictions even when travel support is made available by sources outside the health department (e.g., federal grant funds). In addition to personnel concerns, health departments are making other concessions to address budget cuts. Some jurisdictions are reducing funding to existing contracts that support community-based programming, the frontline programs that provide direct services to populations at greatest risk for HIV. In some jurisdictions, strategic budgeting practices used to ensure the sustainability of programs are being targeted, including the use of carry-forward funding, which is sometimes used to support services like needle and syringe access. Some jurisdictions are closing health department clinics that provide essential services and are reducing their support for public health laboratory programs, entities used to confirm HIV diagnoses. Some health departments are cutting new initiatives and media and social marketing. Some are unable to apply for new funding to support their programs, often funding that can be used for innovative HIV prevention strategies. The economic impact extends beyond reductions in HIV prevention program services and workforce. As with the concerns facing HIV prevention programs, HIV/AIDS care and treatment programs—which are critical partners to successful prevention efforts—also face critical difficulties in the coming year. As state budgets are cut, jurisdictions are faced with issues like meeting federal requirements of Maintenance of Effort, State Match and the constriction of ADAP services, including a possible reemergence of waiting lists and a reduction of medications covered on formularies. Allied public health programs, including sexually transmitted disease (STD) and viral hepatitis prevention, are also experiencing budget cuts. Because of the link between these diseases and HIV/AIDS, cuts often result in diminished services that enhance or are, themselves, strategies for preventing HIV transmission. Other public health programs, like substance abuse and mental health services, are re-directing funding that has historically been used to support HIV/AIDS programming to focus on their own core services, as their programs also retract. Administrative support services within health departments, like finance, procurement and, as mentioned above, personnel, also limit the ability of HIV/AIDS programs to fund essential services. Bottlenecks in the contract development and execution process delay awards to grantees. Sometimes, after contracts are processed, there is also a delay in payment for services that have been rendered. In addition to these bureaucratic barriers and actual reductions in funding from health departments, many community-based organizations face crises in their own fundraising efforts. As more front line organizations are threatened with a shuttering of their doors, entire systems of prevention and care are at serious risk of destabilization. The current economic crisis is made worse by the existence of perennial issues that face health department HIV prevention programs. Restrictive, uncoordinated and unrealistic federal funding requirements, including multiple program announcements and awards, varying grant cycles, disparate reporting systems and multiple project officers, burden health departments and limit their ability to ensure their programs are as efficient and effective as possible. On the state and local level, cumbersome budget and personnel processes in state and local governments mire health departments in a complicated bureaucracy that requires an unacceptable amount of time and resources to navigate. The unnecessarily complex environments in which health departments now function often result in unacceptable outcomes, such as the inability to spend resources when legitimate projects exist. Given dynamic state and local policy environments, a lack of coordination across federal funding streams and the diverse epidemics facing states and cities, health departments need flexibility to organize and deliver services in a manner appropriate to their circumstances, including the ability to shift resources when necessary. Moreover, existing federal funding streams that are ineffective, like abstinence-only-until-marriage funding, serve to undercut health departments’ efforts to prevent disease transmission. In 2009, health departments will continue to provide comprehensive coordination of state and local responses to the HIV/AIDS epidemics, including being the best stewards possible of public funding. But, given the current state of the domestic economy, health departments are obligated to continue analyzing their environments, evaluating existing programs and rethinking service delivery systems and structures. To accomplish this, they will need to ensure that resources are being used effectively, build on existing efficiencies in their programs, prioritize and replicate activities and services that work, eliminate outmoded elements of their programs and appropriately transition elements that are better handled by other existing systems. As a new Administration and Congress take office, health departments continue to hope that their role as essential parts of state and local infrastructure will be recognized and given its due. With a pending stimulus package and in the context of health care reform, health departments believe that the nation will see the need to shift the current paradigm to ensure we all find meaningful opportunities in this current economic crisis. back to top > Meeting and Planning Calendar Capacity Building Opportunities: For a searchable database of CDC-supported capacity building trainings and events, please visit the Capacity Building Branch’s Group Events Management System site. February 7, 2009 National Black HIV/AIDS Awareness Day February 8-11, 2009 16th Conference on Retroviruses and Opportunistic Infections, Montreal, Canada March 1-7, 2009 National Black Church Week of Prayer for the Healing of AIDS March 10, 2009 National Women and Girls HIV/AIDS Awareness Day March 20, 2009 National Native HIV/AIDS Awareness Day April STD Awareness Month April 5-7, 2009 4th International Conference on HIV Treatment Adherence, Miami, FL April 16-18, 2009 HIV/STD Prevention in Rural Communities: Sharing Successful Strategies VI, Bloomington, IN. Abstracts due February 6, 2009. May 2009 Viral Hepatitis Awareness Month May 18, 2009 HIV Vaccine Awareness Day May 19, 2009 National Asian and Pacific Islander HIV/AIDS Awareness Day World Hepatitis Day May 21-24, 2009 HIV/AIDS 2009: The Social Work Response, New Orleans, LA June 8, 2009 Caribbean American HIV/AIDS Awareness Day June 27, 2009 National HIV Testing Day August 23-26, 2009 National HIV Prevention Conference, Atlanta, GA October 29-31, 2009 United States Conference on AIDS, San Francisco, CA. Abstracts due April 24, 2009. November 7-11, 2009 American Public Health Association 137th Meeting and Expo, Philadelphia, PA

	Credits, Feedback and Input The NASTAD Prevention Bulletin is edited by NASTAD staff and is written by staff and prevention experts from around the country. This publication was supported by Cooperative Agreement Number 5U62PS323958-05 from the Centers for Disease Control and Prevention. Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the Centers for Disease Control and Prevention. If you have an idea or program that you would like to include in the Bulletin, please contact Dave Kern or Lynne Greabell (202/434-8090). NASTAD welcomes feedback to issues presented in Bulletin. To submit commentary, please e-mail us at NASTAD@NASTAD.org. Electronic versions of the Bulletin are available on our webpage.
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