Introduction
Federal funding for HIV has increased significantly over the course of the epidemic, rising from just a few hundred thousand dollars in FY 1982 to about $43.0 billion in FY 2022 for combined domestic and global efforts. However, it represents just a small fraction (<1%) of the overall federal budget of the United States. The majority of HIV funding (57%) in FY 2022, and the driver of growth in the HIV budget over time, was spending on mandatory domestic care and treatment programs through Medicaid and Medicare, as more people are living with HIV in the United States than ever before, new treatments have become available, and the cost of medical care has increased. In addition, greater investments to combat HIV in low and middle-income countries have also contributed to growth, though these have slowed since 2010. More generally, discretionary funding for HIV from Congress has brought only minor increases, primarily due to the Ending the HIV Epidemic effort, and most accounts have not kept pace with inflation over the last decade. In addition to federal funding, states also contribute to HIV care (primarily via their shared contributions to the Medicaid program), as do private insurance plans.
This fact sheet provides an overview of the federal HIV budget, including trends in federal funding between FY 2018 and FY 2022. Appendix A provides a full history of topline federal HIV funding from FY 1981 to FY 2022.
Budget Categories
The federal HIV budget can be organized into five broad categories: care & treatment; cash & housing assistance; prevention; research; and global/international. More than two-thirds (67%) of the FY 2022 budget was for domestic care and treatment programs in the U.S.; 8% was for domestic cash/housing assistance; 3% was for domestic HIV prevention; 6% was for domestic HIV research; and 16% was for the global HIV efforts, including funding for international research.
Mandatory/Discretionary
Federal funding is either mandatory or discretionary. Mandatory spending, primarily for entitlement programs (such as Medicaid and Medicare), is determined by eligibility rules, enrollment, and the cost of services for those who are enrolled, and is not dependent on funding from Congress (e.g., if more people are enrolled and/or the cost of services goes up, mandatory spending will also increase). In FY 2022, mandatory spending for HIV accounted for $27.2 billion, or 63%, of the total HIV budget and includes estimated spending levels for: Medicaid, Medicare, Social Security Disability Insurance (SSDI), Supplemental Security Income (SSI), programs which provide health coverage and cash assistance. Mandatory spending has accounted for an increasing share of federal funding for HIV, rising from 52% of total HIV funding in FY 2012 to 63% in FY 2022, largely due to growth in Medicare and Medicaid spending.
Discretionary funding levels are determined by Congress each year through the appropriations process and may, or may not, match the full need for or cost of services. The remaining $15.7 billion (37%) of the federal HIV budget in FY 2022 was discretionary. It was slightly higher than the FY18 level ($14.4 billion). Of the FY 2022 amount, $8.7 billion (20% of the overall HIV budget and 55% of discretionary funding) was for domestic programs – prevention, research, housing, and non-mandatory care programs (e.g., the Ryan White HIV/AIDS Program). The remainder, $7.0 billion (16% of the overall budget and 45% of the discretionary component), was for global HIV/AIDS efforts.
The Domestic HIV Budget
The domestic HIV budget includes funding for care, cash/housing assistance, prevention, and research as follows:
Care
The largest component of the federal HIV budget is health care services and treatment for people living with HIV in the U.S., which totaled $28.7 billion in FY 2022 (67% of the total HIV budget and 80% of the domestic share). This represents a 31% increase over the FY 2018 level, primarily due to increased mandatory spending for Medicaid and Medicare. (Medicare and Medicaid spending includes all care for people with HIV, not just HIV related services.) Medicaid is the largest federal funder of HIV care and treatment, followed by Medicare. States also pay a state share of Medicaid funding, including for HIV care, but those amounts are not included in this analysis. The Ryan White HIV/AIDS Program, the largest HIV-specific discretionary grant program in the U.S. and third largest source of federal funding for HIV care (behind Medicaid and Medicare), was funded at $2.5 billion, representing an 8% increase over FY 2018 level. This increase was due to the launch of the Ending the HIV Epidemic initiative, which included new funding for Ryan White and other domestic HIV programs. Ryan White’s AIDS Drug Assistance Program (ADAP), which provides HIV-related medications and insurance coverage to people with HIV, was flat funded in FY 2022 at $900.3 million.
Cash/Housing Assistance
$3.3 billion of the FY 2022 budget for HIV was for cash and housing assistance in the U.S. (8% of the overall budget and 9% of the domestic budget), a 12% increase over the FY 2018 level of $3 billion. This includes mandatory spending estimates for SSI and SSDI, which provide cash assistance to disabled and older individuals with HIV. Housing assistance, through the Housing Opportunities for Persons with AIDS Program (HOPWA), is discretionary and received $450 million in FY 2022, a $75 million (20%) increase over the FY 2018 level.
Prevention
The smallest category of the federal HIV budget is domestic HIV prevention, which totaled $1.1 billion in FY 2022 (about 3% of the overall HIV budget). This includes funding for domestic HIV prevention across multiple agencies, representing a 21% ($184 million) increase over the FY 2018 level. Most prevention funding is provided to the CDC’s National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention (NCHHSTP), which received $987 million in FY 2022, an increase of $201 million over the FY 2018 level. Funding increases for domestic HIV prevention were largely attributed to the EHE Initiative (which included $195 million for CDC in FY 2022).
Research
$2.7 billion (6% of the overall FY 2022 amount and 7% of the domestic budget) in the FY 2022 HIV budget is for domestic HIV research across multiple agencies, slightly higher than the FY 2018 level ($2.6 billion). The National Institutes of Health (NIH), which carries out almost all HIV research, receives $2.6 billion in FY 2022 for domestic HIV research activities (additional amounts used for international HIV research are attributed to the global category, discussed below), slightly higher than in FY 2018 ($2.4 billion).
Minority HIV/AIDS Initiative
The Minority HIV/AIDS Initiative (MAI), which addresses the disproportionate impact of HIV/AIDS on racial and ethnic minorities in the U.S, was funded at about $57 million through the Office of the Secretary MAI Fund in FY 2022. Additional MAI funding is designated at other agencies within HHS (e.g. within SAMHSA, HRSA, CDC) but levels are not fully available at this time.
The Ending the HIV Epidemic Initiative (EHE)
The “Ending the HIV Epidemic” (EHE) is a federal effort to reduce new HIV infections in the U.S. by 75% in five years and by 90% in ten years. The initiative provides new funds to the regions hardest hit by the HIV epidemic, including 48 counties with a high number of HIV diagnoses, San Juan, Puerto Rico, Washington D.C, and seven states with a substantial rural burden. Funding includes reprogrammed funding FY 2019 and new Congressional appropriations since FY 2020. Funding for the effort has increased each year, representing small but significant increases for the CDC, NIH, and HRSA (Ryan White and Health Centers) and the Indian Health Service (IHS), programs that had effectively been flat funded for many years. In FY 2022, funding for EHE totaled $437.3 million, amounts incorporated in the totals described above. (Overview of the EHE and appropriations history available here.)
The Global HIV Budget
The U.S. government first provided funding to address the global HIV epidemic in 1986. Total funding has increased significantly over time, particularly since the launch of the President’s Emergency Plan for AIDS Relief (PEPFAR) in 2003. However, since 2010, funding for global HIV efforts through regular appropriations has remained relatively flat. Most U.S. funding for global HIV is considered to be part of PEPFAR, including both bilateral HIV efforts (country-to-country funding) as well as contributions to multilateral organizations, including the Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund) and the Joint United Nations Programme on HIV/AIDS (UNAIDS).
The FY 2022 budget for HIV included $7 billion for the global epidemic – $5.4 billion for bilateral programs, $1.6 billion for the U.S. contribution to the Global Fund, and $50 million for UNAIDS. Global HIV funding amounts to 16% of the overall FY 2022 HIV budget and 45% of discretionary funding. As noted above, funding for global HIV efforts has been relatively flat for over a decade.
Bilateral Funding
- Most bilateral HIV funding is channeled to the State Department which received $4.34 billion in FY 2022, a $65 million (2%) increase compared to the FY 2018 level ($4.28 billion), but still $226 million below its peak funding level in FY 2010 ($4.57 billion).
- HIV funding through USAID ($330 million) and CDC ($128.9 million) was flat in FY 2022 compared to the FY 2018 level. Funding for international HIV research activities at NIH was $628.14 million in FY 2022, $63 million above the FY 2018 level.
Multilateral Funding
- Almost all multilateral funding for HIV is provided to the Global Fund, an independent, public-private, multilateral institution which finances HIV, TB, and malaria programs in low- and middle-income countries, and to which the U.S. is its largest contributor. In FY 2022, funding was $1.56 billion for the Global Fund. The FY 2022 budget for the Global Fund increased by $210 million (16%) compared to FY 2018.
- In FY 2022, funding for UNAIDS, the U.N. system’s coordinating body that serves to help galvanize worldwide attention to AIDS, was $50 million, $5 million (11%) above the FY 2018 level.
Appendix A
