More than four years ago, then-President Donald Trump declared an ambitious goal that had bipartisan support: ending the HIV epidemic in the United States.
Now, that Trump program is one of several health initiatives targeted for substantial cuts by members of his own party as they eye next year's elections.
Pushing a slate of conservative political priorities that also takes aim at sex education for teens, health worker vaccine mandates, and more, Republicans in the House of Representatives have proposed a spending bill that would cut $1.6 billion from the Centers for Disease Control and Prevention — one-sixth of the agency's budget.
The proposal would zero out the agency's share of the Trump HIV plan, which was more than a third of the program's budget in the current fiscal year. It would also eliminate funding through other channels, such as the Health Resources and Services Administration's Ryan White HIV/AIDS Program.
With another budget fight and potential government shutdown looming Oct. 1, the specific proposal is unlikely to clear Congress. Still, former CDC officials said they fear it is the opening bid on what could nonetheless be debilitating reductions to a strained agency that has lost some public support in recent years.
The cuts come on the heels of other recent reductions at the CDC, triggered by the eleventh-hour debt-ceiling deal, to its budgets for childhood vaccination programs and prevention of sexually transmitted infections. And they provide an early opportunity for the CDC's new director, Mandy Cohen, to show how well she can convince members of Congress to protect the agency's interests in a polarized political landscape.
"Public health is being politicized to a point that's never been seen," said Kyle McGowan, of consulting firm Ascendant Strategic Partners, who served as chief of staff at the CDC during the Trump administration. Cutting public health spending "is not smart," he said. "These culture wars are now leaking into and harming public health."
He called the proposed cuts unprecedented in their targeting of bipartisan public health initiatives.
"Public health is being politicized to a point that's never been seen."
The House Republican spending proposal, which came from members of the Labor, Health and Human Services, Education subcommittee, also targets programs that have drawn the ire of conservative lawmakers, such as those that focus on climate change and gun violence research.
"Cuts to the Centers for Disease Control and Prevention are as outrageous as they are dangerous," said Connecticut Rep. Rosa DeLauro, the highest-ranking Democrat on the subcommittee.
But Rep. Kay Granger, the Texas Republican who chairs the House Appropriations Committee, said the bill "works to responsibly fund programs that help improve the health and lives of the American people. It also holds agencies accountable when there has been a history of poor performance or controversial activities."
Granger and the chair of the subcommittee that drafted the bill, Rep. Robert Aderholt (R-Ala.), did not respond to requests for further information.
The House Appropriations Committee has yet to mark up and vote on the measure, which would also need the approval of the full Republican-controlled House and Democratic-controlled Senate. The Senate Appropriations Committee has approved its own health spending bill, which largely maintains existing CDC funding for HIV and would require the two chambers to work together to produce a consensus measure.
And any spending measure would also need the signature of President Joe Biden, whose most recent budget proposal included a request for $850 million to reduce new HIV cases.
The CDC declined to comment on the possible cuts, saying it would be premature to do so amid the ongoing budget process.
The Trump administration's HIV program launched in 2019 with the goal of cutting new infections nationwide by 90% by 2030. It has sent more than $1.7 billion, through different federal health agencies, to HIV hot spots around the country.
But the program has run into significant headwinds. The covid-19 pandemic diverted the attention of public health officials. Plus, red tape, along with persistent stigma and discrimination fueled by anti-LGBTQ+ messaging from politicians, have many health officials worried it won't meet its ambitious goals.
House Republicans said the HIV program, well shy of its first main milestone, in 2025, hasn't met its goals.
"This program has demonstrated a lack of performance data based on outcomes, insufficient budget justifications, and vague spend plans. The initiative has not met its original objectives," the Republican-led subcommittee wrote in a report that KFF Health News obtained but could not independently verify as official. Granger and Aderholt did not respond to requests to verify the document.
Trump's Ending the HIV Epidemic initiative isn't the only Republican-created HIV program being targeted.
A number of key provisions in the President's Emergency Plan for AIDS Relief, known as PEPFAR, are set to expire on Sept. 30. The program, which funds HIV and AIDS prevention around the world, has saved millions of lives, and is widely seen as a public health and foreign policy success. It was launched in 2003 under then-president George W. Bush.
But discussions about reauthorizing the program have been derailed by Republican claims it finances abortion. PEPFAR won't immediately stop its work, but missing the deadline could signal an uncertain future for the program, experts say.
Regarding the Trump HIV initiative, service providers say any budget reductions would slow the progress it has made in the fight against the disease.
"There's a lot at stake here," said Justin Smith, of Positive Impact Health Centers, an Atlanta-area HIV clinic. Smith has helped Georgia public health officials plan the distribution of Ending the HIV Epidemic funds among the four priority counties in the state.
Smith said the proposed cuts would be "quite devastating" for the work being done in Cobb, DeKalb, Fulton, and Gwinnett counties in metropolitan Atlanta. That work has included ramping up HIV testing and PrEP, or preexposure prophylaxis, programs, as well as expanding care for transgender people living with the virus.
The South has the highest rate of new HIV diagnoses in the country, and many Ending the HIV Epidemic target areas are in the region.
In Louisiana, which has two of those HIV priority areas, the program has helped reduce the number of late HIV diagnoses and maintain levels of viral suppression, said Samuel Burgess, the director of the state's STI and HIV prevention program.
Even if the budget cuts don't survive the legislative process fully intact, it's "very concerning" that lawmakers would even propose such a cut, Burgess said.
HIV policy advocates are pushing back on the House Republican proposal. In July, the Federal AIDS Policy Partnership sent a letter to House appropriators warning of its potential impact.
"We are deeply concerned that this bill will not only stop progress being made to achieve the goals set forth by former President Trump in 2019, but will exacerbate the HIV epidemic which has plagued our nation for 40 years," they wrote.
Cohen, who started with the CDC in July, is familiar with the budget process, having spent time in top leadership positions within the U.S. Department of Health and Human Services.
But she's new to the CDC and, regardless of her inside-the-Beltway experience, will need time to get up to speed, which could potentially leave the agency vulnerable, said McGowan. "It's a difficult time to have a leadership change at the CDC," he said. But he added that "Dr. Cohen is doing a great job meeting with everyone on the Hill, both Democrats and Republicans."
The fights over HIV programs concern Tom Frieden, who served as CDC director under former President Barack Obama. He estimated he made more than 250 trips to Capitol Hill over nearly eight years to sell the agency's work to lawmakers.
He called the Atlanta-based CDC's location outside of Washington a "double-edged sword."
"People used to say to me, 'Gee, isn't it great, we're not bugged by politicians down here in Atlanta?'" Frieden said.
While the location helps cushion the agency from politics, he said, it also makes it harder to get support from members of Congress.
But the CDC's response to covid pulled it back into the political fray. Frieden said he is hopeful the Democratic-controlled Senate will act as a "hard stop" against the Republican attacks — but he warned that substantial cuts can slip through the cracks.
"It's always a risk that some important stuff at the eleventh hour doesn't happen," Frieden said.
