February 6, 2013

The Honorable Andrew M. Cuomo

Governor of New York State
NYS State Capitol Building
Albany, NY 12224


The Office of Public Health has been cut in the Cuomo budget for this year by $70 million
dollars. This Office is absorbing most of the cuts that are being imposed on DOH,
notwithstanding the critical role that this office plays. The AIDS Institute, which is housed in the
OPH, would experience a cut of nearly $12 million if this budget is approved, though this is hard
to discern as the AIDS Institute budget is largely obscured within the larger OPH budget, and is
only specifically identified in a few lines with no details. So, by way of one large example, it is
not clear what happens to the ADAP portion. It is not clear what the actual dollar amount that
will be made available to ADAP from the HCRA pools. This lack of budget transparency makes
it difficult to determine the actual impact of these cuts or even how or when they will be
implemented. In fact, depending on the nature and timing of these cuts, funds might be taken
away from other budget appropriations made in prior years.

In addition to the cuts themselves, this year`s budget speaks to several important concerns. The
first is the loss of identity of the AIDS Institute as a 'Center that has an independent Iunction in
response to the HIV/AIDS epidemic. This stems, it seems, from the perception that AIDS no
longer requires the level of prioritization as in the past. First, there seems to be a perception,
particularly within the Division of the Budget, that HIV has become manageable and therefore
no longer needs the attention of an independent center. The other is that Medicaid reform and the
Affordable Care Act eliminate the need for an independent center ensuring not only prevention,
but that people living with HIV get access to the care and support that they need.

In fact, the AIDS Institute stands as a model of public health for the country and is bigger than
AIDS. There are several reasons why the AIDS Institute is more important than ever:

First, HIV clinical services and care coordination providers are being increasingly transformed
by the State to serve a larger constituency of low-income people with chronic conditions. While
there is much about this transformation that is positive, the AIDS Institute has already played a
critical role in ensuring that this transition is successful both for consumers and for providers.
This vital role must continue as the 'health home model evolves.

Second, the State has stepped out of its role as direct payer for almost all Medicaid-funded
services. Consequently, providers have been thrown into the role of negotiating rates with
managed care organizations and health homes, something for which they have little experience
or expertise, much less volume that gives them bargaining strength. Having the AIDS Institute
as an independent monitor oI MCO`s and Health Homes is absolutely critical to ensure that vital
services are not diminished in the interest of short-term savings and long-term costs to the health
of people living with HIV and AIDS.

Third, part of the reason we have been so successful in addressing the HIV/AIDS epidemic in
New York is that the AIDS Institute has implemented and maintains effective prevention and
care programs around the state, including comprehensive harm reduction services to people who
use illicit drugs and prevention and care targeted at other key populations, and grant-funded
services that engage in both secondary and primary prevention that will not be replaced by
Medicaid. These prevention and care systems are themselves in the middle of an evolution, but
even as some services are shifted onto Medicaid, there will still be a need for strong state grant
support and strong guidance in program development and implementation.

Fourth, we still have not addressed three of the most critical issues that allow the epidemic to
persist. One is continued transmission of the virus, particularly among marginalized populations
such young men of color who have sex with men. The second is that a large percentage of people
infected with HIV, particularly men and women of color do not learn their status until they have
an AIDS-defining event. Third, we have not addressed the treatment cascade, in which less than
40% of New Yorkers with HIV are fully virally suppressed. While it is true that we have
dramatically decreased the number of HIV-related deaths in New York State over the last
decade, we still have transmission of the virus at the level of a generalized epidemic; though
largely manifest in particular groups. And we still have avoidable medical costs and untimely
deaths. We cannot bring the epidemic to an end unless we address these issues, and we will not
be able to address these issues without a strong and vibrant 'center within the State Department
of Health that marshals resources and maintains a clear focus on bringing HIV deaths and
transmission to zero in New York State.

Fifth, biomedical advances in the prevention of HIV such as the FDA`s approval oI Truvada as
pre-exposure prophylaxis (PrEP) have offered new optimism in curbing the epidemic. New
York State is poised to lead the nation in effectively implementing a comprehensive PrEP
strategy and ensuring access for those most in need in our state, an epicenter of the epidemic. It
was recently announced that New York State Medicaid will include PrEP in its formulary. New
York State AIDS Institute has requested funding for pilot programs for prevention contractors to
conduct outreach to high-risk individuals. Now is the time to invest in these potentially powerful
strategies.

Finally, even before we have ended AIDS as an epidemic, we have other epidemics of Hepatitis
and STDs surging, following the same transmission pathways as HIV. The AIDS Institute has
the experience and expertise to provide leadership in stopping this epidemic as well. But it will
not be able to do so if it is diminished as is proposed in this budget.

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New York already faces devastating federal cuts in HIV prevention, services and care. While
some of the treatment costs will be picked up by health insurance expansion under the affordable
care act, there will remain in New York a large population of people, including immigrants, who
will not be covered in this expansion. And this insurance expansion will not pay for many vital
prevention and care activities. Nor will it pay for many of the support services that have proven
to keep people living with HIV in care. Now is not the time to back away from the fight against
the HIV/AIDS epidemic. Rather, we need to marshal all of our resources, and innovate new
approaches so that we can get to zero. This cannot happen without a strong and vibrant AIDS
Institute within the Department of Health.

We, the undersigned, strongly urge you to reconsider these proposed cuts to the New York State
Department oI Health`s AIDS Institute and Iully restore the Iunding which would make the
AIDS Institute whole.

Sincerely,

Harlem United
HELP/Project Samaritan
Housing Works

List still in formation



Cc James Introne, Director of Health Care Redesign, Office of the Secretary to the Governor
Robert Megna, Director, Division of the Budget
Nirav Shah, MD, Commissioner, Department of Health
Senator Kemp Hannon, Chairperson, NYS Senate Health Committee
Assemblymember Richard Gottfried, Chairperson, NYS Assembly Health Committee