Quiet Cuts in the Republican Budget Would Be Devastating for American Indians and Alaska Natives Living With HIV
For the moment, Republicans have been thwarted by the mobilization of the masses opposed to sweeping cuts to our nation's health care system. But now they're trying to pick off stragglers on the edge of the herd, attacking programs and populations they believe are too small or powerless to fight back, while banking on the likelihood that advocacy groups with more muscle won't come to their aid.
Among the programs currently at grave risk is the Secretary's Minority AIDS Initiative Fund (SMAIF). A $54-million-a-year program designed to improve the federal response to the HIV epidemic in communities of color in the United States, SMAIF is a crucial part of the larger Minority AIDS Initiative and integral to the execution of the National HIV/AIDS Strategy. SMAIF supports a host of programs that stress interagency cooperation at the federal level to expand linkage to and retention in care for people of color living with HIV and that engage in capacity building work to improve the quality of care for racial and ethnic minorities, among others.
Unfortunately, SMAIF has all the hallmarks of a program that is primed for elimination during Congress's fiscal year 2018 budgetary battles. For starters, the program has operated for the past 18 years in relative obscurity from both the general public and many HIV advocates. An HIV.gov video from November entitled "What is SMAIF" consists largely of HIV advocates being unable to identify what SMAIF is or any of the work it does. Couple this with SMAIF's location within the Minority AIDS Initiative (which provides Republicans with the facile and blatantly false argument that the services it provides are duplicative) and its small budgetary footprint, and the odds of SMAIF's survival begin to look slim.
Catastrophic Effect on American Indians and Alaska Natives
Indeed, the House's FY2018 Labor, Health and Human Services and Education and Related Agencies Appropriations Bill slates SMAIF for elimination. While the elimination of SMAIF would do a substantial amount of damage to a number of minority communities dealing with the HIV epidemic in America, the results would likely be catastrophic among American Indians and Alaska Natives.
"Unless everyone found funding elsewhere, the programs currently covered by SMAIF would cease to exist -- which is to say all the HIV programming in Indian Country," explained Jessica Leston, clinical programs director at Northwest Portland Area Indian Health Board.
Unlike other communities of color, American Indians and Alaska Natives do not receive any funds from the larger Minority AIDS Initiative itself, leaving SMAIF as their primary federal funding source.
In fact, the $3.6 million distributed to the Indian Health Service by the Department of Health and Human Services in the most recent round of SMAIF awards represents the vast majority of HIV-specific funding for Native communities in the United States. Programs such as the We R Native Project, an online, multimedia health resource aimed at reducing new HIV infections among American Indian and Alaska Native youth, would be abandoned.
"There's no way to tell exactly what would happen, but there would definitely be a lot of people seeking care who would be unable to access it," Leston told TheBody.com. "It would lead to an increased infection rate and a lot more lives lost."
Out of all racial and ethnic groups recognized by the U.S. Centers for Disease Control and Prevention, American Indians and Alaska Natives have far and away the worst survival rates among people newly diagnosed with HIV, with 8% of newly diagnosed AI/AN individuals failing to live longer than one year. Similarly, a 2014 survey of 32 states and the District of Columbia found that, compared with whites, blacks and Latinx, a greater percentage of "other" racial/ethnic groups, including American Indians and Alaska Natives, were first diagnosed when they had CD4 counts of less than 200 cells/µL -- meaning that they were AIDS defined at the time of their first medical encounter.
Thus, if there is one population that can least afford to lose funding for things such as capacity building, technical assistance and programming aimed at improving the retention in care of people living with HIV, it's American Indians and Alaska Natives. But the odds of them receiving it don't look good according to Northwest Portland Area Indian Health Board governmental affairs/policy director Laura Platero:
"Unless what we're doing works, that SMAIF funding will be gone because Indian Country is invisible," Platero told TheBody.com. "We're not hearing any other proposals coming."
Leston agreed with the bleakness of Platero's assessment, saying that in the eight years she has been working with SMAIF, she's never been more fearful for its future than she is now. Much of this fear comes from the fact that the American Indian and Alaska Native communities have very little political influence due to their comparatively small size and lack of representation in Washington, D.C.
"It is so unfortunate and maddening that Native people are not getting the health care they need," said Leston. "But, there are only about 2.5 million American Indians and Alaska Natives in the United States. That's not enough to get a senator elected or not."
Over the next three and a half years -- and perhaps beyond -- the maintenance of even the most basic access to health care for tens of millions of Americans will depend on placing persistent and unyielding public pressure on our elected officials. If people living with and impacted by HIV are to survive this dire hour of our democratic experiment, we must be unified and unrelenting in our advocacy and remain cognizant of the importance of fighting for HIV-specific issues while also engaging in coalition work with other populations that stand to be decimated by the Republican Party's drastic health care cuts.
There is strength in numbers, but with that strength comes a reliance on the kindness and legwork of organizations and advocacy groups that are more influential than our own. This community mentality will allow us to utilize the power of our collective advocacy and to take care of one another.
If SMAIF -- and by extension the infrastructure that holds American Indian and Alaska Native HIV treatment and prevention services together -- has any chance at survival, it is going to take the sustained and passionate activism of the entire HIV community, as well as many of our allies outside it. Right now, Native communities are the stragglers on the edge of our herd, and it is up to all of us to ensure that they aren't picked off by the rapacious and draconian budget cuts being pushed by congressional Republicans.