Federal Cuts Could Hamper Dallas County's HIV Prevention Programs

Infection with HIV is no longer the death sentence it was when the virus emerged more than 40 years ago, but it is still epidemic. More than a million people in the U.S. have HIV, the virus that causes AIDS. Nearly 32,000 people acquired it in 2022, the most recent year for which national data is available.

HIV infection is a disproportionately large problem in the South, which accounts for nearly half of the nation’s new diagnoses. The region is also home to nearly half of all Americans who lack health insurance, says Adriane Casalotti, government affairs chief for the National Association of County and City Health Officials (NACCHO). Seven states in the region have not expanded Medicaid. Low coverage rates can limit both treatment and prevention.

But it’s not just access to care that can cause problems — stigma is a major barrier, too.

Two-thirds of HIV diagnoses are in men who have had sexual contact with men, but any sexually active person is at risk of contracting it. (A small percentage of cases are caused by intravenous drug use.)

The causes of transmission can be sources of shame, and prevent people from accessing diagnosis and care, says Miranda Grant, a program manager for the Dallas County health department. Changing this would mean a willingness to have open conversations about sex, she says. “We would just rather not do that in the South.”

Dallas County, one of the South’s largest population centers, has worked to facilitate such communication by integrating community health workers in its system of care and through education about HIV and other sexually transmitted infections. New HIV diagnoses are down in Dallas County since 2022, and public health experts in the county say these programs are helping. (The county's cases as a whole are up since 2019, though that may be partly due to increased testing, experts say).

However, programs in Dallas and elsewhere are at risk amid potential shifts in federal funding that could further reduce coverage for medications and hinder the work of community-based organizations that support HIV programs in health departments.

The Dallas County Approach

With treatment, people with HIV can live a normal lifespan and not infect others. Moreover, transmission is readily preventable using both medication and education.

In his 2019 State of the Union address, President Donald Trump asked Congress to fund an effort to tackle this public health challenge. An initiative known as Ending the HIV Epidemic in the U.S. (EHE) was launched that year, with the target of bringing the numbers down to 9,300 new infections by 2025.

With 32,000 new infections in the last count, much remains to be done to reach this goal, but progress is now at risk. Early indications are that the Office of Management and Budget plans to zero out EHE in its next budget, Casalotti says. Layoffs and reorganization happening at the federal level mean the loss of expert support. “Future funding for sexual health education is also very much at risk,” Casalotti says.

Dallas County is one of 57 priority jurisdictions that are the focus of EHE programs.

The county’s EHE work involves partnerships with groups that provide services including diagnosis, treatment and counseling. It runs a no-cost sexual health clinic that served 17,000 people last year. Everyone who visits receives an HIV test.

People who are diagnosed with HIV are connected to community health workers who help them navigate the system of care and ensure they are treated with respect and dignity. In the “old days,” they would simply receive a notice of their diagnosis, or just a message that they needed to contact their doctor, Grant says. In addition to guiding residents through the system, community health workers can pick them up, take them to appointments and wait with them.

They also ensure they stay on their treatment regimen. If those who are HIV-positive discontinue treatment, they again become contagious and are at risk for developing serious symptoms. On average, 96 percent of the people assisted by a community health worker are linked to care, Grant says.

The community health worker program did not exist before the EHE initiative, and at present is dependent on funding from it.

Prevention and Education

HIV transmission is preventable. This starts with understanding how transmission occurs. The highest rates in Dallas County are among youth ages 13 to 24, Grant says. She regularly encounters young women with mistaken ideas about what will keep them safe from sexually transmitted infections.

Dallas County has implemented an education program at its juvenile detention center to give detained youth an opportunity to ask questions and understand sexual health risks. Grant has been shocked by the unawareness of basic biology that some of these conversations have uncovered, she says.

EHE staff have been trained to deliver evidence-based curriculum developed by Healthy Futures of Texas in county schools. Community health workers man booths in public places to provide educational materials and to talk to residents about risks and treatment. “There’s a lot of opportunity if we focus on just educating folks and don’t make it into morals and politics,” Grant says. “Our role is not to judge; we’re just looking at how we reduce transmission.”

The medication PrEP (pre-exposure prophylaxis) is another element of prevention. Administered as a pill or shot, it can prevent HIV infection. (It doesn’t protect against any other sexually transmitted disease.) PrEP isn’t covered under the federal Ryan White program, which helps uninsured and under-insured persons living with AIDs access care, but the EHE can guide them to other ways to obtain it.

Public health is chronically underfunded, and Dallas County can’t afford not to invest in prevention, says Philip Huang, its director of health and human services.

“One single new case of HIV is estimated to lead to $420,000 in lifetime health expenditures,” Huang says. New cases in 2022 alone are expected to lead to more than $382 million in such costs.

Uncertain Future

HIV may not be as common as other chronic diseases, but unlike cancer or heart disease there are straightforward ways to prevent it and eliminate health consequences if it is contracted. Reorganization of federal agencies that have led work to end the HIV epidemic, combined with expected cuts to both HIV-specific programs and Medicaid, are causing concerns about maintaining progress going forward.

“So much is changing that there’s not a lot of air in the room,” NACCHO’s Casalotti says. “Threats to Medicaid are very challenging, but that's not all that we're talking about when we're talking about unprecedented clawbacks and the potential impacts of federal funding going away on a host of public health issues.”

Huang has received national attention for his work modernizing the county’s data systems, moving away from paper-based records to electronic and integrating GIS mapping to add another level of insight to its data. Some of the federal funding for this work has already been cut, he says.

Disrupting treatment and education could unravel a significant public health success. The situation in the U.S. could also be affected by the discontinuation of the U.S. Agency for International Development HIV treatment programs in other countries. Without treatment, the viral loads of those who have HIV will go up, leading to worsening health, drug resistance and more transmission.

“All of that is going to contribute to worsening this situation,” Huang says. But he’s undeterred.

“We have the tools,” he says. “It’s not the death sentence it used to be when someone was told they have HIV, but it takes management, it takes getting people tested and linked to care and staying on their medications.”