1. Estimated Impact of HIV Prevention Budget Cuts
for Selected Jurisdictions in California
Feng Lin, PhD; Arielle Lasry, PhD;
Annette Ladan, MS; Stephanie Sansom, PhD
National HIV Prevention Conference
August 14-17, 2011
National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention
Division of HIV/AIDS Prevention

2. Objective
□ Develop a tool that state and local health departments
can use to measure the impact of HIV prevention budget
cuts on their jurisdictions
■ To examine the effect of budget cuts on people living with or at
risk for HIV
■ To estimate the impact of the budget cuts on HIV incidence
■ To compare different budget allocation scenarios

3. Budget and Program Data
□ Data on selected jurisdictions were provided by the
California State Office of AIDS
 Included jurisdictions that did not receive direct funds from CDC
 Excluded Los Angeles and San Francisco
□ Type of data
 Federal and state HIV prevention budgets administered by the
Office of AIDS
 Number of local agencies that received HIV prevention funds
 Number of clients served
□ Number of positives who received test results
□ Number of unique clients of health education and risk reduction
(HERR) services

4. HIV Prevention Budget Allocated
by Prevention Activities
Pre-cut scenario
21% ↓
70% ↓
* LA and SF excluded

5. Testing and Partner Services
* LA and SF excluded

6. Health Education and Risk Reduction (HERR)
* LA and SF excluded

7. Summary of Prevention Services
Pre-cut &: FY0910 Reduction (%)
FY0506-FY0708
Total prevention budget $21,849,923 $5,860,723 $15,989,200 (73)
Funded local health jurisdictions 59 15 44 (75)
Funded prevention agencies 143 # 36 107 (75)
Testing and partner services
Budget $4,024,634 $3,160,148 $864,486 (21)
Number of tests performed 83,799 52,590 31,209 (37)
Number of positives notified of test result 813 465 348 (43)
Health education and risk reduction (HERR)
Budget $17,825,289 $2,700,575 $15,124,714 (85)
Number of unique clients 11,784 3,386 8,398 (71)
Number of unique positive clients 2,884 1,100 1,784 (62)
Number of unique negative clients 8,900 2,286 6,614 (74)
* LA and SF excluded
& We took the average values from FY0506 to FY0708 for the pre-cut scenario.
# Number of funded local prevention agencies was not available in FY0506 and FY0607.

8. Methods
□ Estimate the number of new infections associated with
the budget cuts
 Prevention service reduction
Number of clients served (pre-cut scenario) – Number of clients
served (FY0910)
 Estimate HIV transmission: Bernoulli process model
□ Testing and partner services
□ Health education and risk reduction (HERR)
■ Compare different budget allocation scenarios

9. Summary of Inputs to Bernoulli Model
Parameter Value (Range) Source
Per-act transmission probability
Vaginal receptive 0.08% (0.06–0.11%) Boily et al. Lancet Infect Dis 2009; 9(2): 118-
29.
Vaginal insertive 0.04% (0.01–0.14%)
Anal receptive 1.40% (0.2–2.5%) Baggaley et al. Int J Epidemiol 2010; 39(4):
1048-63.
Anal insertive 0.70% (0-1.3%)
Condom effectiveness 90% (85–95%) Pinkerton et al. Soc Sci Med 1997; 44(9):
1303-12
Annual nb. of sex acts all partners 85 (26-365) Long et al. Ann Intern Med 2010; 153(12):
778-89
Annual nb. of sexual partners
HET 1.1 (1-20) Long et al. Ann Intern Med 2010; 153(12):
778-89
IDU 3 (1-20) Metsch et al. NHPC2007
MSM 3.5 (1-20) NHBS
ART effectiveness (reduction in 90% (80-99%) Attia et al. AIDS 2009; 23:1397-1404. (Bunnell
et al. Del Romero et al. Donnell et al.)
infectivity)
Proportion new diagnosis among 60% (40-80%) Hanna et al. JAIDS 2009; 51(5): p. 609-14.
ETI data
positives who received test results

10. Summary of Inputs to Bernoulli Model (cont’)
Parameter Value (Range) Source
HIV prevalence in California
HET 1.0%(0.75–1.25%) CDC 2001
IDU 5.9%(4–10.2%) Friedman et al. J Urban Health 2005;
82(3): 434-45
MSM 19.1%(12.8–25.35%) Xia et al. JAIDS 2006; 41(2): 238-45
Proportion of protected sex acts
Undiagnosed positives & those at risk 50% (0-100%) Gary Marks
Positive aware w/o particip ating in HERR 75% (50-100%) Gary Marks
Reduction in UAV for positive aware people 53% (45-60%) Marks et al. JAIDS 2005; 39(4): 446-53.
Effect size of HERR for positives 18% (0-40%) Options/Opciones Project,WiLLOW,
Healthy Living Project, Healthy
Relationships, CLEAR
Effect size of HERR for negatives 8% (0-20%) INSIGHT,Focus on the Future, Sister to
Sister
Proportion linked to care 69% (66-71%) Marks et al. AIDS 2010; 24(17): 2665-78.
Proportion of positive aware in care who 54.5% (40-70%) Marks et al. AIDS 2006; 20: 1447-50.
achieve viral load suppression

11. Estimates of Budget Cut Impact
Testing and Health education Total
partner services and risk reduction
(HERR)
Budget cut ($) $ 864,486 $15,124,714 $15,989,200
Estimated number of new infections
associated with budget cuts
HET 1.4 1.9 3.3
IDU 0.3 0.3 0.6
MSM 24.9 37.2 62.1
Total 26.6 39.4 66.0
Expected life-time HIV treatment $ 9,760,335 $ 14,476,414 $ 24,236,749
cost generated
Number of new infections per one 30.75 1.92 4.13
million dollars cut
* LA and SF excluded

12. Compare Budget Allocation Scenarios
Hypothetical pre-cut Actual allocation in
allocation scenario FY0910
Total prevention budget $5,860,723 (100%) $5,860,723 (100%)
Testing and partner services $1,079,512 (18%) $3,160,148 (54%)
Health education and risk reduction (HERR) $4,781,211 (82%) $2,700,575 (46%)
Number of local health jurisdictions funded 59 15
Number of positives notified of test result 159 465
Number of unique HERR clients 5,995 3,386
Number of unique positive HERR clients 1,467 1,100
Number of unique negative HERR clients 4,527 2,286
Estimated number of infections associated with cuts 88.4 66.0
Testing and partner services 58.9 26.6
HERR for positive 22.2 29.0
HERR for negative 7.2 10.4
Expected life-time treatment cost generated $ 32,439,520 $ 24,236,749
* LA and SF excluded

13. Limitations
□ We did not include Los Angeles and San Francisco
because data for the two jurisdictions were incomplete.
□ Only the first generation of transmissions were captured
in the impact estimates.
□ We assumed the reductions in prevention services
were the same proportionately across risk groups.
□ Data inputs for Bernoulli model had varying degrees of
uncertainty. These were covered in sensitivity analyses.

14. Conclusions
□ Over $15 million was cut from HIV prevention in FY0910
 Testing: we estimated 31,209 fewer tests were performed, 384 fewer
positives were notified of their infection
 Health education and risk reduction (HERR): 1,784 fewer positive clients
and 6,614 fewer negative clients were served
□ Impact of budget cuts in FY0910
 Estimated 66 new infections were associated with the cuts in one year
 The first year new infections were expected to generate $24 million in HIV
life-time treatment cost
□ Budget allocation in FY0910 appeared to partially reduce the
impact of budget cuts
 Allocate larger proportion of budget to testing
 Fewer new infections would occur
* LA and SF excluded

15. Acknowledgements
□ Richard Wolitski, Choi Wan, Jeffrey Brock, Robert
Swayzer, Dale Stratford, Dwight Dunbar; Division of
HIV/AIDS Prevention, Centers for Disease Control and
Prevention
□ Michelle Roland, Susan Sabatier, Karen Mark, Kevin
Sitter, David Webb, Christine Nelson, Karen Doran,
Charlene Anderson, Brian Lew, Phillip Morris, Matt
Facer, Amy Kile-Puente, Mark Damesyn, Schenelle
Flores; Office of AIDS, California Department of Public
Health

16. Questions?
For more information please contact: Feng Lin (Flin@cdc.gov)
Centers for Disease Control and Prevention
1600 Clifton Road NE, Atlanta, GA 30333
Telephone: 1-800-CDC-INFO (232-4636)/TTY: 1-888-232-6348
E-mail: cdcinfo@cdc.gov Web: http://www.cdc.gov
The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of
the Centers for Disease Control and Prevention.
National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention
Division of HIV/AIDS Prevention