A person with HIV spends a lot of money on pharmaceutical drugs -- estimates run up to $15,000 a year. Texans too poor to afford them can get help from the state's Texas HIV Medication Program (THMP). State law allows people making less than $17,720 a year to get the drugs, which can help extend their lives.
But because of Texas's budget shortfall, the state health department says it will be forced to make drastic cuts in the THMP. As early as this fall, anyone in the program making more than $12,404 annually -- that's roughly 4,200 people statewide -- will have to find funding for medications somewhere else.
"We are horrified," admits Houston doctor Natalie Vanek, who sits on the program's advisory board. "But we have to do something." Area activists think that "something" shouldn't include cutting people off from their drugs.
Last week two busloads of HIV-positive indigents and their supporters headed from Houston to Austin to spout off at a state health department public hearing. Without their medication, they argue, not only will these patients risk getting sicker faster, they will increase their chances of spreading the disease.
"This has a huge public health impact; it will have an effect on prevention," says Tracy Wilson, head of the advocacy group Act Now. "It might as well be 1985 again. Why get tested when you can't get access to drugs?"
But Vanek and state employees say this isn't a clear-cut case of the bad guys versus the good guys.
"If only it were that simple," sighs Dwayne Haught, THMP manager. "I think it's going to be really difficult. [But] the hole keeps getting bigger and deeper if you just keep spending."
Federal funding makes up about 80 percent of the THMP's budget, and the state pays the rest. Medicaid typically covers the expenses for minors and pregnant women.
When it began in 1987, the THMP was budgeted a meager $1 million, and the only drug available through the program was AZT. But as new drugs were developed and life spans increased for people with AIDS, the program's client base and expenses grew dramatically. In 2001, it spent $50 million on drugs for more than 11,000 HIV-positive Texans.
"We're failing because we're doing so good," says Haught.
By last September the program anticipated budget deficits of $34 million over the next three years, and the state's overall revenue shortfall looms as high as $12 billion. Unlike some states, such as California, Texas law does not allow its agencies to operate in debt.
"People want us to do nothing, but we can't do that," explains Vanek. She has spent her career working with HIV-positive indigents at the Harris County Hospital District's Thomas Street Clinic. "If we operate in the red, we get shut down and we can serve no one."
With the threat of closure, state health officials proposed the cutbacks last October. Texas health commissioners are likely to vote on the reductions on February 27.
The THMP cuts are harsh, Vanek admits. The income eligibility limits drop by more than $5,000, and the new rules end assistance for those in special situations, who earned income over the limit but spent an unusually large amount of money on medication.
Local activists say the state should put the top priority on assisting those in the worst physical -- not financial -- shape.
"The reason they chose not to do that is if you make medical criteria a question, that means you must increase administration, and they did not want to bear that responsibility," says Rich Arenschieldt, director of education and outreach at The Center for AIDS, a local advocacy group.
"We prepared every scenario possible, and this scenario met the shortfall," argues Haught. "This scenario enabled the program to stay open and serve the poorest of the poor."
In addition to the problem of decreased state revenue, Haupt points out, some pharmaceutical companies claimed they would freeze the prices of certain drugs but have not delivered.
"Some of the larger companies like GlaxoSmithKline have not come through as promised," he says. "And 40 percent of our budget is spent on Glaxo products." (Haught acknowledges that some others, like Abbott Laboratories, have developed special contracts for state drug assistance programs.)
Texas is not as bad off as it could be. Eleven of the 54 U.S. AIDS drug assistance programs are in such poor financial shape they have closed their doors to new clients entirely, says Haught.
For now, the solutions to the Texas funding problems are few. The program could earn designation as an "exceptional" item in the state budget, meaning it would be exempt from the cuts. But with the state's gloomy financial forecast, many groups will be asking for that designation.
Some pharmaceutical companies run drug programs for indigent people who don't qualify for state aid. But activists say those programs are designed as only a stopgap measure.
"They are not meant for long-term use," says Arenschieldt. He worries that those who stop taking their medication will become more susceptible to infectious diseases, perhaps placing an even greater financial burden on the taxpayers.
"When they get pneumonia, liver disease, carcinoma -- that's going to fall on the public medical health system of the county," he says.
Vanek argues that one of the best solutions is also one of the oldest civics lessons: Those who are concerned must contact officials and get out the vote. She has been rallying patients to phone state legislators, and she reminds them to keep the program and other AIDS-related causes in mind when they go to the polls.
"It's really the people in the state legislature who decide how to spend our money," she says. "People think those on advisory committees have so much power. But we all have the same power: one vote on Election Day."