The issues are, however, perennial:
- On the one hand, you've got some big cities with some fairly high numbers of people living with HIV. High concentrations of people with HIV place high demands on services. The solution is generally to create specialized facilities that can provide the quality of services needed and address the quantity issues. This requires a steady and dependable stream of funding.
- On the other hand, you've got the dispersed rural areas and smaller urban areas that do not have the high concentration of cases, but also don't have the quality or quantity of available services. And the epidemic is growing rapidly in some of these areas.
These same issues were hashed over the last two times that the Act was reauthorized: How do you continue to provide services to the many folks in the urban areas who need them without slighting the growing number of folks in the less densely populated areas who also need them?
What's different now is that we no longer see the increases in HIV funding that we could count on in the past. Indeed, over the past five years, funding for both services and prevention have been cut. Funding for medications continues to increase, but at such a slow rate that there are serious waiting lists in many states.
Texas, of course, has it all. There are five "Title I cities": Houston, Dallas, Austin, San Antonio, and Fort Worth. These cities absorb most of the HIV funding that comes to Texas, either through their Title I grants or their access to medications through THMP. The rural areas and smaller cities have fewer cases, to be sure, but they receive much less in terms of funding for services and use a smaller proportion of the funds spent through THMP. Nonetheless, these Texans who do not live in the Title I cities also deserve quality care that is easily accessible.
Depending upon the proposal for how to reauthorize the Ryan White CARE Act, some part of Texas will benefit, some part will not. Whether there is a middle way remains to be seen.
Whatever it is, that middle way needs to be found soon. The President called for reauthorization in his State of the Union Address. Now the HIV/AIDS community's disagreement is cropping up in the media. It's time for one of those Unity Conferences to bring some unity.