IN THE LOOP

Last week Governor Newsom released his revised 2020-21 state budget — also known as the May Revision — which underscores the dramatic economic impact of COVID-19. California is facing a budget deficit of over $54 billion and the administration is proposing steep cuts in nearly every part of state government to help balance the budget.

Some of these cuts would not be enacted if Congress provides additional funding for state and local governments. APLA Health is working with a broad coalition of organizations to pass the HEROES Act, a $3 trillion federal relief package that includes nearly $1 trillion for state and local governments to address budget deficits caused by the COVID-19 crisis.

This week we’re providing a breakdown of the Governor’s proposals that would have the most significant impact on APLA Health and the people we serve. Over the next several weeks, APLA Health will be partnering with other groups to help ensure many of these cuts are not included in the final budget. The Governor and legislature must negotiate a final budget before the fiscal year begins on July 1st.

Public Health

California’s public health infrastructure has long been underfunded, but in recent years the Governor and legislature have supported strategic investments to address the state’s ongoing crisis of HIV, hepatitis C, and STDs. The Governor’s May Revision maintains funding for public health programs, including the recent investment of $5 million each for HIV, hepatitis C, and STD services. Public health officials are urging the administration to provide additional funding to bolster public health infrastructure during the COVID-19 crisis.

Concerningly, the Governor’s May Revision proposes to help balance the budget with a $100 million loan from the AIDS Drug Assistance Program (ADAP) Rebate Fund. The ADAP Rebate Fund is the primary funding source for California’s ADAP and recently created PrEP Assistance Program (PrEP-AP). These programs are the backbone of the state’s efforts to end the HIV epidemic and help ensure people living with and vulnerable to HIV have access to life-saving medication. While the Governor’s proposal is not expected to have an immediate impact on services, the loan would set a dangerous precedent and threaten the ongoing sustainability of California’s most vital HIV safety-net program.

This week APLA Health is cosponsoring the “End the Epidemics Week of Action” to protect critical funding for HIV, hepatitis C, and STD programs and to increase funding for essential harm reduction programs during the COVID-19 crisis. You can get involved and share your story by visiting our virtual action center here.

Healthcare

The May Revision makes deep cuts to the Medi-Cal program at a time when many Californians are facing significant financial challenges. Medi-Cal provides free health coverage to low-income Californians and is expected to see increased enrollment due to job losses during the COVID-19 pandemic.

The Governor’s proposed changes to the Medi-Cal program would have a significant negative impact on community health centers like APLA Health. The May Revision maintains the Governor’s proposal to transition all Medi-Cal pharmacy services from managed care to fee for service — also known as Med-Cal Rx — but without critical supplemental payments for community health centers. Medi-Cal Rx would eliminate savings from the 340B drug discount program that health centers rely on to expand critical healthcare and support services for low-income Californians.

The May Revision withdraws the Governor’s January proposal to expand Medi-Cal to undocumented seniors, although it maintains Medi-Cal coverage for undocumented children and young adults. The revised budget also does not implement a recent expansion of the Medi-Cal Aged and Disabled Program for individuals with incomes between 123% and 138% of the federal poverty level.

Absent additional federal funds, the Governor has proposed significant cuts to Medi-Cal benefits and provider reimbursement rates. Notably, the May Revision proposes to reduce adult dental benefits and eliminate audiology, speech therapy, podiatry, optometry, and referral to treatment for opioids and other illicit drugs, among other services. The budget also proposes to eliminate approximately $1 billion in Proposition 56 tobacco tax funds that currently support supplemental payments for physicians, dentists, and other services and instead use these funds to support growth in the Medi-Cal program.

The May Revision maintains Proposition 56 funding to support rate increases for the AIDS Waiver Program, which provides comprehensive case management and support services to people living with HIV. APLA Health is one of the largest AIDS Waiver providers in California.

Other Safety-Net Programs

Absent additional federal funds, the May Revision proposes to cut two key safety-net programs for seniors and people with disabilities: In-Home Supportive Services (IHSS) and Supplemental Security Income/State Supplementary Payment (SSI/SSP) grants. The administration proposes to reduce IHSS consumers’ hours of care by 7%. The administration also proposes to reduce the state’s SSP grant by the same amount as the pending federal SSI increase. Because the SSP portion would go down while the SSI portion would rise, the administration expects this change would have “no impact on the grant amount” that people receive.

There are no proposed changes to the CalFresh program, known federally as the Supplemental Nutrition Assistance Program or SNAP. The budget also maintains reversal of the SSI “cash out” policy, which has allowed thousands of Californians with disabilities and seniors who rely on SSI/SSP to receive CalFresh benefits for the first time.

There are no grant cuts or eligibility cuts proposed for CalWORKs, but the May Revision includes significant reductions to the program if additional federal relief funding is not approved by Congress. The impact of these cuts would be a sharp curtailment of CalWORKs welfare-to-work activities.

Housing and Homelessness

The May Revision recognizes the need to protect unhoused Californians from the devastating impacts of COVID-19. The revised budget includes $750 million in federal funding for homelessness and directs the use of these funds to purchase hotels and motels secured through Project Roomkey. The revised budget also preserves $500 million in funding for state tax credits for affordable housing construction. Finally, the May Revision proposes to use over $300 million in National Mortgage Settlement funds for housing counseling, mortgage assistance and renter legal aid services.

You can find a more detailed analysis of the Governor’s May Revision from the California Budget and Policy Center here.

In a first for HIV prevention, a large trial looking at injectable PrEP found that a long-acting form of the HIV drug cabotegravir, injected once every 8 weeks, safely and effectively prevents HIV in men who have sex with men and transgender women who have sex with men.

The trial and an ongoing companion study evaluating long-acting injectable cabotegravir for HIV prevention in women are sponsored by the National Institute of Allergy and Infectious Diseases (NIAID), part of the National Institutes of Health.

Currently, only two oral drugs, Truvada and Descovy, are FDA-approved for HIV pre-exposure prophylaxis, or PrEP. Taking pills can be challenging for some individuals, and an injectable form of PrEP promises an easier option for some.

The HIV Prevention Trials Network study (HPTN 083) enrolled 4,570 HIV-negative men who have sex with men and transgender women who have sex with men at 43 sites in Argentina, Brazil, Peru, South Africa, Thailand, the United States and Vietnam. Two-thirds of study participants were under 30 years of age, and 12% were transgender women. Half of the participants in the United States identified as black or African American.

Participants were randomly assigned to receive either injections of cabotegravir and placebo oral tablets or placebo injections and daily oral Truvada tablets. Neither the participants nor the study team knew who was receiving which medication.

In a planned interim review of HPTN 083 on May 14, 2020, an independent data and safety monitoring board (DSMB) found that the study data clearly indicated that long-acting injectable cabotegravir was highly effective at preventing HIV in the study population. Among the 50 people in the trial who acquired HIV, 12 were receiving long-acting cabotegravir and 38 were receiving daily oral Truvada. This translated to an HIV incidence rate of 0.38% in the cabotegravir group and 1.21% in the Truvada group.

Consequently, the DSMB recommended that NIAID stop the blinded phase of the trial, which was originally expected to continue until 2021, and share the results. NIAID has accepted the DSMB’s recommendations and is releasing the results now to serve the interests of public health. The study investigators will report more detailed information about the HPTN 083 results in the coming weeks.

All study participants, including those who initially received Truvada, will be offered long-acting cabotegravir as soon as it can be made available. Study investigators will continue following HPTN 083 participants to gather additional data about the long-term safety of injectable cabotegravir for HIV prevention.

Many questions remain about the injectable. The announcement came in a press release from ViiV Pharmaceuticals, and so was not published in a peer reviewed scientific journal. When injectable PrEP will be approved, how it will perform in the trials for women, how much it will cost and compete with generics coming to the market soon, and whether individuals eligible for PrEP will want to visit a doctor every two months are all open questions.

“It is inspiring that we may soon have additional HIV prevention options for at-risk individuals who have difficulty with or prefer not to take pills. We are indebted to our study participants and clinical research sites,” said HPTN 083 protocol chair Raphael J. Landovitz. Dr. Landovitz is a professor of medicine in the Division of Infectious Diseases at the David Geffen School of Medicine at UCLA and associate director of the UCLA Center for Clinical AIDS Research & Education (CARE).

The Los Angeles County Department of Public Health (DPH) recently released a report entitled COVID-19: Racial, Ethnic & Socioeconomic Data & Strategies Report detailing the disproportionate impact of COVID-19 on several racial/ethnic communities and other vulnerable populations. The report summarizes key findings from available data on testing, total cases, and deaths, highlighting the following:

• African Americans comprised 8% of positive cases but 14% of deaths, with a mortality rate of 22 per 100,000 individuals.
• Latinx individuals comprised 46.4% of positive cases and 37% of deaths, with a mortality rate of 19 per 100,000 individuals.
• Native Hawaiian or Pacific Islanders comprised 1.5% of positive cases and 1% of deaths, but have an exceptionally high (though unstable) mortality rate of 55 per 100,000 to 150 per 100,000 individuals.
• Asians comprised 11.5% of tests and 18% of deaths, with a mortality rate of 15 per 100,000 individuals.
• Whites comprised 23.7% of tests and 28% of deaths, with a mortality rate of 11 per 100,000 individuals.
• The death rate was three times higher in areas of the County with high poverty rates, at 34 per 100,000, as opposed to 9 per 100,000 individuals in areas with low poverty rates.

Overall, the data indicate that COVID-19 cases and deaths are extremely high among Native Hawaiian or Pacific Islanders, and high among African Americans and Latinx communities. The report notes that many communities of color are historically disproportionately affected by poor health outcomes as a result of longstanding inequities across various social determinants of health including access to healthcare, affordable housing, and nutritious foods. Notably, the data on COVID-19 among Angelenos is similar to demographic data on people living with HIV, including that a disproportionate number of people newly diagnosed with HIV are African American and Latinx, and there tend to be higher rates of new HIV cases in areas with increased socioeconomic disparities.

The report identifies nine recommendations to address COVID-19 inequities, including the urgent need for more intensive efforts to expand culturally competent and accessible testing, treatment, and prevention services. DPH is working with other County departments and community partners to implement the set of recommendations, including ensuring access to testing, integrating testing with care coordination, ensuring access to potential treatments, facilitating access to resources for small clinics, supporting policies that promote equity, including community voices in COVID-19-related planning, fostering inclusive data collection, reporting, and analysis, strong contract tracing, and improved communication, including offering resources in many languages. DPH hopes to close the gap and advance conditions that support optimal health and well-being for vulnerable populations, in alignment with DPH’s commitment to promoting health equity for all Angelenos.

You can learn more about LA County’s demographic data on COVID-19 here and guidance related to all aspects of COVID-19 and the County’s Recovery Plan here.