Slicing the pie

A new distribution formula for Maine's HIV-prevention funds is gutting Portland's AIDS-awareness efforts

by Lance Tapley

GOOD INTENTIONS: Nate Nickerson says it would be great to have a statewide HIV-prevention program, but there needs to be more money to do that effectively.

Instead of two city health workers prowling the Portland streets trying to get injection-drug users not to share needles and the HIV infection, there now is only one.

Instead of a city substance-abuse counselor trying to prevent people from putting themselves at risk for HIV by having unprotected sex while drunk or otherwise intoxicated, there now is no one doing this in Portland.

There are fewer safe-sex and safe-needle workers on the streets because Nate Nickerson, with big cuts in HIV-AIDS prevention funds possible for the city, doesn't dare fill these vacancies on his staff. Nickerson, head of Portland's adult health services, runs the sexually-transmitted-diseases prevention effort at the India Street Public Health Center.

He feels hoist on his own sense of generosity. It was the right thing to do, he thought, when he served on a state bureau of health committee this past year that agreed to a new formula for the distribution of the annual $500,000 in federal AIDS-HIV-prevention money that comes into the state. The committee work was done to prepare for a new five-year funding of agencies statewide beginning next January 1. Nickerson knew that the old formula was weighted toward Portland and that some kind of cut was coming.

But now the health bureau has told him the new distribution scheme could result in a 55 percent slash to his own agency's AIDS-HIV-prevention budget. Basically, money may be taken from Cumberland County, which the Portland program serves, and given to more rural counties.

A slash of this size is more like the cut of a guillotine. Specifically, the sum going to Nickerson's program may drop from about $120,000 a year to $54,000, according to the health bureau, which administers this federal Centers for Disease Control-provided kitty. The funds will be distributed for educational purposes in three categories: "unsafe sex male-male," "sharing needles," and "unsafe sex opposite sex."

Nickerson believes the Portland area can ill afford the cuts. He estimates there are about 500 needle users in Cumberland County shooting up heroin, cocaine, or a hot new drug, the prescription painkiller oxicodone hydrochloride, an addictive narcotic that goes under the brand name Oxycontin.

And there are "thousands" of women and men at risk if you count all the people who have multiple sexual partners, he says. The AIDS-HIV epidemic has long hit Cumberland County, by far the state's biggest urban area, the hardest of any region.

(The state health bureau estimates that there are about 1100 people with HIV, the human immunodeficiency virus, in the state. Since it was first diagnosed in the 1980s, about 500 people in Maine have died from AIDS, the acquired immunodeficiency syndrome that the virus usually leads to.)

In addition to the city program that Nickerson oversees, the AIDS Project in Portland also gets a share of the CDC funds for a program targeted against male homosexual unsafe sex. It, too, expects a big cut in funding.

"It wasn't a surprise to us that we were going to be getting less money," says AIDS Project Executive Director George Friou, who was involved in the planning process leading up to the new formula. "What was a surprise was the amount."

Friou says his group usually gets around $200,000 a year to run its prevention program. They are looking at at least a 50 percent cut. "That's not going to leave much of a prevention program," he says.

Specifically Friou expects, even if they secure all the funds available to them, that the AIDS Project will lose its HIV Hotline, which allows Mainers to call an 800 number for information on HIV and AIDS; one of its outreach workers; and the director of its HIV-prevention program, Doug Eaton.

"If the state would have just brought this new formula in gradually, over a three year period or so, we could have made it work," says Friou. "But they didn't do that."

"This is not about Portland whining," Nickerson adds. "The funding formula is well-intentioned." He doesn't want to see the rural agencies get less than proposed. In some counties the amount for them in the past in some categories was zero.

"But the pie is not big enough," he maintains. Even the new, beefed-up funding proposed for the rural counties [see chart] doesn't seem like a lot. For example, can $3100 a year do much against unsafe heterosexual practices in Washington County?

"I don't know what sort of prevention program you could establish with that amount of money," says Nickerson.

Nickerson raises his objections in a quiet voice. State Rep. Michael Quint (D-Portland) is more vociferous.

"I was shocked to discover this," he says of the proposed cuts. "The only people who really lost were in Portland." The health bureau should not have asked for the committee's consent until it showed them the numbers, he says. The committee was largely made up of people representing service providers such as Nickerson and Friou and "consumers" such as people with HIV.

Now Quint plans to sponsor a bill in the next legislative session (he is running unopposed at the November election) to supplement the CDC money with an appropriation of at least $500,000 "for direct services." This would double the targeted AIDS-HIV-prevention effort statewide. Quint says it was "appalling" for him to learn that the health bureau had never asked the legislature for funding except to cover "administrative costs" for prevention work.

However, if the appropriation passed it probably wouldn't become available until a year from now. Thus, for the interim Quint would like to get an agreement from the health bureau to block or reduce any cuts to Cumberland County.

The health bureau, in the person of Paul Kuehnert, director of its division of disease control, says it can't negotiate anything with Quint because the funding is a competitive process under strict rules. But Kuehnert holds out the hope that Cumberland County's cuts may not be as drastic as Nickerson, Friou, and Quint fear. While being cautious in his statements -- "I can't talk about the specific allocation for this year" -- he emphasizes that "the funding decisions are not yet made."

His agency "will try to be flexible," he says. The numbers Nickerson, Friou, and Quint are reacting to are more guidelines than absolute numbers, he suggests: "We will look at the impact of shifting funds." For example, if no acceptable proposal is received from a county, the bureau might reallocate funds to another county.

Kuehnert also observes that the state government's own spending on AIDS-HIV prevention -- what Quint described as covering "administrative costs" -- has remained flat at an annual appropriation of $184,500 since 1989. This money is distributed in grants to a statewide AIDS alliance of nonprofit organizations such as the AIDS Project (though not to municipal agencies like Nickerson's). It is spent in a variety of ways, including providing counseling to people with HIV or AIDS.

So, after more than 10 years of the same state funding level, "I would totally agree there needs to be a larger pie," Kuehnert says, although the bureau would reserve judgment on Rep. Quint's funding proposal until it sees the specific legislation.

In defense of the new formula, Kuehnert says "the rationale for changing it didn't come from the bureau of health" but from advocates for more AIDS-HIV prevention work in rural counties. "The epidemic is shifting," he notes. "Fifty-three percent of the new cases since 1995 are outside Cumberland and York Counties."

One of the rural advocates, Ron King, director of the Down East AIDS Network in Ellsworth, which serves both Hancock and Washington counties, says the old Portland-weighted formula was simply "unconscionable." Last year his group got $33,500 a year for targeted AIDS-HIV prevention work for both counties. He expects the amount under the new formula, if his agency is funded, to increase to $40,400.

Washington County hadn't been getting any specific funds to combat HIV transmitted by people sharing needles, he says, but the number of people shooting up in this poor, remote county is now "amazing." Oxycontin, he says, is known locally as "Washington County heroin."

He believes that even the small sum of $3100 under the new formula would provide for useful heterosexual AIDS-HIV prevention in Washington County. His agency has proposed spending it by setting up peer education teams in schools

The Down East AIDS Network served 3000 people in both counties last year, he says. That number supports the view that the AIDS-HIV epidemic is continuing to spread beyond Southern Maine. New AIDS cases are decreasing in the city of Portland itself, and only 36 percent of new 1998 cases involved residents of the heavily populated southern part of the state.

Still, 48 percent of those testing positive for HIV in 1998 lived in Southern Maine. "There's absolutely no doubt there's a big problem in the Portland area," comments Kuehnert. But "it's clear that slicing up this small pie is a problem, too."

Lance Tapley can be reached at ltapley@ctel.net.

NEW DISTRIBUTION FOR ANNUAL AIDS-HIV-PREVENTION FUNDING source: Maine Bureau of Health