Tennessee replaced its federal HIV funding with state money. Public health experts say the change is causing damage.

Tennessee Gov. Bill Lee made waves in early 2023, when he rejected millions of dollars in federal HIV prevention programming. Since then, the state has been replacing that money. But that new process is already causing damage, according to public health experts, and models show this could mean more infections and more deaths in the long term.

One example: It’s harder to retain workers when they don’t know if their jobs will disappear.

Amna Osman is the CEO of Nashville CARES, an agency that both offers HIV prevention services and oversees funding for other Middle Tennessee organizations. She sees the struggle some agencies have with staffing.

“There’s no sustainable grant funding to support these positions,” she said. “Employees really want some stability.”

That’s because, before the change, federal HIV/AIDS prevention grants funded Tennessee’s programming for five years at a time. But the funding cycle is only one year now that the state is paying for the program. It’s included in the budget that lawmakers pass every legislative session, and there’s no guarantee they’ll continue.

Osman says even before the funding change, community surveys found that about a third of people who need pre-exposure prophylaxis, or PReP — a medicine that protects against HIV— don’t know where to get it. Now, it’s even worse.

“‘Well, I’m hearing there’s no dollars for prevention education for HIV.’ Then, that means ‘I think there’s no money for me to get a service,'” she said. “And so people then don’t know where to go, and it creates even more fear.”

The state has maintained that the new model, using state funding, is more straightforward and effective.

“The replacement of federal with state funding has provided a more efficient process for grant recipients to apply for and draw down funding for their HIV prevention work,” Department of Health spokesperson Bill Christian said in a written statement. “In effect, this has eliminated the financially burdensome federal process where grant recipients were required to use their own funds up front and then request reimbursement from the CDC of their expenditures. Under the state model, the grant funding is made available to recipients at the beginning of the grant term.”

Critics cite other problems, like Tennessee’s plan to move investment away from traditional high-risk groups, like men who have sex with men. The state has pledged to pivot to new priority groups: first responders, pregnant people and sex trafficking survivors.

That priority shift is the focus of a white paper published in the journal, “Clinical Infectious Diseases.” Traditional high-risk groups account for 99% of Tennessee’s current HIV cases.

The authors of the study project that Tennessee’s disinvestment in those high-risk groups could cause 190 additional deaths in the state over the next decade.

In January 2023, a statement from Lee’s office said the administration dropped the federal funding because it “is examining areas where it can decrease its reliance on federal funding and assume increased independence.”

That’s been a focal point for Tennessee Republicans over the past few years.

Legislative leaders have spent significant time and state resources trying to find a way to reject and replace federal education funding. House Speaker Cameron Sexton was the first to float that idea, and later said part of the issue for him was the standardized testing attached to federal funding.

This also isn’t the first time Tennessee has replaced federal funding for reproductive health care. It was the first state to lose Title X funding under the Biden administration. That program gives money to clinics like county health departments to help low-income people access STI testing, contraception and family planning services. Federal officials started requiring all the clinics that accept this funding to include abortion in the options they explain when counseling pregnant people. State officials refused and lost $7 million in funding.

First, the state sued in an attempt to force the federal government to give the state funding anyway. (The court sided against Tennessee.) Then, the state began footing the bill for those services in its county health departments, and Planned Parenthood is offering Title X-funded services after securing a $7 million grant from the program.