A backlash has stalled a plan to reallocate HIV prevention money among two state agencies. Even so, the Minnesota departments of Human Services and Health still plan to hold a listening session in Duluth Friday to gather more feedback.
The disagreement over the best way to address HIV and AIDS is reminiscent of some of the early days of the crisis three decades ago.
The state agencies say transferring more than $10 million in federal dollars from Human Services to Health would enhance support for patients.
Kris Ehresmann, infectious disease director at the Health Department, says it would also bolster HIV prevention efforts.
"The goal is to get to zero, which is the phrase that's used when we say we don't want to see any more new HIV infections," she said.
The plan has preliminary support from the Minnesota AIDS project and other advocacy groups.
But critics say the plan would do more harm than good.
"That has absolutely nothing to do with prevention," said Aaron Wittnebel.
He's a member of the Minnesota HIV Services Planning Council and the Minnesota HIV/AIDS Consumer Advisory Committee. Each group passed no confidence votes on the proposal.
Wittnebel fears that moving the money would disrupt services funded through the Ryan White CARE Act that people with HIV rely on. Plus, he said the Health Department doesn't have a good track record on preventing HIV/AIDS. He points out that new infections held steady at around 300 per year for a decade, despite ample state prevention funding.
"They've had $1.2 million each of those 10 years to work just on reducing that number and they have failed to do so," he said.
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Health officials maintain that the state's current funding stream is partly to blame for that, because it stymies the use of best practices.
By law, the Health Department keeps track when someone tests positive for HIV. The monitoring includes subsequent test results, which can show which patients are getting care and which ones haven't been seen by a physician in more than a year. That provides a powerful tool to identify people who are not getting treatment and therefore more likely to spread HIV to others.
The data can be powerful in other ways, too, because they often reveal clusters of untreated cases. This is occurs more frequently in neighborhoods where poverty and barriers to transportation make it more difficult to access health care.
Ehresmann said studies now show the best way to prevent the spread of HIV is to get anti-viral medications to someone who is infected as soon as possible.
Last month, the World Health Organization issued new guidelines urging doctors to treat every HIV patient with anti-retroviral drugs as soon as they test positive for the virus. The WHO also recommends giving preventative drugs to everyone at risk of contracting HIV.
"Now individuals who are treated for HIV, they can have their viral load suppressed," Ehresmann said. "And what that means is, that if you have a suppressed viral load you're not infectious."
But there's a Catch-22 in state law that gets in the way. The Health Department knows who those people are but can't legally share that information with Human Services, which funds that kind of outreach.
So the agencies worked out a plan to transfer $13.1 million in federal funds to the Health Department so it could use its data to get more infected people in treatment.
Some cities and states are already successfully using these tactics to reduce HIV infections. An aggressive campaign in San Francisco has reduced the virus to very low levels in almost three-quarters of the city's HIV-positive residents. New infections have also dropped substantially.
San Francisco also has a widespread campaign to get uninfected gay men to take a preventative drug regime called PrEP.
Dr. Keith Henry, an HIV specialist at the Positive Care Center at Hennepin County Medical Center, said San Francisco is way ahead of Minnesota on deploying PrEP.
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"You drive around (San Francisco), there's billboards. The Health Department is promoting this. It's aggressive campaigns," he said. "There's no billboards here. Zero. Nada."
Henry said part of San Francisco's success can be attributed to strong leadership within its medical community. He said HIV/AIDS physicians across the city work closely together to make sure that patients aren't falling through the cracks. It's challenging work with sometimes difficult patients.
Henry supports the state's new outreach and prevention strategy, at least in principle. But he doubts Health Department bureaucrats are up to getting the job done.
"They don't know what it's like to stay extra evenings to see a difficult patient or have a patient on a weekend or a holiday," he said. "Care is 24/7 and there's a reason why people don't want to do that because it's difficult, particularly if the patients are challenging. And so this is a sort of nuts and bolts sort of stuff you have to iron out to make this work."
The Minnesota AIDS Project's public policy director Matt Toburen said the debate is a reflection of the fact that many silos have developed around HIV/AIDS funding.
And while the dispute over the state's proposed funding shift has divided some HIV/AIDS advocates, Toburen thinks the conversation may be helpful in the long run. He said it has pushed people to think bigger about what Minnesota can achieve.
"We know that we can make a difference, we know that we can bend this curve down," Toburen said. "We just need to get everyone moving in the same direction."
There may be time for that. The state Health Department's funding shift proposal is off the table for now. Public health officials say they want to reset the conversation.