David Austin and his partner, Walter Smith, are having an argument — one of those simple, meaningless disputes couples have on quiet Saturday nights.
They’re sitting in their living room of their southside Birmingham, Alabama home watching a documentary on YouTube about Johnny Depp, when a question about the celebrity’s relationship history comes up.
“That’s not true, they were married,” Austin says. They go back and forth, until Austin decides to fact-check it. He pauses the documentary and runs a Google search using voice-to-text.
“Did Madonna and Johnny Depp ever get married,” he says aloud. The search results quickly reveal that he’s wrong. But Smith doesn’t rub it in. He just smiles, and they continue watching the documentary.
Both Austin and Smith are HIV-positive, and they’ve been together for a few years. They met by chance on an empty bus shortly after Austin came to Birmingham in 2020 to care for his mother, who was dying of cancer.
“Me and Walter would go all over, he would show me his state, his city,” Austin said.
Austin also has opioid use disorder, and Smith has helped him with it, including calling an ambulance when Austin overdosed a few months ago. He saved his life. Austin’s right arm was amputated while he was in a coma after his overdose because of an infection caused by xylazine, a tranquilizer that’s sometimes mixed with fentanyl.
Tonight, Austin isn’t feeling well. He’s been living on his own and using opioids like heroin since he was 14. He’s 58 now and fentanyl is what’s mostly available on the street. But he hasn’t used any today and he’s starting to go through withdrawals.
Austin pauses the documentary again and pulls out a ball of tinfoil with fentanyl inside. It takes him a few minutes to prepare and inject the drug, doing it all with one arm.
Austin said he’s struggled to find stable housing and access treatment and medications for most of his life — until he met Smith.
“And then, I got plugged into the 1917 Clinic,” he said.
The 1917 Clinic is the largest HIV clinic in Alabama, and it’s helped Austin and Smith access treatment for HIV and substance use. The couple is able to pay their rent with help from a service organization called AIDS Alabama. Both organizations rely heavily on federal funding, which is now in jeopardy after cuts from the Trump administration.
Birmingham has the highest rates of HIV in the state, and the South has the highest number of people with HIV. Because of their higher rates, Mississippi and Alabama were among seven states that received additional federal funding through the Department of Health and Human Services’ Ending the HIV Epidemic (EHE), an initiative started by President Trump in his first term — one of the federal programs that would be eliminated from the Department.
Much of the 1917 Clinic’s funding comes from programs that support health care, prevention and research for HIV from the Department of Health and Human Services. That department has lost at least nearly a quarter of its budget after cuts from the Department of Government Efficiency (DOGE).
Dr. Ellen Eaton, who treats people with HIV in Birmingham, said she’s having tough conversations with her patients about the future. They hear about federal budget cuts on the news and they ask her what they could mean for them.
“I don't think many of our patients appreciate what's coming and I think a lot of our service providers also do not have a clear understanding of what care will look like moving forward,” Eaton said. “When there is uncertainty, I am honest with them that I don't know what their care will look like.”
Substance use and HIV often go hand-in-hand, Eaton said, meaning people like David Austin often require comprehensive care. This rings especially true in places like Alabama, which has been hard-hit by both the opioid crisis and the HIV epidemic.
“I know that treating the HIV alone is a band-aid if I don’t treat the substance use that led to the HIV,” Eaton said.
It’s not just health care that could be at risk from federal cuts. Other support for people with HIV, like housing, are at risk, too.
Kathie Hiers, CEO of AIDS Alabama, said housing is the main focus of their organization because of how crucial it is for people living with HIV — like Austin and Smith. Housing is health care, Hiers said. It provides stability, allowing people to be better able to access treatment and stay on medication.
“Without housing,” Hiers said, “it’s very difficult for a person to follow their medical regimes.”
Like the 19717 Clinic, AIDS Alabama relies heavily on federal funding. AIDS Alabama lost 23 of their 27 “Navigators” — which help enroll people in Affordable Care Act (ACA) health plans and conduct outreach and education — across the state after the Trump administration cut 90% of the funding for the position.
But what worries Hiers the most are cuts to HIV prevention and layoffs at the Centers for Disease Control and Prevention (CDC) — which provides more than 90% of all federal funding for HIV prevention. If the funding is eliminated, it could lead to more than 143,000 new infections and almost 15,000 AIDS-related deaths by 2030, according to amfAR, a nonprofit that researches HIV.
“The DOGE group has gone in and pretty much dismantled the HIV prevention department of the CDC,” Hiers said. “And how in the world do we stop HIV without prevention? It’s just nonsensical.”
The Trump administration said it will move some prevention work to a new agency, the Administration for a Healthy America. But experts say these cuts put an already fragile support system at risk.
“All of those programs work together. Prevention and care and treatment, it’s somewhat of an artificial distinction,” said Dr. Jennifer Kates, director of global health and HIV policy at KFF, a health policy research group.
For clinics like the 1917 Clinic, which rely on federal funding, Kates said even a small reduction in funds could have a really big impact. And cuts to programs across the federal government, including for substance use and mental health, which she said may also be reduced in the budget, could leave people like David Austin at particular risk.
“If there's reductions in support for people who are using drugs or trying to stay off drugs, coupled with reductions in support for HIV directly, that would be more like a double or triple whammy for people in those pretty vulnerable positions,” Kates said.
Federal funding for HIV has been well-spent in Alabama, Hiers said. The funding from the EHE initiative helped to reduce new infections at almost twice the rate as states that didn’t receive the funding.
The Trump administration hasn’t yet released a proposed budget for the Department of Housing and Urban Development (HUD), but Hiers said she’s “already heard rumors” of staff reductions and budget cuts. AIDS Alabama manages HUD’s Housing Opportunities for Persons with AIDS (HOPWA) Program for the state.
“If that money goes away and all those people are on the streets, we are going to have an epidemic like we haven't seen since the early days of HIV,” Hiers said. “That’s terrifying to me because we have the tools to stop it now, but it's almost as if we're just intentionally throwing them away.”
This story was produced by the Gulf States Newsroom, a collaboration between Mississippi Public Broadcasting, WBHM in Alabama, WWNO and WRKF in Louisiana and NPR. Support for public health coverage comes from The Commonwealth Fund.
