Kim Holmes doesn’t like to sit still. When she’s busy — and she usually is, volunteering as an outreach worker and peer advocate for people struggling with substance use disorders — it’s easier to not think about the past.

A trauma-filled childhood spent in West Baltimore’s Murphy Homes. Two sons lost to gun violence. Family members claimed by cancer. Years spent with a heroin and cocaine addiction that consumed her every waking thought. And then HIV, an infection that attacks the immune system and can become AIDS without treatment. At her sickest, Holmes required dozens of prescriptions and daily blood transfusions to stay alive.

Now 62, Holmes only takes four pills a day. She has an apartment near Morgan State University in Northeast Baltimore and recently celebrated her 15th year sober. That wouldn’t have been possible, she said, without the help of Johns Hopkins Medicine and groups like Project PLASE, which provides temporary housing, case management and other services to Baltimore’s unhoused residents.

But some of the programs that Holmes credits with saving her life — and many more organizations across Maryland that provide counseling, education and other services to people with HIV — are in danger after a surplus fund operated by the Maryland Department of Health ran out of money last fiscal year.

The Baltimore City Health Department sent a letter in April to providers, telling them that for the fiscal year starting July 1, it would receive 76% less state funding for HIV-related programs than it had expected for the previous year. The city anticipates getting only $5.3 million from a combination of federal dollars through the Ryan White Part B Program and rebates from the Maryland AIDS Drug Assistance Program. That’s compared to what the health department expected to get in the last fiscal year — $22 million — although that figure later dropped to $17.9 million, the letter said.

“It’s sad. It’s really sad,” said Holmes, who found her apartment through Project PLASE and regularly volunteers with the organization. “You got something that’s working. Why, if it’s working, why try to break it?”

Officials at the state health department said service providers and organizations had plenty of time and notice to prepare for the drop in funding. And the surplus fund — which the agency started spending in 2016 — wasn’t meant to be a permanent funding source.

Even though some service providers knew budget cuts loomed, some said they weren’t given sufficient warning of how drastic the cuts would be. And with only a few months before the fiscal year ended, some providers said they didn’t have enough time to apply for other funding to make up for the cuts.

The city’s letter advised providers that certain services previously covered by the fund — like outreach, health education and risk reduction, substance abuse treatment and psychosocial services — would no longer be prioritized.

Services providers in the city and across the state are still figuring out what the change in funding means for their organizations, but many worry mostly about what it will mean for the people they serve.

About 10,252 people live with HIV in Baltimore, according to the most recent data from AIDSVu, a database run by Emory University. That’s 2,088 people for every 100,000 — a rate that towers over Maryland’s rate of 643 per 100,000 and the national rate of 383 per 100,000.

People with HIV can live long and healthy lives, but that requires consistent engagement with treatment —something that can be challenging for vulnerable populations disproportionately at risk of becoming infected with HIV, such as those with substance use disorders, sex workers and people who don’t have a home.

In Baltimore, according to AIDSVu, 62.3% of people living with HIV have a suppressed viral load, meaning there is effectively no risk of virus transmission during sex. That’s slightly less than the national figure of 65.9%.

Outreach and support groups are vital tools for keeping vulnerable populations, and others with HIV, connected with testing and treatment, said Sharon Coker, executive director of the SLK Health Services Corp. in Lanham. Her organization, previously supported by the state health department’s surplus fund, is preparing to pause its psychosocial support services and outreach efforts until it can find more funding, she said.

“One thing I’ve learned from people living with [HIV]? They don’t like abrupt change,” Coker said. “It will send some into a spiral. Some will say, ‘You don’t believe in us anymore. You don’t love us anymore.’ Because sometimes, they’re like your children.”

The surplus fund saga started in 2016 when the Health Resources and Services Administration, the federal agency charged with distributing Ryan White HIV funding, took issue with how the state health department was saving money it brought in through the state’s AIDS Drug Assistance Program.

That program helps eligible people with HIV or AIDS pay for their medications and afford insurance.

The drug assistance program is funded primarily through Ryan White Part B, but also receives money from pharmaceutical manufacturers in the form of rebates on certain medications.

The state health department was saving the rebates in a rainy day fund — not spending them all in the year it received them, like HRSA wanted. So state officials created a plan for spending the surplus, primarily by distributing it to local health departments to support local priorities related to HIV.

In October 2021, close to when the fund was initially projected to expire, the state health department started holding stakeholder meetings to plan for the change, department spokesperson Chase Cook said in an email. But due partly to the pandemic, the surplus lasted years longer, Cook said.

The department reached out to local health departments and HIV community planning groups again in August 2023, when officials realized the surplus would be exhausted in 2024.

Since then, Cook said, officials have been working closely with partners to help them prepare for the reductions.

Maryland Medicaid remains the largest payer of health care for state residents with HIV, averaging about 14,000 participants every year, Cook said. The end of the surplus fund doesn’t affect the core Ryan White funding that the state and localities receive, and no changes will be made to the Maryland AIDS Drug Assistance Program, which serves an average 5,600 people on average.

“The Maryland Department of Health understands changes in funding can have an impact on providers and their patients,” Cook said. “HIV services and programs are not ending in Maryland. The Department and our planning partners remain committed to ending the epidemic in Maryland and supporting all of our constituents through this transition.”

Advocates and service providers in Baltimore tell a different story. For years, they said, the city and state warned of large, looming cuts that never quite materialized. Earlier this year, HIV advocates prepared themselves for funding to drop by about 30% in July — or by 60% in a worst-case scenario.

They weren’t ready for the city health department’s April letter, said Lynda Dee, a longtime HIV advocate in Maryland and executive director of AIDS Action Baltimore.

The group provides emergency financial assistance, education, testing, patient navigation and other services to city residents living with HIV

“Talk about not having people be adequately prepared,” Dee said. “And then [the state had] the nerve to say, ‘Well, we told them. We told them.’ What exactly is it that you told them?”

Elsewhere in Maryland, other health departments are feeling the pinch. Statewide, localities saw their funding drop by roughly a third, although Baltimore got the worst of the cuts, according to data provided by the state health department.

Montgomery County — which has 445 people living with HIV per every 100,000 — saw its funding drop by roughly $960,000, according to state data. In Harford County, which saw its funding drop by roughly $388,000, health department spokesperson Ronya Nassar said it had to make staffing changes to continue running its HIV clinic in Edgewood, though she added the county is “confident that we will be able to provide the same quality of service as we previously have.”

In Carroll County, which saw its funding drop by about $63,000, the health department is searching for alternative funding sources to continue offering nonmedical case management and appointment transportation. In Howard County, the health department’s funding fell nearly a quarter, but it reallocated other funding to sustain services, a spokesperson said.

Baltimore City Health Department also is trying to soften the funding blow. In an email last month to service providers, the department said it will solicit bids later this year for a company to provide HIV prevention services. It’s also exploring short-term transitional funding for providers that specialize in caring for populations disproportionately affected by the HIV epidemic and who face barriers to care — including Black women, commercial sex workers, unstably housed young people and members of the LGBTQ community.

In the meantime, people like Miriam Whitehead — who until recently attended a women’s support group at Sinai Hospital that will no longer be funded — wonder what to do next.

Whitehead, who was diagnosed with HIV in 2000, is an advocate for others with the virus. She tells them that there’s life beyond the diagnosis — that their story, if they choose to share it, has incredible power. That’s something she learned by participating in support groups, she said.

She’s worried about what will happen to the people who have no one else to talk to.

“Some people need that personal experience,” she said. “I can hold your hand. You can see my tears. You can hug me. A lot of people don’t get that — even if they’re not HIV positive. That touch, that personal touch, that real touch, it’s important.”