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Progress on HIV, But Will It Last?

[Guest post by Harold Pollack]

On Tuesday, the Obama administration released its National HIV/AIDS Strategy. It's imperfect, but its authors should be proud. Whatever criticisms one may have of this administration, its policy analysts are allowed to discuss serious problems as mature adults, with a minimum of the embarrassing oversimplification, euphemism, or blatant political shading. In areas such as HIV and drug policy, this is refreshing.

One participant expressed pride in the product, but quickly added, "I'm just afraid America is getting bored with it." The Strategy acknowledges similar fears, noting the sharp declines in public concern about AIDS over the past 15 years. Secretary Sebelius cited the same polls at the podium, introducing the report. Her comments might be amended to read: HIV no longer seems so pressing to those soccer moms and dads who hold the balance of political power in America. Millions of more politically marginal people are all too aware of the continuing threat.

As if to highlight Sebelius's point, the news media and the blogosphere largely ignored the Strategy and its release. President Obama gracefully presided over an event to mark its release. The usual news sources covered it below the fold, behind more important stories about George Steinbrenner and Bristol Palin. I follow various progressive bloggers on Twitter. I didn't receive a single tweet about HIV/AIDS. #fail.

Almost 600,000 Americans have died of AIDS. HIV/AIDS still causes about 14,000 U.S. deaths each year. Some unknowable number of these deaths could have been prevented had we acted with greater speed, competence, and humanity, especially in the epidemic's early days. Many things account for our poor response, not least the ferociousness of the epidemic itself which infected thousands of hemophiliacs and others before an effective response was possible. Still, other countries responded better. Reading And the Band Played On or watching PBS's remarkable Age of AIDS, my undergraduates are genuinely shocked by the callousness of national politicians, community leaders, and most Americans in the emergency of 30 years ago. President Reagan responded especially badly, disfiguring his legacy.

Much of our subsequent response has been shaped—for better and for worse--by our history of inaction, delay, and discrimination. Overcoming this history required efforts to educate every American that we all face some risk, and that we are all affected by HIV/AIDS. A universal message was essential to reach sexual minorities and drug users who hail from every community and culture in America. Millions of people at-risk would never have been reached by efforts to target stereotypical risk groups.

Lack of targeting still brought real costs, since HIV prevention resources were spread very thin. We spend hundreds of millions of dollars on HIV prevention in low-risk populations or on measures to prevent a handful of cases spread through tainted blood while street injection drug users doing sex work are stuck on waiting lists for methadone. A determined and comprehensive prevention effort must do better.

Tuesday's Strategy document states the issue forthrightly: "Stopping HIV transmission requires that we focus more intently on the groups and communities where the most cases of infection are occurring." As one participant noted, "I think the country has matured enough that we can talk about this." Historian and bioethicist Ron Bayer had a similar reaction: "The most interesting thing about this report is its effort to do two things: note our collective responsibility, while acknowledging the reality of who bears this burden."

By the numbers, the concentration of the HIV epidemic has been obvious for many years. The subject remains sensitive. In screening pregnant women, for example, public health authorities and advocates have favored broad guidelines rather than more focused efforts that might stigmatize particular populations. HIV activists feared--not without reason--that openly targeted services would promote stigma while undercutting political support for doing what must be done. Popular HIV prevention posters of the 1980s shouted "the virus doesn't discriminate," telegraphed the same anxiety.

The intense suffering and discrimination experienced by infected persons cast related shadows over prevention interventions to serve people living with HIV and AIDS. Measures routinely applied to contain other sexually-transmitted infections could not be deployed, at least not in the same way, to contain HIV/AIDS. "AIDS exceptionalism," as Bayer called it, sometimes hindered effective public health policy. There was no way to avoid it.

Yet times have changed. President Obama speaks with ease about the need to overcome homophobia (including homophobia in the African-American community). The President's 2010 Father's Day Proclamation includes kind words for homes with two fathers. On the global scene, there is PEPFAR, George W. Bush's one shining legacy. The National HIV/AIDS Strategy casually endorses syringe exchanges and active cooperation between the federal government and the LGBT community. There isn't much detail here, but there isn't much backlash, either. The culture wars swirling around AIDS suddenly seem like yesterday's news.

There is on-the-ground progress, as well. In any given year, a person living with HIV today is only about 1/9 as likely to infect others as his counterpart in 1984. New prevention strategies are more science-based, as is the Obama administration's approach to illicit drugs. And as HIV/AIDS become a less cruelly-stigmatized, more treatable disease, the politics of HIV prevention and treatment have changed, too.

Despite all of these accomplishments, an estimated 56,000 Americans are infected with HIV every year. The number of Americans living with HIV surpasses one million. It will be a heavy lift to appreciably reduce the number of new infections. HIV incidence has been steadily rising among gay and bisexual men, the only high-risk population that replenishes itself with tens of thousands of vulnerable uninfected young people every year.

Effective vaccines and microbicides remain elusive. The track record of behavioral risk-reduction interventions is decidedly mixed. These efforts are cost-effective, given the huge financial and human costs of HIV infection. Yet the absolute number of HIV infections prevented by these efforts is disappointing. A better-resourced, more scientifically grounded effort is essential and offers real opportunities to do better. How muchbetter is another question. Abstinence-only education is not the only ineffective intervention receiving scarce public funds.

Then there are racial disparities, ubiquitous in so many areas but remarkable in the case of HIV. African-American heterosexual women face twenty times the risk faced by their white counterparts. African-American gay and bisexual men also have much higher infection rates than their white counterparts. We can't curb the epidemic without addressing these disparities.

Tuesday's documents touch more complicated subjects than can be considered in one column. Four things are apparent, though.

Health reform is the most important change in HIV prevention and treatment in years.

It is impossible to overstate the importance of the Affordable Care Act (ACA) for HIV prevention and treatment. It's a more important HIV/AIDS policy than the National HIV/AIDS Strategy. ACA is a more important drug control policy than the National Drug Control Strategy. and more.

When fully implemented, ACA will revolutionize HIV treatment and care, just as it will revolutionize substance abuse treatment and mental health care. It notes that long-standing programs such as the Ryan White CARE Act require modification once health reform produces near universal coverage. In sheer dollar terms, the structures created through ACA--insurance exchanges, expanded Medicaid eligibility, affordability credits, expanded coverage for substance use and mental health, and protections for people with costly preexisting conditions--will eventually provide much more for HIV treatment and prevention than any HIV-specific program. Tuesday's Strategy documents acknowledge these facts. Unfortunately, most of these structures won't be operative until 2014. A key challenge in the new strategy is to get through the next four years.

We finally pay attention to marginalized critical populations which are now badly served

The Strategy notes one such population: Inmates in state and federal prisons, and in jails, too. The Bureau of Prisons could be a best-practice model. More systematic attention to correctional health services is long overdue. (I wish the Strategy provided more details. I also wish it had said more about millions of Americans on parole or probation. These men and women face more immediate HIV risks than their incarcerated counterparts.)

Expanded HIV testing for clients in federally-funded substance abuse treatment is also welcome. Right now, less than 1/3 of clients appear to receive testing from such providers. Locating other forms of infectious disease screening and other services at treatment centers would also be very helpful for HIV prevention.The alphabet soup of federal public health agencies such as HRSA and SAMHSA can make a major contribution in these areas.

The Strategy requires money

At least they can if they are provided proper funding. The new Strategy provides many welcome recommendations and aspirations. It provides fewer financial resources. HIV prevention requires greater funding. For example, since 2006 the Centers for Disease Control and Prevented has recommended aggressive population HIV screening in many settings. Such screening is essential to achieve the Strategy's goal of increasing the proportion of infected persons who know their status from 79 to 90 percent.

That's a great idea for many reasons. Early detection and treatment is one of the very few interventions reliably linked with improved survival. "Test-and-treat" is quite cost-effective, even in populations facing much lower risk than the traditional risk groups. Such strategies thus warrant broad population screening. Who will pay for this testing? Who will pay for the required follow-up care when people test positive, particularly before 2014.

CDC recommendations were not accompanied by the funds required to execute them. ACA requires reimbursement for preventive services rated "A" or "B" by the U.S. Preventive Services Task Force. Unfortunately, HIV screening got a grade of "C." The Strategy does not get under the hood to address these financial and logistical obstacles.

HIV/AIDS policy requires healthy public health infrastructure—precisely what is being damaged in the state and local budget crisis

Then there is the elephant in the room: the state and local budget crisis. HIV prevention requires adequate funding. It also requires an infrastructure to identify people at risk, perform partner notification, deliver complementary services such as supportive housing, partner notification, and drug treatment.

Most of these activities are undertaken by state and local health departments, which are now absorbing punishing cuts. In 2008 and 2009, local health departments lost 15 percent of their workforce. Another 15 percent faced reduced hours or mandatory furloughs. When these front-line organizations lack the staff to do their jobs well, they will not effectively prevent HIV. As one expert put things, "No one puts gonorrhea on a t-shirt." Yet the infrastructure to address these basic challenges is essential to confronting HIV.

More cuts are coming, particularly as current stimulus funds dry up. Forty-nine states face budget difficulties. Constrained from cutting other big-ticket expenditures, many states, cities, and counties are cutting public health. For the first time in years, state AIDS Drug Assistance Programs (ADAP) are capping enrollment or turning people away. An ambitious national strategy of more aggressive testing and treatment will stress these systems even more.

The troubles go deeper. In correctional health, for example, Texas's prison health care system recently announced plans to lay off nearly 12 percent of its workforce. Other states are imposing similar cuts that erode their capacity to continue existing public health tasks, let alone assume ambitious new efforts preventing and treating HIV.

In this moment, national HIV/AIDS policy demands a systematic response to the budget crisis. The best solution would be a second stimulus that matches the scale of the recession and the state and local budget crisis. Since that appears politically impossible, the new Strategy requires more ambitious specific expenditures. States and localities just can’t carry this load right now.

Johns Hopkins researcher David Holtgrave, who directed CDC's HIV prevention efforts in the Clinton administration and has supported policies similar to those noted in the current Strategy, has proposed an increase in HIV prevention outlays on the order of $750 million annually to meet identified but unmet needs. That's about 0.04 percent of the federal budget.

The new Strategy provides a humane and sensible vision of HIV prevention and treatment. Given what is at stake, it merits the resources required to carry it out. One more thing: people should pay more attention.