August 13, 2010

August 13, 2010
Is Obama's HIV/AIDS Strategy Achievable?

Welcome to another day in my life. Today is Friday and we have made it through another work week. I hope you have had a safe and great one. This coming weekend is going to be a very busy one for Dab the AIDS Bear and myself.

Now if you read my blog, you know I was not exactly a happy camper when our national HIV/AIDS strategy was announced a few weeks ago. So now the question is the strategy achievable?

The following remarks were presented at the 2010 International AIDS Conference in Vienna, Austria as part of the Regional Session on Canada & United States for a section entitled Current Issues & Future Directions: USA.

"The United States will become a place where new HIV infections are rare and when they do occur, every person regardless of age, gender, race/ethnicity, sexual orientation, gender identity, or socio-economic circumstance, will have unfettered access to high quality, life extending care, free from stigma and discrimination."

This is the vision of the National HIV/AIDS Strategy for the United States, which was released at the White House last week.

As a gay man living with HIV for the past 29 years, I find this vision inspiring.

As a longtime AIDS advocate, I find it useful in efforts to realize a progressive policy agenda that lives up to these inspirational words.

While various federal agencies and advisory groups have developed plans in the past, the new Strategy is the first to encompass multiple branches of federal government in a singular, coordinated plan of action. It details specific metrics of success, requires annual progress reports, and assigns responsibility. Most importantly, the President stands behind his government's plan, which he described in an HIV/AIDS address he made last week.

The plan will serve many purposes. It gives us an authoritative, critical analysis of the state of the epidemic in our country and what the minimum is that must be done based on the strongest available evidence.

Over five years, the plan seeks a 25% reduction in annual HIV infections to reach a level of 42,000 annual transmissions or less. The plan will strive to help 132,000 individuals living with HIV/AIDS learn their status and immediately link to continuous care. And the number of HIV-positive people who are stably housed and adherent to HIV treatments would also increase. The plan pledges greater transparency, coordination, and efficiency and seeks to align efforts with the populations and geographic areas of greatest need.

As advocates, we applaud the goals and recognize that much more must be done. While current resources will need to be aligned with the plan, existing funding alone cannot do the job. Federal and state governments will need to commit considerably more to realize the Strategy's measures of success. The government will also need to mobilize policymakers and the private sector to care more and do more in the fight against HIV/AIDS.

But this is a bold plan precisely because it takes a risk. Success is by no means assured and given the severe impact of the economic recession on communities across the US, our country could well see transmission rates, prevalence, and care access worsen.

A new paper published the day after the Strategy's release in the Journal of Acquired Immune Deficiency Syndrome (JAIDS) by Irene Hall, David Holtgrave and others describes the humanitarian and economic implications of HIV not being controlled.

The paper predicts that at current rates of growth, annual new infections will reach 75,000 by 2015 and prevalence will reach 1.5 million individuals living with HIV.

That means that rather than a 25% reduction in incidence by 2015, as called for in the Strategy, new infections are actually on course to increase 34% (and prevalence by 30%). By 2015, the lifetime medical costs for HIV could exceed $273 billion.

Basically, momentum is not on our side and will not be without new, dedicated funding and strong central leadership.

I will add that the paper gives a convincing argument about the economic urgency to lower HIV incidence as quickly as possible. While an array of interventions may be deployed to reduce HIV transmissions over time, doing so quickly has an economic advantage by slowing the rate of growth in HIV prevalence and therefore achieving greater savings on lifetime costs.

This is all to say that we all have a stake in seeing the National HIV/AIDS Strategy succeed. But how exactly can we work together to ensure its success? I have four ideas to share that I have already begun to make to federal officials and you should as well.

1. We need to sell the Strategy to politicians and the American people: I believe in this Strategy and I think it is an eloquent, evidence based public health plan. If fully implemented, it will help us manage our way out of the current crisis we are in. But I fear it falls short of being an informed political strategy. I am not convince the general public in the US cares about HIV/AIDS or that we are making salient points people can relate to about the benefits of expanded HIV prevention and care efforts.

We need to own up to the fact that the information we are collecting about the epidemic is making virtually no impact on the voting behaviors of our elected officials. In 2008, at this very conference, we showed that new infections are actually 40% higher than previously estimated. We anticipated that such information would compel greater awareness and support. We were wrong and must face the fact that the numbers of HIV infections, numbers of AIDS cases, disparities, and many of the metrics we collect are not swaying public opinion.

HIV is not as scary as it once was, deaths have declined, and the visible impact of the crisis is no longer apparent. We need new paradigms to recapture urgency in HIV/AIDS and explain why controlling this epidemic is broadly beneficial. This is particularly important as we concentrate our efforts on the populations most affected but who also are among the most disenfranchised politically and economically.

And we need help with messaging in general. We speak in riddles of powerful medications, of a potentially deadly yet controllable virus, of the virtues of being HIV free in a hopeful world for those infected.

I know the nuances are important but our lack of a clear, simple messaging that resonates with most Americans is hurting our cause. We need to recapture some relevance to keep this fight in the hearts and minds of the public.

2. Strong leadership at all levels: I commend Jeff Crowley, his team, and other federal officials for pulling together such a strong, ambitious plan but the work has only just begun. We must move quickly and aggressively toward implementation of this plan to stay relevant and credible.

We expect the government to show us measurable progress by July 13, 2011: year 1 of the 5 year plan. We call on President Barack Obama himself to detail progress made on the Strategy at the 19th International AIDS Conference in July 2012 in Washington, DC, our nation's capital. By then we will be nearly half way through the five year period of the Strategy and expect to see nearly half the progress.

We must confront the issue of funding. In this recession, states have cut nearly $200 million for HIV prevention and care programs and federal funding has not keep pace with the needs. One need only look toward escalating incidence rates and poor health outcomes to see the disparities. Most recently the AIDS Drug Assistance Program crisis has shined a light on the inequities and the challenges of serving greater numbers of people with fewer and fewer resources.

Congress and the White House must immediately consult the Strategy in setting appropriations for the years ahead. I also suggest that members of Congress consult with the nonpartisan Congressional Budget Office to tell us the true cost of realizing this Strategy. We need to know what it will take to fully implement this plan if we are to achieve it.

We need early wins. We need every state in the US to provide antiretroviral access through their AIDS Drug Assistance Programs to all people living at or below 350% of federal poverty and, recognizing that ARV medications are a lifetime commitment, support states in sustaining their program if their income eligibility is higher. If ARV access is assured, expansion of test/linkage/care models is truly possible.

Working closely with states and federal officials on Medicaid expansion, housing assistance, pilot programs, intensive and bundled services in hotspots across the country, and radical reforms in the way HIV prevention is organized and delivered at the local level can all leverage quick gains. And finally we need to refine our data systems to ensure we can quickly monitor the Strategy's indicators of success and course correct as needed.

3. Global leadership: PEPFAR is held as a model in the Strategy for effective implementation, coordination, and quick results. If we are to look toward and learn from our bilateral activities on AIDS to inform our work domestically, we must sustain and grow our global commitments. This means making good on our financial promises and motivating the other wealthy nations of the world to do their part.

4. Look beyond AIDS: I am delighted the White House involved people living with HIV, like me, advocates and other stakeholders in the development of the Strategy. I believe our input strengthened the plan and I hope federal implementers will continue to rely on our expertise.

But now that we have a plan, the time is ripe to go beyond AIDS an engage the private sector, philanthropy, and areas of federal government not typically associated with HIV activities to see what they can do to help achieve the Strategy's goals.

We know all too well that structural and societal forces shape the epidemic, as much or more than individual decisions, which is why we need government to improve structural interventions that look at reforming entire systems that help make people vulnerable to HIV.

In closing, President Obama's remarks last week on the Strategy are illuminating and sobering:

"So the question is not whether we know what to do, but whether we will do it. Whether we will fulfill those obligations; whether we will marshal our resources and the political will to confront a tragedy that is preventable."

Until we meet again; here's wishing you health, hope, happiness and just enough.

big bear hug,

Daddy Dab