The AIDS Crisis in the United States: Will the Obama Administration Meet the Challenge?


On August 23rd, 2009, the first major HIV/AIDS gathering of the Obama Administration began, promising much debate and new data on approaches to HIV prevention. But critical questions loom over the meeting: Will the depth and breadth of the National HIV Prevention Conference in Atlanta and the first town meeting on the National HIV/AIDS Strategy be overshadowed by devastating cuts to prevention programs in a time of economic crisis, threats to health care reform and HIV care funding, and the lingering ghosts of the anti-science, anti-choice Bush years?

This week, RH Reality Check is partnering with the Community HIV/AIDS Mobilization Project (CHAMP), the HIV Prevention Justice Alliance, and AIDS Foundation of Chicago, among others, to cover the conference, and to raise issues about the domestic AIDS crisis.  We start here with an overview from Julie Davids and David Munar on the twin challenges of  re-inventing HIV prevention and  the need to bolster the pillars of a comprehensive approach to HIV and health care, both of which, the authors argue, must be embraced by the Federal government and its partners if we are to turn back the relentless pace of new infections in our nation.

Throughout the conference, correspondents from the HIV Prevention
Justice Alliance will lay out the issues of the day and share the
concerns and insights of people living with HIV and their allies.

As members of the new Administration open their first
federal scientific gathering on HIV/AIDS six-months into the Presidency of
Barack Obama, they face a mix of high expectations and serious challenges
facing HIV-fighting efforts in the U.S. 
AIDS advocates are poised to assess the course on HIV/AIDS charted by the
Administration and attempt to apply their influence.


Dr. Kevin Fenton, of the CDC, answers some frequently asked questions about HIV transmission.

More than 3,000 scientists, service providers, public
officials and advocates have joined in downtown Atlanta for the National
Conference on HIV Prevention
(NHPC) sponsored by the U.S. Centers for Disease Control and Prevention (CDC). With
the newly appointed heads of the Department of Health and Human Services,
Kathleen Sebelius, and CDC Director Tom Frieden welcoming delegates today,
the conference opened last night (August 23rd) with a panel of speakers who are all living with
HIV, including Magic Johnson and a member of this reporting team, David Ernesto
Munar of the AIDS Foundation of Chicago (see his remarks here).

The conference marks just over a year since CDC officials,
presenting at the International Conference on AIDS in Mexico City,
unveiled stark new data suggesting the annual number of HIV infections in the
U.S. is 40 percent higher than previously estimated
, with African Americans
shouldering the greatest number of new cases and rates still on the rise among
gay and bisexual men of all races. 
Based on its new calculations, CDC says that an estimated 56,300 people
become infected with HIV each year, far greater than the long-standing, prior
estimate of 40,000 annual infections.

HIV prevention providers and advocates are prepared to use
the conference to highlight a range of economic and political issues undermining the fight against HIV and AIDS, calling for a greater focus on prevention through efforts
to strengthen the “pillars” of a comprehensive, combination approach grounded
in access to healthcare; integration and expansion of voluntary HIV testing,
prevention and treatment; and long-overdue attention to social inequalities
that can further the spread of new infections.  Advocates also are seeking to be at the table to ensure a steady focus on HIV, and to help set this Administration’s priorities for fighting HIV, especially given so many competing challenges. 

Health Reform as HIV
Prevention

In her August 24 address to the conference (this morning), U.S. Health and Human
Services Secretary Kathleen Sebelius is expected to describe the
transformational impact comprehensive national health reform could have on
efforts to end the epidemic. 

With one-half of all people with HIV in the U.S. estimated
to lack access to HIV-related healthcare, health insurance reform could accelerate
efforts to control the epidemic, helping greater numbers of people with HIV
improve their lives. 

For HIV prevention efforts, provisions currently in
legislation before Congress to create a Public Health and Wellness program to
finance community and public health activities could prove critically
important.  Moreover, a
standardized benefits package, greater protections and choices for insurance
beneficiaries, access to voluntary health screenings, and an array of essential
services—such as prevention, detection, and treatment of Sexually Transmitted
Infections—could have enormous HIV prevention benefits.  Likewise, efforts to ensure that more
people with HIV receive the HIV medical care and treatments they need could
reduce “community-level viral load,” meaning that the much lower level of virus
in the bodies of people living with HIV, thanks to effective treatment, could
have a population-level impact resulting in fewer HIV transmissions overall.

Of course, the battle lines on healthcare have been drawn and
a contentious legislative fight is expected next month when Congress returns
from August recess.  Among the many
provisions in jeopardy is the fate of the public insurance option desperately
needed to ensure people with HIV and other chronic health conditions have at
least one high-quality plan configured to meet their needs.

And as reported on RH Reality Check last week,
another thorny issue yet to be decided is to what extent public and private
plans may cover (or beneficiaries who purchase coverage with a federal subsidy
may receive) reproductive health services.  Any efforts to reduce access to reproductive health care
(including access to condoms and reproductive health education) would disadvantage
beneficiaries in efforts to protect themselves and others from HIV
transmission. 

Toward a Strategic
Approach

Health reform will fold into another spotlight topic at this
week’s conference: recommendations for the White House-led National HIV/AIDS
Strategy (NHAS).

As a candidate and early in his presidency, Obama announced
plans to develop a results-oriented plan of action against domestic
HIV/AIDS.  Jeff Crowley, Director
of the White House Office of National AIDS Policy
,
is spearheading the task of drafting the plan with input from an
inter-governmental federal working group, the members of which have yet to be
announced.  For the remainder of
calendar 2009, Crowley is expected to visit 13 communities across the country and
open online mechanisms to solicit recommendations on ways to achieve better
national outcomes in reducing new HIV infections, helping people with HIV gain
access to and benefit from care services, and reducing HIV-related health
disparities. 

The White House’s inaugural town-hall meeting will take
place here on Tuesday night August 25th; thousands of conference attendees and hundreds of
local residents are expected to participate.  To prepare, the HIV Prevention Justice Alliance,
a coalition led by Community HIV/AIDS Mobilization Project (CHAMP), AIDS
Foundation of Chicago and SisterLove, have distributed tools for people living
with HIV, prevention providers and other advocates to help them craft effective
testimony
.

Truly Partners in
Prevention?

This week, AIDS advocates are expected to challenge members
of the incoming Administration on the federal government’s failure to reverse
the pace of new infections.  In
addition, they will call for an end to a culture of disengagement with
community actors and outright distain for science in the development of program
and policy-making. 

While pleased to learn of the White House’s commitment to
conduct NHAS town-hall meetings across the country, various groups have already
criticized the process, which appears to exclude community voices from any top-line
decision-making roles.   They
have called on the Administration to ensure federal departments and agencies fully
engage community panels in the creation of a results-oriented plan against
HIV/AIDS.  Furthermore, advocates
have suggested the Office on National AIDS Policy ensure that a panel of
community stakeholders with high-level influence on the detailed content and
implementation of the NHAS.

This issue notwithstanding, the Obama Administration has
already garnered cautious approval from community advocates for rolling out the
first HIV social marketing campaign in recent memory, called “Act against AIDS.”  AIDS advocates have also enjoyed unprecedented access to the ONAP
director.  Before joining the
Administration, Mr. Crowley, who formerly worked at the National Association of
People with AIDS (NAPWA), most recently acted as a health and HIV policy
researcher at Georgetown University. 

Advocates have been closely monitoring the Administration’s
efforts to redirect funding for failed abstinence-only sex education to teen
pregnancy prevention programs, which is a welcome start.  In addition, the White House seems
poised to support an even broader mission to support health-promotion among
teens, whether pregnant or not. 

Advocates also applauded CDC for releasing a draft
regulation ending immigration and travel restrictions against HIV-positive
foreign nationals.  The draft rule
would also eliminate mandated HIV testing requirements for those applying to immigrate to the United States.  Now that the public comment period has
closed, advocates urge the CDC to promptly finalize the regulation as
originally drafted.

Still, the political pressures on this fledging Administration to meet
the full range of its ambitious agenda are beginning to show.  On Inauguration Day, the White
House website included specific language supporting an end to the decades old ban
against federal funding for needle-exchange services, which have been proven
effective in reducing HIV transmission among intravenous drug users.  But the website no longer includes such
a bold statement — and the White House passed on an opportunity to urge Congress
to drop the ban as part of FY10 appropriations legislation, spurring activists
to take over the Capitol Rotunda as part of successful efforts to insist on
ban-lifting language in the appropriations bills
.  Thus, while there’s a real possibility
that an end to the ban might happen anyway, amendments might severely restrict
where federally funded needle exchange can operate
. 

The Administration has also been rather quiet about the need
for swift congressional action to extend the Ryan White HIV Treatment Act
beyond its September 30, 2009 expiration date.  As the deadline approaches quickly, advocates are urging
Obama officials to guarantee they will take needed actions to ensure vital HIV
care and treatment services continue without interruption.

And Then There’s the
Economy…

While the Bush
Administration garnered rare compliments for scaling up global access to
treatment, it’s widely acknowledged that the domestic AIDS battle suffered
under its tenure. But the neglect of prevention efforts is long-standing, with
prevention representing only 4% of the Federal investment in fighting HIV and
AIDS.

There’s much hope
that the Obama Administration will not only move forward in the U.S. epidemic
overall, but bring long-needed attention to specific efforts to reduce
incidence at home. But the question now is how will they pay for it, as the
economic recession threatens to undermine a decade of progress responding to
HIV/AIDS at the state and federal levels.

States across the country from California to Illinois and
Massachusetts are slashing state appropriations for essential HIV prevention
and care services. The impact of these
funding cuts is especially severe on HIV prevention services,
which are among
the first wave of services reductions in down economic times. Sadly, many
conference participants presenting about their front-line HIV prevention work
are unclear if their jobs and programs will still exist in the months ahead.

Medicaid services, housing, and the AIDS Drug Assistance
Program (ADAP) are other areas facing funding reductions that will slow the
nation’s response to HIV/AIDS, and the overall impact of budget reductions on
the social safety net will be especially hard on those living with HIV or
vulnerable to infection.

Advocates note that funding cuts mean we can neither
maintain existing services nor deploy desperately needed innovations to tackle
the root causes fueling HIV, particularly in hard-hit communities. Thus,
leaders at the conference are prepared to insist that the National HIV/AIDS
Strategy must not only articulate clear, measurable and achievable strategic
goals, but also hold lawmakers accountable for appropriating adequate economic
resources for program expansion and implementation.  

Putting the National Back into the National HIV Prevention Conference

The timing of the conference the first major Obama
Administration gathering on HIV, as well as the high visibility of healthcare
reform and the National HIV/AIDS Strategy as potential game-changers has
brought uncommonly broad attention and participation to the National HIV Prevention
Conference. The coming days will reveal possible challenges and opportunities
in our struggles against the domestic epidemic; what’s clear is that the way
ahead will not be easy and require shoring up the “pillars” of treatment, care
and justice even as we push for desperately-needed innovations in HIV prevention.

We will be keeping you posted as the conference progresses.

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