March 27, 2012
In July 2012, the International AIDS Conference returns to the U.S. for the first time in 22 years thanks to the administration's lifting of the travel ban on persons living with HIV. With over 25,000 researchers, advocates, government officials, journalists, non-governmental organization service providers, clinicians, health department staff, people living with HIV and other committed persons waiting anxiously to hear what President Obama (or the administration's representative) says at the meeting, we must urgently consider what preparations the U.S. needs to make for this global stage.
Here, I focus on issues related to HIV in the U.S. because the conference traditionally spotlights the epidemic in the host country. We have serious policy and programmatic work to do to get our house in order before the world comes to our door.
The president is clearly interested in HIV/AIDS. On July 13, 2010, he released the National HIV/AIDS Strategy (NHAS), and challenged the country, saying, "So the question is not whether we know what to do, but whether we will do it." This landmark comprehensive HIV plan includes five-year goals regarding HIV prevention, care, housing, program coordination and health disparities (highlighting especially the disproportionate burden of HIV among gay men of all races and ethnicities, and in African American and Latino/Latina communities). But in the past 20 months roadblocks have emerged, and we have real hurdles to overcome quickly to stay on track for NHAS progress; it will be critical for the administration to address these challenges before the conference. I describe below some challenges I believe are critical, and hope that HuffPost readers will add their own.
It is widely recognized that there are roughly 4,000 persons living with HIV in the U.S. who are on treatment waiting lists for the federal AIDS Drug Assistance Program (ADAP is the payer of last resort). However, CDC has recently estimated that of the approximately 1.2 million people living with HIV in the U.S. just 80 percent are diagnosed, only 62 percent are linked to care, just 41 percent are retained in care and a mere 28 percent have suppressed viral load; this "cascade" indicates that the unmet care, treatment and support needs in the U.S. are dramatically larger than ADAP waiting lists. The federal government has taken very important steps to bolster ADAP, but to truly address unmet needs will require an effort of a new scale even prior to the full implementation of the Affordable Care Act. When we talk about unmet care and treatment needs, we must begin to refer to the entire treatment needs cascade, and we must address the infrastructure cracks evident in the already strained systems of prevention and care service delivery.
During the President's Dec. 1, 2011 World AIDS Day talk, he referred to "the beginning of the end of AIDS" and "getting to zero" because a remarkable new study has found that HIV treatment in heterosexual couples in which one person is living with HIV and the other partner is HIV negative can reduce the relative risk of HIV transmission by up to 96 percent. We do know what to do to "end AIDS." But at the population level, this goal cannot be realized if we do not address the cascade of unmet care, treatment and support needs noted above. We should use this wonderfully inspiring phraseology in July... if we mean to make the investments to achieve it.
Some HIV advocates, researchers and members of Congress have asked that the federal government produce an official estimate of the cost of implementing the NHAS. I agree. In a 2010 academic paper, I estimated that the total five-year cost of the NHAS would be just over $15 billion in new funding from either the public sector, private sector or both (roughly two billion in prevention programs, one billion in housing and the remainder for care and treatment). Making this investment was estimated to save just under $18 billion in future treatment costs, and therefore would more than pay for itself. But the longer we wait to make the investment, the worse the public health and economic returns before 2015. A Congressional Budget Office "official" estimate of the NHAS could still be produced before July, current investments gauged against it, and a plan developed and announced for phased-in "full funding" of the NHAS.
During the President's World AIDS Day talk, and during Secretary Clinton's Nov. 8, 2011 speech on "Creating an AIDS-Free Generation," references to the behavioral aspects of HIV were notably scarce. Neither said "sex" or referred to injection drug use behaviors; Secretary Clinton mentioned condoms once. Clear statements about the importance of age-appropriate comprehensive sexual education and sterile syringe exchange programs that provide a pathway to substance use treatment will be especially important at the July conference.
When it was released, the administration positioned the NHAS as a living document that might change over time. Since 2010, it has been repeatedly noted by advocates that structural factors which disproportionately impact women and homeless populations are insufficiently addressed by the NHAS. Also, HIV-related discrimination is noted, but solutions need additional development. A small set of truly critical NHAS amendments could be issued in July to further strengthen our response to the domestic epidemic.
The NHAS was unveiled with five-year goals, but several of the key goals (such as reducing HIV incidence in the U.S. by 25 percent) do not yet have a 2010 baseline measure. The Department of Health and Human Services has done an excellent job of identifying a draft set of indicators by which to track NHAS progress; but we urgently need the baseline data on those metrics to help inform midcourse corrections.
The next four months are a critical time for the Administration, the International AIDS Conference, and the National HIV/AIDS Strategy. We might ask a familiar question: We know what to do, but will we do it?
David Holtgrave, Ph.D., is professor and chair, department of health, behavior and society, Johns Hopkins Bloomberg School of Public Health.
Disclaimer: This post is my personal opinion, and does not reflect the views of my employer or the views of any advisory council on which I serve.