January 6, 2014
We are increasingly living in an environment where biomedical interventions are advancing in terms not only of treatment, but also of prevention. But it is not just the discovery that antiretrovirals are as useful at preventing HIV as they are at treating it. Through the relatively new research field of implementation science, we are learning more about how to measure what prevention and treatment policies we need and what it will cost to reduce the number of new infections and provide people with HIV the opportunity to be healthy.
Two recent policy developments give us a good start toward these goals, but fall short of enabling us to achieve them. The National HIV/AIDS Strategy (NHAS) was long fought for by AIDS activists and provides us with a governmental framework for policy priorities; the geographic areas and demographic groups we should invest the most resources in; and the goals we're attempting to reach by 2015. With only two years to go, it remains unclear whether many of the goals of the NHAS will be achieved. Many of those goals have been undermined by a lack of political will to fund the policies and the scale-up of research that the strategy calls for.
The Affordable Care Act (ACA) is going into effect in just a few weeks. While the ACA will greatly expand access to health care for many Americans, a 2012 Supreme Court decision gutted several of its key provisions, particularly the expansion of Medicaid to all states. The expansion is designed to give more Americans greater health coverage, encourage people to be engaged in preventive care, and reduce the use of emergency rooms, which proves costly, as people without insurance often wait until their condition is so severe they have no other option. But 26 states, most of them in the South, that rank high in poverty and HIV rates have decided not to expand Medicaid coverage under the provisions of the ACA. Federal funding would pay the states nearly 100 percent of the cost of coverage, freeing up many states' budgets and creating new jobs necessary to carry out the expansion.
It is no exaggeration to call this a travesty and an injustice. A recent report by the Kaiser Family Foundation finds that nearly six in 10 African Americans who would have qualified for Medicaid under ACA expansion live in states that are not moving forward with the program. And while cities like Washington, D.C., have recently shown recent massive reductions in new HIV infections, we will lose this momentum if we can't expand access to health care to more people nationwide.
Following the recent federal government shutdown and the semiannual self-imposed budget crisis, social safety net programs like the Supplemental Nutritional Assistance Program (SNAP) that feed thousands of people with HIV annually, as well as research being planned or conducted by the National Institutes of Health, have become weapons in budget battles while people in need are caught in the crossfire.
It's not just domestic HIV prevention and treatment that are under threat. Under the U.S. President's Emergency Plan for AIDS Relief (PEPFAR), there has been a massive scale-up of people being treated for HIV in sub-Saharan Africa. In consequence of this, among other efforts, many African countries this year are showing double-digit reductions in mortality from HIV-related illnesses and similar reductions in new infections. This could be a major game-changer for the continent. However, we are in a fight to keep PEPFAR and the Global Fund fully funded to meet the needs that they serve. The massive across-the-board cuts caused by sequestration in the United States along with austerity measures in Europe threaten a much-needed infrastructure that was has been built over the last decade. Are we ready to throw that away?
I say no.
We are at a critical moment in treatment advocacy globally. Not because we don't understand what to do, but because political and economic restraints are making it more difficult to do what's necessary. Effective strategies to fund, implement, and evaluate policies are critical. And so is marshaling the global community to act together, and to once again build public consensus for action.
Kenyon Farrow is the U.S. & Global Health Policy Director of Treatment Action Group.