AIDS and the Next President
The U.S. response to the AIDS epidemic has been hampered by public health approaches based on ideology rather than science. Anti-gay, sexist, and inaccurate "abstinence-only" sex ed programs have been promoted over comprehensive sex education. Restrictions on syringe exchange have also interfered with proven prevention strategies.
It is estimated that about a quarter of Americans who have HIV are not aware of it. This is a public health disaster, since 50 to 70% percent of new infections are transmitted by people who don't know they have HIV. People who know their HIV status are much more likely to practice safer sex and to avoid infecting others.
In August 2008, the Centers for Disease Control and Prevention (CDC) announced that over 56,000 people are infected with HIV each year in the U.S., and that this has been the case since the early 1990s. Men who have sex with men (MSM) made up 53% of new infections reported in 2006. Another 4% percent of new infections were among MSM who use intravenous drugs. Blacks, and to a lesser extent Latinos, are also overrepresented among new diagnoses. This news has underlined the country's inadequate response to the domestic AIDS crisis, and the opportunity that exists with the upcoming Presidential election.
A National AIDS Strategy
The U.S. requires countries receiving funds under the President's Emergency Plan for AIDS Relief (PEPFAR) to have a national AIDS strategy, yet 27 years into the epidemic, we have never created one for ourselves. Numerous government and private studies have pointed to the need for better planning of U.S. AIDS policy. In 2004, the Institute of Medicine determined that federal financing of AIDS-related health care "does not allow for comprehensive and sustained access to quality HIV care" in the U.S. Our failure to bring down new infec-tion rates has a fiscal as well as a human cost: a 2003 study found that failure to meet the CDC's then goal of reducing HIV infections by half would lead to $18 billion in excess expenses through 2010.
The next administration must develop and implement a national AIDS strategy that is comprehensive across federal agencies; sets timelines and assigns responsibility for implementing changes; identifies targets for improved prevention and treatment outcomes; reduces racial disparities; prioritizes gay and bisexual men (especially MSM of color); and mandates annual progress reporting.
Barack Obama has committed to creating and implementing a national AIDS strategy if elected. In August 2008 this commitment was written into the Democratic Party National Platform. As of this writing, John McCain has yet to make such a commitment, despite repeated outreach from AIDS activists since summer 2007. Gay rights and AIDS activists, however, including the Log Cabin Republicans, are still pushing him and the Republican Party to endorse a national AIDS strategy. The plan has bipartisan support in Congress.
Preventing people from getting HIV is the best way to stem the epidemic nationally and globally. We will not be able to keep pace with the disease if we focus mainly on treatment. Currently only 4% of federal funding devoted to AIDS goes to prevention efforts. Since 2001, federal prevention funding has declined 19% in real, inflation-adjusted dollars. We cannot continue funding at such low levels if we ever hope to eradicate HIV in the U.S.
For the past eight years, the Bush administration has focused its prevention efforts in ways that have been proven ineffective. Millions of U.S. tax dollars have gone to fund "abstinence-only" programs that study after study have shown do not work. It is clear that comprehensive sex education and the widespread availability of condoms are the only means to ensure that young people learn and practice healthy sexual behaviors.
Providing clean needles to IV drug users has proven effective, dropping infection rates by 78% in New York City from 1990 to 2002. This has occurred without an increase in drug use or crime, defying opponents' predictions. Yet the prohibition against federal funding of such programs remains.
In the area of prevention, the differences between the two nominees are stark. Obama supports an end to federal funding for abstinence-only education with those funds redirected to comprehensive sex education, and an end to the ban on federal funds for syringe exchange. He is also the lead sponsor of the Microbicides Development Act, which would support research and development of new vaginal and rectal technologies that could prevent infections.
McCain supports abstinence-only programs and does not support comprehensive sex education. He has not taken a clear position on syringe exchange and has not signed on as a co-sponsor of the Microbicides Development Act.
The Entry Ban
In the recent PEPFAR reauthorization bill, a provision was included to allow for the lifting of the U.S. entry ban for people with HIV. The ban undermines public health in the U.S., as immigrants and visitors avoid seeking HIV testing and treatment for fear of jeopardizing their ability to stay here.
President Bush signed PEPFAR II into law in July 2008. While the lifting of the ban from statute is a promising development, it is clear that Senator McCain did not support that provision of PEPFAR. In 1993, McCain voted for a bill that prevented people with HIV from entering the U.S., whereas Obama completed a survey from GMHC and aidsvote.org indicating he supports lifting the entry ban.
While McCain and Obama were united in their support of PEPFAR (which funds prevention and treatment outside the U.S.), questions remain about McCain's positions on the domestic epidemic. Perhaps most troubling is that McCain's key advisor on AIDS is the staunchly antigay Senator Thomas Coburn.
Health Care Reform
The candidates' proposals for reform of the overall health care system have stark differences ranging from accessibility and taxation to financing and state contribution.
Obama would create a new national health plan available to all Americans. According to his campaign, this health care plan, released May 29, 2007, would save the American family $2,500 per year by "providing affordable, comprehensive and portable health coverage for every American; modernizing the U.S. health care system to contain spiraling health care costs and improve the quality of patient care; and promoting prevention and strengthening public health, to prevent disease and protect against natural and man-made disasters."
Palin opposes comprehensive sex education and is a supporter of "abstinence-only" education. Her position on other AIDS policy issues is unknown. Biden supports comprehensive sex education as well as syringe exchange.
McCain announced his health care plan on October 11, 2007. It stressed three goals: the importance of paying only for quality health care; having multiple insurance choices; and personal responsibility. In the speech announcing his health care plan, Senator McCain stated, "The 'solution,' my friends, isn't a one-size-fits-all-big government takeover of health care. It resides where every important social advance has always resided -- with the American people themselves, with well-informed American families, making practical decisions to address their imperatives for better health and more secure prosperity."
The Running Mates
Sarah Palin and Joseph Biden have very different records on HIV/AIDS. Palin is a staunch opponent of comprehensive sex education and a supporter of "abstinence only" education. Her position on other AIDS policy issues is unknown. Biden supports comprehensive sex education as well as syringe exchange. Most recently, Biden worked to ensure that the recently passed PEPFAR legislation included a repeal of the entry ban for people with HIV. It also promotes prevention among MSM, along with research on HIV incidence among MSM. While Biden supports civil unions, Palin opposes domestic partner health insurance benefits for state workers in same-sex relationships.
Twenty-seven years into the AIDS epidemic, the situation in the U.S. is getting worse, and we continue to fight AIDS with one hand tied behind our back. The gay, lesbian, bi, and transgender communities need to reconnect with the AIDS movement and work closely with black and Latino organizations to address health disparities affecting all of our communities. We need to use all the tools available, including sex education, condoms, and syringe exchange, to reverse the tide and bring down the rate of new infections. The science shows that these approaches work. We need a renewed focus on the domestic HIV epidemic, and to embrace science-based prevention, treatment, and care fully. We need a president who will lead a domestic emergency plan for AIDS relief.
Sean Cahill is Managing Director of Public Policy, Research and Community Health for GMHC.
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