News and Views
What "To Do" About AIDS
Public Policy Priorities for Combating a Preventable Epidemic
February 12, 2001
Although a preventable epidemic, AIDS rages more powerfully than ever. The Centers for Disease Control and Prevention recently confirmed that HIV infection rates remain high, deaths continue, and the mirror epidemic of fear and ignorance is as healthy in some ways as it was more than a decade ago.
There are basic steps needed right now that could change this epidemic's course. Most of these do not require drastically increased funding, although that is needed as well. Rather, what is most needed is that we spend our money more wisely -- in sensible, science-based directions -- to stop new infections, save more lives, and avert suffering.
If the president and other elected officials are serious about stopping HIV, these 15 recommendations -- a "To Do" list, as it were -- should be prominent on their desks.
- Ensure that every requirement of HIV testing, reporting, treatment and prevention programs has a sound, scientific basis. This standard alone will save government officials and advocates alike untold time and dollars now wasted on unscientific initiatives like mandatory testing of pregnant women and HIV case reporting, which promise to do little more than delay entry into care.
- Provide young people with accurate and truthful sex education, including safer sex and negotiation skills, support groups, and other programs aimed at building self-esteem. A Kaiser Family Foundation report found that parents want it, and young people, with an increasing rate of HIV transmission, need it.
- Invest in efforts to erase stigma about being gay. Several studies over the years have noted the connection between homophobia and increased risks and rates of HIV transmission. These findings should inform all prevention programs, including those in institutionalized settings such as detention centers and group foster homes.
- Mandate that, as a condition of federal funding, all foster care agencies provide specific, practical programs about sexual health, HIV prevention, and sex education, including support and self-esteem components. Since roughly half of all young people with HIV pass through the foster care system at some point, and all those in foster care are at considerable risk, it is sheer insanity that only a handful of jurisdictions have anything resembling an HIV prevention program for youth in their care. Congress also should create separate programs and funding initiatives that encourage development of creative approaches to increasing safety, and safer behavior, among institutionalized youth.
- Ensure sufficient funding for states' in-patient drug treatment programs so individuals seeking help with their addictions no longer get turned away when they seek help. Such programs often are overburdened and have long waiting lists. Policy makers also should provide additional, incentive funding for states to develop effective programs to decrease infection rates and increase voluntary addiction treatment rates among intravenous drug users.
- Support syringe exchange programs, which dramatically decrease infection rates among injection drug users without increasing illegal drug use. Despite the mountain of scientific evidence proving the effectiveness of these programs, federal officials remain cowed by the perceived political consequence of endorsing them.
- Deny federal crime prevention or HIV/AIDS prevention funding to states with laws or regulations that deny access to essential services to drug users, adopt laws that criminalize HIV or make it proof of a crime, or eliminate anonymous HIV testing options. Punishing HIV status or drug addiction is counterproductive, and anonymous testing options encourage earlier access to treatment.
- Declare a national crisis over the barbaric suffering of prisoners with HIV and Hepatitis C, and respond accordingly. A portion of federal crime prevention funds should be hinged both on states' adoption and implementation of the National Institutes of Health Guidelines for anti-retroviral treatment of HIV and AIDS, and on plans to ensure access to voluntary, confidential HIV and Hepatitis C testing and access to treatment, within correctional facilities.
- Eliminate irrational, government-sponsored discrimination in federal programs and professional licensing. This includes mandatory testing and exclusion of those with HIV by the Federal Aviation Administration, the Job Corps, the Peace Corps, the State Department, the United States Foreign Service, and the military. The CDC also must be directed to revise its 1993 guidelines that encourage discrimination against HIV-infected health care workers, destroying many professional careers and ignoring current scientific and medical information about HIV transmission.
- Similarly, Congress and the new Administration should reject proposals that target pregnant women with HIV. These proposals would subject pregnant women to mandatory or "routine" HIV testing that includes diluted standards of informed consent and a de-emphasis on the role of counseling and patient participation in treatment decisions. Moreover, these proposals would only delay entry into the health care system for mothers and their children.
- Officially rescind the ban on the entry of foreign citizens with HIV. The Immigration and Naturalization Service quietly has begun to allow some people with AIDS into the country for treatment purposes, but the policy must be repealed outright.
- Increase resources and encourage more public-private organizational collaborations to expedite development of a vaccine. This vaccine should be effective for HIV viral types found both in the U.S. and in developing countries.
- Congress and the new Administration should muster the political will to pass the long-languishing proposal to expand Medicaid coverage to poor individuals with HIV who are not yet incapacitated by their illness.
- The Administration should leverage its political and buying power -- as the government now does with its operation of Veteran's Administration medical centers, for example -- to pressure the pharmaceutical industry and its lobbying group, PhRMA, to adjust drug prices to better reflect the real costs of development. The Administration also should cease any political pressure against developing nations making use of legitimate channels to ensure access to life-saving drugs.
- Implement the primary recommendations of No Time to Lose, the report issued by the Institute of Medicine in October 2000. The report calls for dispensing with reliance on HIV case reporting as a substitute for real surveillance, greatly expanding condom distribution programs for adolescents, and dramatically increasing the percentage of funds devoted to prevention of new infections.
As the IOM aptly pointed out, there is no time to lose: "It is time for the nation to adopt a coordinated set of strategies to prevent the spread of HIV/AIDS. We must learn from our past successes, as well as from our failures, in prevention and we must focus prevention efforts on those individuals and communities who are increasingly affected by the epidemic."
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