Preparing President Obama for the International AIDS Conference, July 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.

1. Acknowledging That Care Needs Are Larger Than Commonly Perceived.
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.

2. "The Beginning of the End of AIDS."
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.

3. Price Tag.
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.

4. HIV Is Transmitted By Human Behavior -- You Might Have To Say "Sex."
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.

5. Initial Amendments to the NHAS.
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.

6. Measuring Progress.
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?

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.

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Comments

[Lifeskills]

07:18 PM on 03/22/2012

I just want to add that there is away for total privacy and that is the Self Test
Do it at home. If you're uncomfortable about going to a testing site and want the privacy of testing at home, the Home Access HIV-1 Test System is a U.S. Food and Drug Administration
http://www.everydayhealth.com/hiv-aids/quick-ways-to-test-for-hiv.aspx

[tiffanywoods]

02:20 PM on 03/22/2012

As an HIV prevention direct service provider in the SF Bay Area, (Alameda County), I can tell you that prevention funding across the board is beyond inadequate at present levels & continues to dwindle. Women, including mothers with children, & transgender women continue to be invisible in the strategy, with resources continuously being cut. The few RFA’s that come out for specific populations breeds too much competition/ drama for far too little funding that will barely make a difference in the long run. We won't go into the hoops they make you jump through to get it.

While there is more funding going to capacity building for organizations to be inclusive of all populations, if we keep cutting funding to prevention/direct services, who will they be capacity building?
The talent and HIV specific expertise loss from all of these cuts and programs /agencies closing must also be acknowledged. As many longtime warriors in the HIV field move on, i'ts not that easy to replace that repository of knowledge & experience.

The CDC mandate of test & treat needs much reworking if it is going to be effective. They need to get a grip on the realities of how much time/money/ resources it takes. Getting hard to reach & test populations to test is one hurdle, keeping them in care is another hurdle, & unless they seriously address housing/economic issues as structural barriers to keeping people in care, & increase resources across the country, there will be little progress in achieving

[E de Mas]

10:09 AM on 03/22/2012

Very interesting, an article about AIDS and no comments yet. It's still taboo and there's a generational gap... When I came out in 1999 the gay community was still recovering from the shock of all the deaths of the two previous decades but on the other hand we knew aids was no longer a death sentence, so concern was dwindling. I was sexually naive then and somewhat irresponsible. I can only put down never having gotten an std in my early days to the people who had lived through the carnage and were there to tap me on the shoulder and hand me a condom. Of course my responsibility developed once I met someone who lives with aids and has to confront its pitfalls.

As we repackage ourselves as non-sexual, married gays for mainstream public consumption, we've moved sexuality back into the closet. It's not that people stopped having sex, it's just that we pretend we don't, or at least we don't talk about it. But judging by the popularity of gay social media from grindr to gaydar, I'm pretty sure it still happens. It's time to drag everything back out into the open, because when people don't, the consequences can be devastating.