To End America's AIDS Crisis, Reinvest in Prevention

For the past decade, America's response to its domestic AIDS epidemic has stalled, due to declining resources and attention at all levels. Last month, HIV advocates thought the tide was finally turning when, in its first domestic action on AIDS, the Obama administration and the CDC announced a $45 million, five-year communication campaign to put HIV/AIDS back on America's radar. A key theme: Every 9½ minutes, another person in the U.S. becomes infected with HIV.

But last Thursday President Obama released a deeply disappointing 2010 budget proposal with only a small increase in domestic HIV prevention funding. The $53 million in new funds requested of Congress is less than one-tenth of what is needed to drive down HIV infection rates in the United States, and is even less than President Bush's most recent annual requests to Congress.

We learned last year that the number of Americans becoming infected with HIV is far higher than previously known -- about 56,000 per year. HIV continues to take a disproportionate toll on African American communities, and HIV infections have been increasing at an alarming pace among gay and bisexual men of all races.

If we are to reduce HIV infection rates in the U.S., we must invest significantly more resources into prevention programs. My research demonstrates that federal funding for prevention is highly effective. There is a direct correlation between federal dollars spent and national HIV infection rates. Yet, the CDC's budget for HIV prevention has declined by almost 20% in real dollars since 2002.

To turn the tide of this epidemic, CDC's domestic HIV prevention budget should be expanded from its current level of roughly $750 million to $1.3 billion per year for the next five years. This would undo the harmful effects of inflation, address the unmet needs that have continued to grow over time, and rectify our failure as a nation to invest in programs at the scale needed to dramatically alter the course of the epidemic. This is one of the smartest public health investments the U.S. can make -- over five years, it could prevent approximately 89,000 new HIV infections, save $18.5 billion in averted treatment costs, and, most importantly, save some 1,350 lives.

A renewed investment in HIV prevention does not need to wait for a vaccine or other major new breakthrough. We have a range of effective HIV prevention tools at our disposal right now that could allow us to make dramatic progress in reducing new infections. The problem is that the scale of our response has been insufficient. The House and Senate considered investing substantial new resources in HIV prevention in the recent stimulus package, but removed that provision before the final bill was signed into law. That decision was not only terrible public health policy, it was also bad economics that will cost the nation more in the long run. Last Thursday's budget request was another missed opportunity.

Today, one in five individuals living with HIV does not know it, indicating that too few people are being reached by testing and counseling services. Only a small percentage of people at risk for HIV are able to access the effective behavior-changing programs that are proven to reduce a person's chances of becoming infected. Prevention services for people who are HIV-positive also need to be expanded, particularly as the number of people living with the disease continues to increase, thankfully, due to effective treatments.

Complacency about HIV is another key challenge. Data show that America has largely forgotten about AIDS. According to the Kaiser Family Foundation, the proportion of Americans who say they have seen, heard, or read about the problem of AIDS in the U.S. declined from 70% to 45% in the past five years. The percentage ranking HIV/AIDS as the most urgent health problem facing the nation fell to just 6%, down from 44% in the mid-1990s.

It was my hope that, by elevating the visibility of HIV/AIDS through the new communication campaign, the administration was signaling a renewed commitment to prevention. The campaign -- coupled with more robust prevention resources in the 2010 budget -- could have jump-started national efforts to finally tackle this disease in a serious way here at home. Sadly, my hopes took a major step backwards with the administration's anemic budget request.

We're at a historic crossroads in the HIV epidemic in the United States. We must work to combat complacency and increase our national commitment to prevention. With the terrible human and fiscal consequences of HIV, a new infection every 9½ minutes in the U.S. simply is not acceptable to me, and I hope not to anyone.

Comments

[joelaf]

Dr. Holtgrave,

Before her death, my wife was a longtime CDC employee. This includes during your tenure. As early as the 1980's, we were reading papers about this "new" disease. The biggest shift I have seen in attitude towards HIV/AIDS was the first; when the "A" changed from Auto to "acquired". This shift in policy signaled that the person diagnosed with AIDS had brought it on themselves. Lecturing or judging someone who has a possibly deadly disease has 100% failure rate in curing the disease.

Keep up the good fight.

Joel Floyd

[mergina]

Wrong. Invest HEAVILY in this.

http://www.plosbiology.org/article/info%3Adoi%2F10.1371%2Fjournal.pbio.1000093;jsessionid=9F19EBA2861B97F4FACC294EDF7DE101

We have the immunity. We simply need to wake it up.

[bkca]

Hey David, maybe nobody told you, but...... THERE'S NO MORE MONEY. 53 million isn't chump change. Try living within your means. The HIV lobby is getting a lot more money than most. Deal with it.

[donwarnersaklad]

How widespread is the phenomenon?... the strategy of "Let's get tested TOGETHER BEFORE we have sex, for A VARIETY of STDs."

Sexual health checkups reduce ambiguity and can be like anything else POTENTIAL sex partners do together.

[donwarnersaklad]

How widespread is the phenomenon?... the strategy of "Let's get tested TOGETHER BEFORE we have sex, for A VARIETY of STDs."

Sexual health checkups reduce ambiguity and can be like anything else POTENTIAL sex partner do together.

[DrSparkles]

As someone who works in HIV prevention, I have to say that when words like "promiscuous" and "risky practices" are used with judgemental tone, you become part of the problem.

[JEP57]

Stating the facts of how the disease is mostly spread isn't being judgemental. We need to be honest about it.

[mikefina]

Your attitude is why AIDS became known as the 'Gay plague'. Because you rejected the medical advice to cool it with the multiple partners and the ATM play, a generation of gay men died, and the following one was stigmatized.

[web15]

In response to "most Americans are smart enough to know that when you have sex, you're at risk for STDs and know what to do to prevent them" I am not sure that is true based on how much emphasis is placed on abstinence-only education.

If that is a problem in America, where in theory at least the resources are there, what about the rest of the world?

You might be interested in the campaign to get governments to deliver on promises they made 15 years ago: http://www­.15andcoun­ting.org/

[Randian]

Dr. Holtgrave,
I applaud you in your interest in advancing the health of so many, however, history has shown us that many Americans simply do not choose to listen or to act and aggressive intervention results in only a fractional response. Case in point tobacco use. Despite the clearly established linkage between smoking and cancer, despite the billions of dollars spent by the Federal govt in terms of education, despite the penalty paid by users in terms of excessive taxes on tobacco products, lung cancer remains in the top cause of cancer related death.
One can only surmise that a certain percentage of Americans are just incapable of learning or acting on information or alternatively, to these individuals, the few moments of pleasure are worth the risk and money will not overcome either of these facts.

[ndem]

Could someone PLEASE talk about write about the genetic links to those who more easily become infected and die??????

[poliguy70130]

In a perfect world, Im sure the President would have increased funding by a greater amount. However, the reality of our current financial situation calls for financial constraint. Considering the fact that many government programs are facing drastic cuts, any icrease at all should be appreciated.

[STG 44]

Well said! Behaviour has consequences. If you CHOOSE to ignore those consequences you MAY have to pay the price.

[JEP57]

Although there are innocent victims of HIV/AIDS such as caused by blood transfusions and rape, or a partner who withholds their disease status. I believe after 25 years or so of hearing about it, people have lost some sympathy and interest in the victims and the epidemic because it's primarily a behaviourly caused disease, spread by promiscuity and risky practices. I think most Americans are smart enough to know that when you have sex, you're at risk for STDs and know what to do to prevent them such as not being promiscuous or using condoms.