11/23/2009 05:12 am ET | Updated May 25, 2011

The Politics of AIDS and Health Care Reform

Two weeks after President Barack Obama delivered an impassioned address on health reform to the nation and a joint session of Congress, I sat down with David Ernesto Munar of the AIDS Foundation of Chicago and Julie Davids of the Community HIV/AIDS Mobilization Project (CHAMP) to discuss how the Obama administration is approaching the fight against HIV/AIDS.

How might health reform affect people living with HIV and those at risk of infection?

Munar: National health reform could significantly accelerate U.S. efforts against HIV/AIDS by helping us reach the estimated half a million HIV-positive people (50 percent of all those living with HIV) who currently lack needed medical care. The impact of health reform on efforts to control the epidemic could be profound. Of course, it all depends how comprehensive the final package is and what measures are in the legislation to serve low-income people and those with chronic conditions.

Health reform could also mean more people are offered voluntary HIV testing, treatment for the other sexually transmitted diseases that can make bodies more susceptible to HIV infection and education about protecting themselves from HIV through healthy sexual practices and safer substance use. Bills before Congress would also establish funding for public health and community programs to promote a broad spectrum of prevention and wellness activities.

Health reform is certainly no silver bullet, and much work will remain no matter what's in the legislation, but the truth is that too much time, energy and resources get spent trying to close the health care gap for people with HIV and those at risk of infection. If we make progress addressing these concerns, we would significantly advance efforts against HIV/AIDS -- and get to turn our sights to the tricky challenges of HIV prevention that haven't gotten due attention.


Davids: People fighting HIV/AIDS feel passionately about health care reform. My co-conspirator David gave a rousing address during the opening plenary of the recent National HIV Prevention Conference about what health reform could mean for people living with HIV/AIDS.

On the second day of the conference, supporters of health reform greeted Secretary Kathleen Sebelius with pro-reform placards and chants ahead of her plenary address. Congresswoman Maxine Waters (D-CA) closed the conference with a detailed explanation, complete with effective visuals, of the types of provisions Congress is considering. Like other speakers, she debunked the lies being spread about health reform and made a strong case that progress against HIV/AIDS depends on a strong health system in the U.S.

What HIV data did the U.S. Centers for Disease Control and Prevention (CDC) recently release that hardly got noticed?

Munar: Believe it or not, for the first time, the CDC has put out preliminary data about the rates of HIV and AIDS in gay and bisexual men.

Calculating the rate of disease for a given population is a useful tool to compare severity between groups of different sizes. But the CDC has never before estimated the rates of HIV or AIDS for gay/bisexual men and other men who have sex with men, ostensibly because of the inherent difficulty of counting how many men identity as gay/bi or become intimate with other men. But we also suspect the chill effect of the Bush Administration made this statistical challenge less of a priority issue.

So finally, the CDC examined data from various studies to estimate the total size of the gay/bi male population in the U.S. and determined that 4% of U.S. male population -- essentially 2% of the U.S. population overall -- is likely comprised of gay/bi men. Having calculated the size of the gay/bi population, the CDC can now calculate and compare the severity of the epidemic between this and other populations.

And the disparities are shocking. As reported by Dr. Amy Lansky of the CDC, gay/bisexual men in the U.S. acquire HIV at rates that are 50 times greater than women and non-gay/bisexual men.

This was coupled by more CDC analyses on the final day of the conference showing that the use of their prevention funding across the country in 2005 drastically shortchanged gay/bi men if you compare it to how deeply they are affected by the epidemic. So, combined with the data revealed a year ago that gay and bi men are the only populations with rising annual rates of HIV infection, this all really should put an end to the myth that HIV/AIDS has somehow been tackled in gay communities.

Davids: I agree that this one-two punch of the 50 times higher rates plus the confirmation of the drastic underfunding of gay/bi prevention efforts in the already underfunded prevention response was, no pun intended, the money shot of the conference.

So then we need to ask, what of it? What do we do? Well, first, we should recognize that the new data underscore that more than individual behavior is contributing to high rates of infection among gay/bi men. With such high concentrations of infection among gay/bi men, even low or moderate risk-behavior has a proportionally higher chance of resulting in infection than if the same behavior occurred within another population. And at previous conferences we've seen data showing that mistreatment of very young gay, bi and transgender people increases their likelihood for higher rates of HIV infection, drug problems and domestic violence later in life.

Confronting the deeply-rooted societal prejudice and homophobia against sexual and gender variance may be what it takes to truly control the spread of the epidemic -- and that's a task that stretches far beyond the mandate of CDC alone.

Six months into the new Administration, are there any signs the CDC is approaching the fight against HIV any differently?

Munar: While it's still early to know whether a new approach to HIV prevention has actually taken hold in the federal government, CDC officials gave tantalizing hints that their strategies are changing. Federal officials appeared more inclined to broach such lighting-rod issues of the past as condom distribution, sterile syringe availability, and even the topic of gay men and gay sex.

Davids: We've wanted the CDC to stand up and make a real case for the importance of HIV prevention, even though it requires explicit and sometimes unpopular discussion of sexuality and drug use. So we're happy that the CDC rolled out a new briefing book that makes a compelling case for HIV prevention as a science and practice that has averted hundreds of thousands of HIV infections and saved society tens of millions of dollars in health care expenses, and makes it clear that progress in reducing HIV infections in the U.S. requires an increased investment that will ultimately pay for itself in dividends by lowering medical costs.

The briefing book also has some striking charts that really spell out the drastic differences in infection rates by race and sexuality, cross-referencing how hard the epidemic is hitting gay people of color. In the past, all this info has been out there, but the CDC never made it plain by putting it all in one place. I'd like to say we've made more progress than simply stating the obvious more simply, but for veteran CDC-watchers, it is notable.

What are "social determinants" and why is talk about them increasing in HIV prevention circles?

Davids: Social determinants refer to the social and structural factors that correlate with heightened rates of HIV infection. Such factors believed to contribute to high rates of HIV in our country include mass imprisonment, health care inequality, poverty, the marginalization of young gay and transgender people and other forms of oppression. The HIV Prevention Justice Alliance was launched earlier this year precisely to spur activities designed to address these underlying forces.

We believe that efforts against HIV must not only teach people about ways to protect themselves and others against HIV and other STDs but also address the social and structural factors that elevate risk for entire groups of people. So-called "structural interventions" that help homeless gay youth get housing, health services and education, for example, could have a protective effort and decrease chances they will be impoverished, abuse substances or engage in survival sex, all of which have been shown to greatly increase risk for getting HIV.

Munar: The CDC appears ready to conduct research on effective interventions tackling these systemic drivers of infection, and possibly invest in these approaches, if only new resources were made available to try them.

Davids: Well, there's the rub -- new resources -- and we're calling on the Obama Administration to make prevention a priority in the National HIV/AIDS Strategy they've started to construct. But we are also calling out for the CDC to invest in re-training our shovel-ready community prevention workers, so they could be a force in these kinds of structural interventions, if it's thought they could be more effective than some of our past approaches.

How is the economic recession impacting HIV prevention in the U.S.?

Munar: The real tragedy of the recent National HIV Prevention Conference was the realization that the new federal Administration is poised to take a more expansive and evidence-based approach to HIV prevention at the very time as states are jettisoning HIV prevention and public health budgets.

In his plenary address, the CDC's newly appointed HIV prevention director Dr. Jonathan Mermin, cited evidence that states have more than $84 million in funding cuts planned for HIV prevention services -- and this was before the State of California zeroed its $31 million investment for HIV prevention activities. Even with the $53 million increase slated for HIV prevention activities in President Obama's Fiscal Year 2010 budget request, HIV prevention services will experience a net funding decrease that is sure the slow efforts to stop growth in the epidemic.

The White House recently kicked off a series of town-hall meetings meant to garner public recommendations on a soon-to-be-developed National HIV/AIDS Strategy . What's your assessment of the start of this process?

Munar: To be honest, it was stunning to see the Administration bring together a local panel of outspoken doctors and community advocates at the inaugural meeting in Atlanta to call the federal government to task for not having a strategic approach to combating the epidemic. And then dozens and dozens of people from all walks of life -- many from the local Atlanta community -- got their turn at the mic to give a really striking range of observations and recommendations. But the challenges to turning all this into a measurable, practical, government-wide strategy are huge, and this process is not going to be easy.

Davids: Right as the meeting began, about 30 people took over the stage, organized by the coalition of HIV-positive women called the U.S. Positive Women's Network. They not only urged the Administration to make women a priority in the strategy but to "make everyone a priority."

For me, that sums up one of the big hurdles the Strategy must surmount. The HIV epidemic in the United States is not just persistent and severe -- it's complex, more like a series of different epidemics spanning rural African-American communities to multi-racial gay urban enclaves to neighborhoods with high imprisonment rates and isolated women across the nation infected in monogamous marriages.

But with limited resources, the strategy needs to set a few key priorities that can be tracked and evaluated, with responsibility shared across the government -- and make a compelling case that these strategies will start us on the road to truly "prioritizing everyone."