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July 2010 Archives

Thumbnail image for CIMG0106.JPGThe following remarks were presented at the 2010 International AIDS Conference in Vienna, Austria as part of the Regional Session on Canada & United States for a section entitled Current Issues & Future Directions: USA.

"The United States will become a place where new HIV infections are rare and when they do occur, every person regardless of age, gender, race/ethnicity, sexual orientation, gender identity, or socio-economic circumstance, will have unfettered access to high quality, life-extending care, free from stigma and discrimination."

This is the vision of the National HIV/AIDS Strategy for the United States, which was released at the White House last week.  

As a gay Latino man living with HIV for the past 16 years, I find this vision inspiring.  

As a longtime AIDS advocate, I find it useful in efforts to realize a progressive policy agenda that lives up to these inspirational words.

While various federal agencies and advisory groups have developed plans in the past, the new Strategy is the first to encompass multiple branches of federal government in a singular, coordinated plan of action.  It details specific metrics of success, requires annual progress reports, and assigns responsibility.  Most importantly, the President stands behind his government's plan, which he described in an HIV/AIDS address he made last week.

The plan will serve many purposes.  It gives us an authoritative, critical analysis of the state of the epidemic in our country and what the minimum is that must be done based on the strongest available evidence.  

Over five years, the plan seeks a 25% reduction in annual HIV infections to reach a level of 42,000 annual transmissions or less.  The plan will strive to help 132,000 individuals living with HIV/AIDS learn their status and immediately link to continuous care.  And the number of HIV-positive people who are stably housed and adherent to HIV treatments would also increase.  The plan pledges greater transparency, coordination, and efficiency and seeks to align efforts with the populations and geographic areas of greatest need.  

As advocates, we applaud the goals and recognize that much more must be done.  While current resources will need to be aligned with the plan, existing funding alone cannot do the job.  Federal and state governments will need to commit considerably more to realize the Strategy's measures of success.   The government will also need to mobilize policymakers and the private sector to care more and do more in the fight against HIV/AIDS.

But this is a bold plan precisely because it takes a risk.  Success is by no means assured and given the severe impact of the economic recession on communities across the U.S., our country could well see transmission rates, prevalence, and care- access worsen.  

A new paper published the day after the Strategy's release in the Journal of Acquired Immune Deficiency Syndrome (JAIDS) by Irene Hall, David Holtgrave and others describes the humanitarian and economic implications of HIV not being controlled.  

The paper predicts that at current rates of growth, annual new infections will reach 75,000 by 2015 and prevalence will reach 1.5 million individuals living with HIV.  

That means that rather than a 25% reduction in incidence by 2015, as called for in the Strategy, new infections are actually on course to increase 34% (and prevalence by 30%). By 2015, the lifetime medical costs for HIV could exceed $273 billion.  

Basically, momentum is not on our side and won't be without new dedicated funding and strong central leadership. 

I'll add that the paper gives a convincing argument about the economic urgency to lower HIV incidence as quickly as possible.  While an array of interventions may be deployed to reduce HIV transmissions over time, doing so quickly has an economic advantage by slowing the rate of growth in HIV prevalence and therefore achieving greater savings on lifetime costs.  

This is all to say that we all have a stake in seeing the National HIV/AIDS Strategy succeed.  But how exactly can we work together to ensure its success?  I have four ideas to share that I've already begun to make to federal officials and you should as well.

1.  We need to sell the Strategy to politicians and the American people: I believe in this Strategy and I think it is an eloquent, evidence-based public health plan. If fully implemented, it will help us manage our way out of the current crisis we are in.  But I fear it falls short of being an informed political strategy.  I'm not convince the general public in the U.S. cares about HIV/AIDS or that we are making salient points people can relate to about the benefits of expanded HIV prevention and care efforts.

We need to own up to the fact that the information we are collecting about the epidemic is making virtually no impact on the voting behaviors of our elected officials.  In 2008, at this very conference, we showed that new infections are actually 40% higher than previously estimated.  We anticipated that such information would compel greater awareness and support.  We were wrong and must face the fact that the numbers of HIV infections, numbers of AIDS cases, disparities, and many of the metrics we collect are not swaying public opinion.  

HIV is not as scary as it once was, deaths have declined, and the visible impact of the crisis is no longer apparent.  We need new paradigms to recapture urgency in HIV/AIDS and explain why controlling this epidemic is broadly beneficial.  This is particularly important as we concentrate our efforts on the populations most affected but who also are among the most disenfranchised politically and economically.

And we need help with messaging in general.  We speak in riddles ... of powerful medications, of a potentially deadly yet controllable virus, of the virtues of being HIV free in a hopeful world for those infected.  

I know the nuances are important but our lack of a clear, simple messaging that resonates with most Americans is hurting our cause.  We need to recapture some relevance to keep this fight in the hearts and minds of the public. 

2.  Strong leadership at all levels: I commend Jeff Crowley, his team, and other federal officials for pulling together such a strong, ambitious plan but the work has only just begun.  We must move quickly and aggressively toward implementation of this plan to stay relevant and credible.  

We expect the government to show us measurable progress by July 13, 2011: year 1 of the 5-year plan.  We call on President Barack Obama himself to detail progress made on the Strategy at the 19th International AIDS Conference in July 2012 in Washington, DC, our nation's capital.  By then we will be nearly half way through the five-year period of the Strategy and expect to see nearly half the progress.

We must confront the issue of funding.  In this recession, states have cut nearly $200 million for HIV prevention and care programs and federal funding has not keep pace with the needs.  One need only look toward escalating incidence rates and poor health outcomes to see the disparities.  Most recently the AIDS Drug Assistance Program crisis has shined a light on the inequities and the challenges of serving greater numbers of people with fewer and fewer resources.

Congress and the White House must immediately consult the Strategy in setting appropriations for the years ahead.  I also suggest that members of Congress consult with the nonpartisan Congressional Budget Office to tell us the true cost of realizing this Strategy.  We need to know what it will take to fully implement this plan if we are to achieve it.

We need early wins.  We need every state in the U.S. to provide antiretroviral access through their AIDS Drug Assistance Programs to all people living at or below 350% of federal poverty and, recognizing that ARV medications are a lifetime commitment, support states in sustaining their program if their income eligibility is higher. If ARV access is assured, expansion of test/linkage/care models is truly possible.

Working closely with states and federal officials on Medicaid expansion, housing assistance, pilot programs, intensive and bundled services in hotspots across the country, and radical reforms in the way HIV prevention is organized and delivered at the local level can all leverage quick gains.  And finally we need to refine our data systems to ensure we can quickly monitor the Strategy's indicators of success and course-correct as needed.

3.  Global leadership: PEPFAR is held as a model in the Strategy for effective implementation, coordination, and quick results.  If we are to look toward and learn from our bilateral activities on AIDS to inform our work domestically, we must sustain and grow our global commitments.  This means making good on our financial promises and motivating the other wealthy nations of the world to do their part.    

4.  Look beyond AIDS: I'm delighted the White House involved people living with HIV, like me, advocates and other stakeholders in the development of the Strategy.  I believe our input strengthened the plan and I hope federal implementers will continue to rely on our expertise.  

But now that we have a plan, the time is ripe to go beyond AIDS an engage the private sector, philanthropy, and areas of federal government not typically associated with HIV activities to see what they can do to help achieve the Strategy's goals.  

We know all too well that structural and societal forces shape the epidemic, as much or more than individual decisions, which is why we need government to improve structural interventions that look at reforming entire systems that help make people vulnerable to HIV.

In closing, President Obama's remarks last week on the Strategy are illuminating and sobering:

"So the question is not whether we know what to do, but whether we will do it. Whether we will fulfill those obligations; whether we will marshal our resources and the political will to confront a tragedy that is preventable."

All That We Desire

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A potent cocktail of celebrity, power, and wealth dominated discussions Monday at the International AIDS Conference in Vienna.

Former US President Bill Clinton urged patience in efforts to achieve universal HIV treatment access in the wake of the economic crisis.  Billionaire philanthropist Bill Gates called for greater efficiency responding to global AIDS and pop icon Annie Lennox warned of the destabilizing impact of millions of untreated HIV-positive mothers across the developing world.

But the 20,000 assembled delegates flirted with more than just stardom.  Noting that travel and conferences can be dis-inhibiting for some people, sexual health advocates deployed a guerrilla poster campaign on the Messe Wien conference center to raise participants' consciousness of their own sexual health.

"We talk about mobile populations as being vulnerable to HIV, but you look around here and everyone is away from home, traveling and in situations where they might need safer sex education," said Netherlands-based Krissy Ferris of the Pleasure Project.

A grassroots education and mobilization effort, the Pleasure Project promotes a range of safer sexual behaviors including fantasy, kissing, and masturbation.  The group trains healthcare professional on sexual health counseling and has encouraged porn producers to model erotic, safer behaviors.

Navigating sexual desire, encounters, and relationships in a world with HIV/AIDS was the topic of several sessions.  In one such presentation, British researchers described barriers to greater adoption of risk-reduction among HIV-positive gay men who engage in unprotected anal intercourse.  Most men surveyed viewed condoms as highly effective barrier methods but expressed reluctance about other harm-reduction strategies such as sero-concordant sex, not assuming the insertive position, refraining from anal sex altogether, or recommending post-exposure prophylaxis to partners who might need it. 

Study authors concluded that greater education and skills would be needed for wider adoption of sexual harm-reduction among the cohort.

"It wasn't that they were planning to use these strategies [sexual harm reduction] in order to reduce risk, it's that they used their understanding of them to make sense of the risk they had already taken," said Adam Bourne of London-based Sigma Research. "Risk reduction rationalisations are a way of trying to reconcile the impact of behaviours with their potential outcomes, which may present discomfort when thinking back on it."

To better manage risk, men must come to terms with and evaluate the risks involved in the sex they are having, study authors said. 

The desire for new preventive options for use during vaginal intercourse grew stronger as news spread about the clinical trial findings, which demonstrate that effective microbicides can be developed from antiviral medications.  Perhaps the most significant scientific finding of the conference, the news will accelerate the field of microbicide research and bring new hope to the fight against HIV/AIDS.

"It seems that pleasure has caught on within AIDS work," Krissy said. 

See the video interview with The Pleasure Project.
IMG00301-20100718-1055.jpgVIENNA (July 18)--In a region of the world where wars and genocide have indelibly marked its history, AIDS activists raised alarm over the lack of treatment imperiling more than 10 million HIV-positive people worldwide to premature illness and death.

"Right here, right now," the official theme of the 18th International AIDS Conference that opened today, sounded empty to many of the 20,000 participants from 185 countries.  Hundreds of AIDS activists disrupted today's opening session to protest the world's wealth nations for failing to finance universal HIV treatment access by 2010 as pledged at the 2005 G8 summit in Gleneagles, Scotland.  Participants also chastised the governments of developing world nations for failure to devote up to 15% of their annual budgets to health services. 

"Obama lies as people die," activists chatted to draw attention to a slowdown in treatment expansion from US and other wealthy nations.  

Speakers and activists highlighted the contours of the global HIV crisis:

  • 33.4 million people live with HIV, two-thirds of whom reside in Sub-Saharan African nations
  • 2.7 million people including 430,000 children are infected with HIV each year
  • 2 million HIV-related deaths occur annually
  • HIV cases in Eastern Europe and Central Asia have more than doubled since 2001 to 1.5 million in 2008, with Russian and Ukrainian substance users, sex workers, and their partners comprising the majority of new cases.
HIV treatment access in low- and middle-income countries has increased ten-fold in just five year, conference organizers lauded.  Yet the global economic crisis has contributed to wealthy nations slowing, and in some case reversing, their financial commitments to global AIDS efforts.  Global complacency on treatment scale-up will not only jeopardize the lives of more than 10 millions HIV-positive people worldwide but also hamper efforts to reduce new HIV infections, activists warn.

Once at the crossroads of World War II and the extermination of more than 65,000 Austrian Jews, this European capital has the potential to usher a new legacy rallying world leaders to deliver on universal treatment access and anti-HIV approaches grounded in human rights and science.  The Vienna Declaration might be just such an effort to change the course of history: the treatise calls for governments to respect the civil and human rights of substance users by investing in harm reduction strategies and utilizing proven public health rather than criminal approaches to reverse the spread of HIV and other blood-borne pathogens.

Speakers at the opening plenary also called for greater protections for sexual minorities, women, and youth worldwide as central to the fight against HIV/AIDS.

"We are watching," demonstrators' signs read, but are the globe's power-brokers listening?  With the aggregate costs of this gathering estimated at greater than $40 million, one can only hope so.



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