Rhetoric Versus Reality: Can the Next President 'End AIDS' in the United States?

By Drew Gibson From TheBody.com

May 27, 2016

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Next January, a new president will be sworn in outside the U.S. Capitol and endowed with a mandate from the American people to run the country as he or she sees fit. As they are every four years, the fates of a multitude of government programs, advocacy groups and special interests will be suspended in the budgetary ether, waiting for policy decisions by whoever walks down the halls of Congress and works in the house at 1600 Pennsylvania Ave. For HIV/AIDS advocates, a President Clinton or a President Sanders brings with it the possibility of increased funding and a commitment to fighting the virus, while a President Trump portends a considerably less optimistic prospect. But, regardless of who becomes president, there will be an uphill battle to attract eyes and wallets to an issue that seems to fade farther from the national consciousness each year.

In 1987, as the AIDS epidemic was hitting full stride in the United States and public fear of the virus was at its height, a Gallup survey found that a staggering 68% of Americans said AIDS was the most urgent health problem facing the country. Fast forward through nearly three decades of scientific breakthroughs, public health initiatives and advocacy campaigns, and today only 1% of Americans cite AIDS as the country's most urgent health problem.

On the one hand, this is tremendously positive. The precipitous decline in the general public's urgent concern about AIDS is precisely because of all the advances that have been made since the 1980s and the fact that an HIV diagnosis has changed from a death sentence to a serious but manageable chronic illness that no longer prevents people from living full, healthy lives. On the other hand, the advent of ever more effective antiretroviral drugs and the sheer magnitude of positive people living well has turned HIV from the health crisis that defined a decade to one of many diseases fighting to differentiate themselves in the quest for media attention, political support and funding.

 So, what is the most effective way to get the political and the non-profit worlds to commit resources to the fight against HIV/AIDS? One school of thought says that it's better to focus more on process than on outcomes and to set robust, yet realistic, goals based on past performance and scientific consensus. There's nothing terribly flashy about this, which may make it harder to generate enthusiasm and -- by extension -- funding, but it is very likely to produce results that get close to, meet, or exceed expectations. Another view maintains that it is more important to build up as much engagement as possible from key stakeholders by setting goals that are more aspirational than achievable and that have a rather Panglossian sheen to most who aren't intimately involved in their development. It is fairly safe to say that the policy document that was endorsed by more than 70 HIV/AIDS activists and presented to Secretary Clinton earlier this month would fall into the latter category, as asking the next president to "commit to end AIDS as an epidemic in the United States by 2025" is about as aspirational as asking gets.


What would "ending AIDS" as an epidemic in the U.S. by 2025 look like? Well, some of the bigger goals drawn up in the policy paper are ending AIDS deaths in the next decade, reducing HIV-related health disparities, overhauling the country's lagging HIV surveillance system, inducing all the Affordable Care Act holdout states to buy into Medicaid expansion and cutting avoidable new HIV infections -- which the CDC estimates have remained stable at around 50,000 a year over the past decade -- down to fewer than 12,000 each year so that the number of people newly diagnosed with HIV is less than the number of deaths among people already living with HIV.

At the same time, the plan calls for the next president to increase the budget of the President's Emergency Plan for AIDS Relief (PEPFAR) by at least $2 billion (PEPFAR's budget has been between $6.5 and 7 billion for President Obama's entire tenure); to help the UNAIDS fast track initiative to end AIDS globally by 2030; to commit to a 10% to 15% per year increase for the National Institutes of Health (NIH) along with corresponding increases in the NIH HIV research budget to look for vaccines, cures and better treatments for the virus; and to enact a new, $1 billion a year funding initiative to address the social and structural drivers of the HIV epidemic by 2020.

Is all of this actually achievable? In public statements, some HIV/AIDS advocates such as Hilary McQuie, the director of U.S. policy and grassroots mobilization at Health Gap, have maintained that ending the AIDS epidemic globally by 2030 -- and by extension, domestically by 2025 -- is an achievable goal if access to treatment and prevention programs are adequately increased over the next five years. Other advocates, such as AIDS Alabama CEO Kathie Hiers, aren't as confident.

"From my perspective as a southerner, I get frustrated by the end of AIDS talk because we're nowhere near it," Hiers told TheBody.com last week while attending the HIV Is Not A Crime II National Training Academy. "I understand. The end of the epidemic has a good sound and feel to it. I get it. But 27% of people who are diagnosed with AIDS in the Deep South die within five years of their diagnosis."

James Krellenstein, an HIV/AIDS activist with ACT UP New York, shared Hiers's skepticism when he spoke with TheBody.com, due to what he perceives as insurmountable shortcomings in HIV/AIDS surveillance.

"We're working backwards," Krellenstein said. "This process requires that you actually look at reality on the ground and we don't even know where the epidemic is. We don't have the surveillance. We don't have the modeling. What happens if 2025 comes around and the progress isn't there?"

Both Krellenstein and Hiers emphasized the need to more clearly set forth what the ultimate goal of ending the AIDS epidemic would look like and to firmly establish the incremental steps that would be needed to achieve it.

"I don't want to be leading policymakers down the primrose path," Hiers said. However, as one of the 20 HIV/AIDS activists who met with Hillary Clinton, she seemed optimistic about the potential for working with the Democratic presidential frontrunner should she win in November, and she vouched for the former secretary of state's reputation as a policy wonk.

"Hillary knew all the acronyms, and it's very clear that she cares about HIV." Hiers remarked. "She was throwing around terms such as PrEP (pre-exposure prophylaxis) and TasP (treatment as prevention). I mean, what politician knows what TasP is? I was really impressed with her."

Drew Gibson is a social worker and freelance writer based out of Cincinnati, Ohio. You can follow him on Twitter at @SuppressThis or visit his blog "Virally Suppressed," which covers a multitude of issues related to public health and social justice.

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