Friday, July 16, 2010

New Day Redux: The National HIV/AIDS Strategy Arrives

by Mark Hubbard
[pictured below]
“Vision for the National HIV/AIDS Strategy: 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.” *

On Tuesday of this week, the Obama administration began movement towards atonement for the mortal sins perpetrated to a lesser or greater degree by each and every administration since AIDS was first recognized.  

I was honored to be one of many individuals invited to the release of the United States’ first National HIV/AIDS Strategy and later to a reception in the White House honoring the HIV/AIDS community and featuring a speech by President Obama.

A blueprint for addressing the domestic epidemic, the strategy outlines challenges faced, steps to be taken, and five-year goals in a reasonably comprehensive and detailed manner.  To reflect a line from Jeffrey, this historic action cannot reverse the losses created by years of inaction, neglect, distraction, and dogma (vs. science)-driven policy, but it is the opposite of those losses.

Making the Promises

Driving home from last August’s National HIV Prevention Conference (NHPC) in Atlanta, I tried to process what I’d experienced.  One aspect of the event struck me as odd and even a little annoying.  I couldn’t help comparing the plenaries there to those I’d attended at other research conferences where the field’s latest discoveries are typically painted in broad but succinct strokes.  Most of the NHPC plenaries felt like cheerleading sessions – big pep rallies for the team.  It was great to have our activist ideals validated, but wasn’t all of that just so much preaching to the choir?  As I got closer to Nashville my thinking changed.  I came to believe the plenaries had effectively emphasized one simple message: 

It’s a new day.

Eight years of slogging under an anti-science, anti-data, anti-expert administration had taken a bitter toll.  The quietly (and not-so-quietly) suffering folks who’d remained at the CDC during the previous administration must have realized that professionals and volunteers on the front lines had experienced an unprecedented level of frustration and cynicism. 

The doctor’s orders were to provide a hopeful indication that staying engaged, involved, and dedicated would be worthwhile.  The organizers filled that prescription with both words and actions.  The remarkably consistent message presented was affirming, focused, and unfettered:  the Obama administration would return to science, address stigma, recognize the significance of social injustice, embrace the idea of “combination prevention,” and quickly get about the work of developing a National HIV/AIDS Strategy.  One of the first of fourteen community discussions on the strategy was held then and there at the conference. 
“The United States cannot reduce the number of HIV infections nationally without better addressing HIV among gay and bisexual men.”*
Who spoke in Atlanta mattered as much as what they said.  A highly experienced, diverse, and qualified leadership had been appointed.  Conference organizers had clearly made an attempt to address the Prevention Justice Alliance’s demand for participation by a wide range of federal agencies and departments beyond the CDC and DHHS. 

One by one, a series of new appointees and guests, many of them openly gay and/or HIV-positive, began to hold forth.  We laughed and cheered in shared relief when the words of one guest speaker, “ding, dong, the witch is dead,” rang amplified through the huge ballroom. 
“Another issue involves trying to assess the effect of incarceration on these communities and the impact it has on HIV transmission.”*
Robert Fullilove addressed the social context of the epidemic, dramatically asserting that reducing the impact of mass incarceration of those most at risk is “the greatest opportunity for transforming the social environment and the social drivers of HIV/AIDS at this point in the 21st century.”
“… we need to adopt policies that will produce a workforce that is large enough to care for all people living with HIV, is diverse, has the appropriate training and technical expertise to provide high-quality care consistent with the latest treatment guidelines, and has the capacity, through shared experiences or training, to provide care in a non-stigmatizing manner and create relationships of trust with their patients.” *
Kathleen Sebelius, Secretary of the U.S. Department of Health and Human Services, gave the thumbs up from the podium to a group of us demonstrating for health care reform.  Congresswoman Maxine Waters unapologetically and emphatically made the case with great flair.  Various promises were made – there would be healthcare reform, the HIV entry ban would be lifted, and above all, the community would be consulted.

In short, we were inspired.

Releasing the Documents

Promises are just that, but those made at the NHPC have been kept.  A healthcare reform bill was passed, the entry ban was lifted, and the community was consulted.  Most importantly, a National HIV/AIDS Strategy is now a matter of public record.

It will take time for professionals and activists to thoroughly analyze the strategy.  Critique it they must and critique it they will.  The document isn’t perfect, but I view it as brilliant - brilliant because it’s grounded in current data and science, brilliant because the administration appointed the right people from within our midst to lead its development, and most importantly, brilliant as a result of having the rest of the community as its co-authors and editors. 

The primary goals announced at NHPC remain steadfast.  We must 1) reduce new HIV infections, 2) increase access to care and optimize health outcomes for persons living with HIV, and 3) reduce HIV-related health disparities.  A fourth goal has been added:  4) achieve a more coordinated national response to the HIV epidemic in the U.S.  (This explicitly includes monitoring and reporting on achievement of the goals detailed in a companion Federal Implementation
“…providing sterilized equipment to injection drug users substantially reduces risk of HIV infection, increases the probability that they will initiate drug treatment, and does not increase drug use.” *
There is some tiptoeing in the document (particularly the notable lack of mention of anything anal or rectal.) It and those who introduced it on Tuesday spoke plainly to issues that have been, are, and will continue to be difficult and controversial.  The mood among those in attendance was mostly enthusiastic, even triumphant.
“People at high risk for HIV cannot be expected to, nor will they seek testing or treatment services if they fear that it would result in adverse consequences of discrimination.
“In many instances, the continued existence and enforcement of these types of [HIV-specific, i.e. criminal transmission] laws run counter to scientific evidence about routes of HIV transmission and may undermine the public health goals of promoting HIV screening and treatment.” *
While the temptation to feel cynical about the community’s presence at what were clearly media events exists, I have consciously chosen to resist.  When I had the chance, I shook President Obama’s hand, looked him in the eye, and simply said, “Thank you.”  Having grassroots community attend these events made a profound statement:  “We couldn’t have and can’t do this without all of you.”

Moving Forward into Action

That’s the point, and it’s also the challenge.  We have a blueprint, but remodeling has yet to begin.  The administration does not serve in isolation.  Those who have opposed what’s needed in the past will continue to do so.  Funding will be a major challenge.  There will be pushback and compromises and setbacks and disappointments.  As the Coalition for a National AIDS Strategy and the Prevention Justice Alliance have reminded us, we must hold the administration’s feet to the fire and Congress must be pressured to act in accordance with the strategy.  A living process must be nurtured that is driven by aggressive implementation, ongoing research, and community activism.  We must continue to better address other aspects of the epidemic more specifically, including research.
“…safe and effective vaccines and microbicides are not yet available and investments in research to produce safe and effective vaccines and microbicides must continue.”
Perhaps the next conversation should involve creating a succinct National HIV/AIDS Research Agenda.  Based on ONAP’s contention that prevention resources must be targeted to address disparities and to help the most affected communities, such a plan must address the failure to equitably fund anorectal-focused research.  It must commit to an infusion of resources that will bring our scientific knowledge of the rectal compartment, lubricants we know are commonly used for anal sex, anorectal transmission, and new rectal-specific prevention technologies into parity with our knowledge of the vaginal compartment, products, transmission, and technologies.

Whoever you are, wherever you live, whatever you do, if you give a damn about HIV/AIDS in our communities, please read these documents.  The videos from Tuesday are also well worth your time.

* Excerpted from The National HIV/AIDS Strategy for the United States


  1. Mark,

    Like you, I have devoted so much of the last couple of years working and educating communties of the importance of a national HIV & AIDS stratagy. Although I am in a relationship with a same sex partner, I often have to push my sexuality to the side for the greater good.

    I am very pleased that we have a national stratage and I realize that this is just the begining of the a new chapter and a contiuation of the previous, but when do we get a break?

    Thanks for your continued support,
    Dave Shamer
    Baltimore, MD

  2. Dave,

    I humbled by your question, which addresses an important and sensitive issue that is not exclusive to the topic of HIV/AIDS. Those of us who work in communities often struggle with what can be a knife edge between authenticity and prudence. When you are dealing with public relations and politics, I understand it may be a challenge to know when to compromise the former in order to avoid "losing your audience." For me, barriers to revealing my sexuality or any other intimate or potentially controversial part of my identity come nearly equally from within and without. The process of personal change and growth may be slow, but sometimes it seems like societies and structures change even more slowly.

    Over time I've come to a personal choice to almost never conceal my sexual orientation when dealing with HIV/AIDS, whether or not I am currently in a relationship. I recognize that this is a personal decision that others may not have the privilege of making because of job or family or other considerations. I confess there are other aspects of my personal life about which I may be more discrete.

    I can't offer you an easy answer but I can try to further explain my own hope. That comes from many places: seeing hundreds of families defying society by building gay families that show up every year for gay pride even in Nashville Tennessee, from seeing small advances over the decades everywhere - in churches, the workplace etc, from observing whole new generations experiencing less angst about and having more resources to help then deal with being gay or bi or queer, and to bring it back to the subject at hand, from having seen the following Obama appointees on stage at last year's national HIV Prevention Conference in Atlanta, all described in my notes from the conference as out gay men:

    ->Division of HIV/AIDS Prevention (DHAP) Interim Director, Rich Wolitski, PhD
    ->White House Director of the Office of National HIV/AIDS Policy (ONAP) Jeffrey Crowley, MPH
    ->Office of National HIV/AIDS Policy (ONAP) Senior Policy Advisor Greg Millett, MPH
    ->Director, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention (NCHHSTP) Kevin Fenton MD, Phd

    I'm confident there are many others. Today, I believe that because of the overwhelming, disproportionate impact of this pandemic on gay and bi men, any discussion of HIV/AIDS that means to seriously deal with the issue must include frank, non-judgemental, open discussions about them and their lives.

    I also get, however, that sometimes you can't start the conversation there. Hang in there and keep doing what you're doing!



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