On August 23rd, 2009, the first major HIV/AIDS gathering of the Obama Administration began, promising much debate and new data on approaches to HIV prevention. But critical questions loom over the meeting: Will the depth and breadth of the National HIV Prevention Conference in Atlanta and the first town meeting on the National HIV/AIDS Strategy be overshadowed by devastating cuts to prevention programs in a time of economic crisis, threats to health care reform and HIV care funding, and the lingering ghosts of the anti-science, anti-choice Bush years?

This week, RH Reality Check is partnering with the Community HIV/AIDS Mobilization Project (CHAMP), the HIV Prevention Justice Alliance, and AIDS Foundation of Chicago, among others, to cover the conference, and to raise issues about the domestic AIDS crisis.  We start here with an overview from Julie Davids and David Munar on the twin challenges of  re-inventing HIV prevention and  the need to bolster the pillars of a comprehensive approach to HIV and health care, both of which, the authors argue, must be embraced by the Federal government and its partners if we are to turn back the relentless pace of new infections in our nation.

Throughout the conference, correspondents from the HIV Prevention Justice Alliance will lay out the issues of the day and share the concerns and insights of people living with HIV and their allies.

As members of the new Administration open their first federal scientific gathering on HIV/AIDS six-months into the Presidency of Barack Obama, they face a mix of high expectations and serious challenges facing HIV-fighting efforts in the U.S.  AIDS advocates are poised to assess the course on HIV/AIDS charted by the Administration and attempt to apply their influence.

More than 3,000 scientists, service providers, public officials and advocates have joined in downtown Atlanta for the National Conference on HIV Prevention (NHPC) sponsored by the U.S. Centers for Disease Control and Prevention (CDC). With the newly appointed heads of the Department of Health and Human Services, Kathleen Sebelius, and CDC Director Tom Frieden welcoming delegates today, the conference opened last night (August 23rd) with a panel of speakers who are all living with HIV, including Magic Johnson and a member of this reporting team, David Ernesto Munar of the AIDS Foundation of Chicago (see his remarks here).

The conference marks just over a year since CDC officials, presenting at the International Conference on AIDS in Mexico City, unveiled stark new data suggesting the annual number of HIV infections in the U.S. is 40 percent higher than previously estimated, with African Americans shouldering the greatest number of new cases and rates still on the rise among gay and bisexual men of all races.  Based on its new calculations, CDC says that an estimated 56,300 people become infected with HIV each year, far greater than the long-standing, prior estimate of 40,000 annual infections.

HIV prevention providers and advocates are prepared to use the conference to highlight a range of economic and political issues undermining the fight against HIV and AIDS, calling for a greater focus on prevention through efforts to strengthen the “pillars” of a comprehensive, combination approach grounded in access to healthcare; integration and expansion of voluntary HIV testing, prevention and treatment; and long-overdue attention to social inequalities that can further the spread of new infections.  Advocates also are seeking to be at the table to ensure a steady focus on HIV, and to help set this Administration's priorities for fighting HIV, especially given so many competing challenges. 

Health Reform as HIV Prevention

In her August 24 address to the conference (this morning), U.S. Health and Human Services Secretary Kathleen Sebelius is expected to describe the transformational impact comprehensive national health reform could have on efforts to end the epidemic. 

With one-half of all people with HIV in the U.S. estimated to lack access to HIV-related healthcare, health insurance reform could accelerate efforts to control the epidemic, helping greater numbers of people with HIV improve their lives. 

For HIV prevention efforts, provisions currently in legislation before Congress to create a Public Health and Wellness program to finance community and public health activities could prove critically important.  Moreover, a standardized benefits package, greater protections and choices for insurance beneficiaries, access to voluntary health screenings, and an array of essential services—such as prevention, detection, and treatment of Sexually Transmitted Infections—could have enormous HIV prevention benefits.  Likewise, efforts to ensure that more people with HIV receive the HIV medical care and treatments they need could reduce “community-level viral load,” meaning that the much lower level of virus in the bodies of people living with HIV, thanks to effective treatment, could have a population-level impact resulting in fewer HIV transmissions overall.

Of course, the battle lines on healthcare have been drawn and a contentious legislative fight is expected next month when Congress returns from August recess.  Among the many provisions in jeopardy is the fate of the public insurance option desperately needed to ensure people with HIV and other chronic health conditions have at least one high-quality plan configured to meet their needs.

And as reported on RH Reality Check last week, another thorny issue yet to be decided is to what extent public and private plans may cover (or beneficiaries who purchase coverage with a federal subsidy may receive) reproductive health services.  Any efforts to reduce access to reproductive health care (including access to condoms and reproductive health education) would disadvantage beneficiaries in efforts to protect themselves and others from HIV transmission. 

Toward a Strategic Approach

Health reform will fold into another spotlight topic at this week’s conference: recommendations for the White House-led National HIV/AIDS Strategy (NHAS).

As a candidate and early in his presidency, Obama announced plans to develop a results-oriented plan of action against domestic HIV/AIDS.  Jeff Crowley, Director of the White House Office of National AIDS Policy, is spearheading the task of drafting the plan with input from an inter-governmental federal working group, the members of which have yet to be announced.  For the remainder of calendar 2009, Crowley is expected to visit 13 communities across the country and open online mechanisms to solicit recommendations on ways to achieve better national outcomes in reducing new HIV infections, helping people with HIV gain access to and benefit from care services, and reducing HIV-related health disparities. 

The White House’s inaugural town-hall meeting will take place here on Tuesday night August 25th; thousands of conference attendees and hundreds of local residents are expected to participate.  To prepare, the HIV Prevention Justice Alliance, a coalition led by Community HIV/AIDS Mobilization Project (CHAMP), AIDS Foundation of Chicago and SisterLove, have distributed tools for people living with HIV, prevention providers and other advocates to help them craft effective testimony.

Truly Partners in Prevention?

This week, AIDS advocates are expected to challenge members of the incoming Administration on the federal government’s failure to reverse the pace of new infections.  In addition, they will call for an end to a culture of disengagement with community actors and outright distain for science in the development of program and policy-making. 

While pleased to learn of the White House’s commitment to conduct NHAS town-hall meetings across the country, various groups have already criticized the process, which appears to exclude community voices from any top-line decision-making roles.   They have called on the Administration to ensure federal departments and agencies fully engage community panels in the creation of a results-oriented plan against HIV/AIDS.  Furthermore, advocates have suggested the Office on National AIDS Policy ensure that a panel of community stakeholders with high-level influence on the detailed content and implementation of the NHAS.

This issue notwithstanding, the Obama Administration has already garnered cautious approval from community advocates for rolling out the first HIV social marketing campaign in recent memory, called “Act against AIDS.”  AIDS advocates have also enjoyed unprecedented access to the ONAP director.  Before joining the Administration, Mr. Crowley, who formerly worked at the National Association of People with AIDS (NAPWA), most recently acted as a health and HIV policy researcher at Georgetown University. 

Advocates have been closely monitoring the Administration’s efforts to redirect funding for failed abstinence-only sex education to teen pregnancy prevention programs, which is a welcome start.  In addition, the White House seems poised to support an even broader mission to support health-promotion among teens, whether pregnant or not. 

Advocates also applauded CDC for releasing a draft regulation ending immigration and travel restrictions against HIV-positive foreign nationals.  The draft rule would also eliminate mandated HIV testing requirements for those applying to immigrate to the United States.  Now that the public comment period has closed, advocates urge the CDC to promptly finalize the regulation as originally drafted.

Still, the political pressures on this fledging Administration to meet the full range of its ambitious agenda are beginning to show.  On Inauguration Day, the White House website included specific language supporting an end to the decades old ban against federal funding for needle-exchange services, which have been proven effective in reducing HIV transmission among intravenous drug users.  But the website no longer includes such a bold statement -- and the White House passed on an opportunity to urge Congress to drop the ban as part of FY10 appropriations legislation, spurring activists to take over the Capitol Rotunda as part of successful efforts to insist on ban-lifting language in the appropriations bills.  Thus, while there’s a real possibility that an end to the ban might happen anyway, amendments might severely restrict where federally funded needle exchange can operate. 

The Administration has also been rather quiet about the need for swift congressional action to extend the Ryan White HIV Treatment Act beyond its September 30, 2009 expiration date.  As the deadline approaches quickly, advocates are urging Obama officials to guarantee they will take needed actions to ensure vital HIV care and treatment services continue without interruption.

And Then There’s the Economy…

While the Bush Administration garnered rare compliments for scaling up global access to treatment, it’s widely acknowledged that the domestic AIDS battle suffered under its tenure. But the neglect of prevention efforts is long-standing, with prevention representing only 4% of the Federal investment in fighting HIV and AIDS.

There’s much hope that the Obama Administration will not only move forward in the U.S. epidemic overall, but bring long-needed attention to specific efforts to reduce incidence at home. But the question now is how will they pay for it, as the economic recession threatens to undermine a decade of progress responding to HIV/AIDS at the state and federal levels.

States across the country from California to Illinois and Massachusetts are slashing state appropriations for essential HIV prevention and care services. The impact of these funding cuts is especially severe on HIV prevention services, which are among the first wave of services reductions in down economic times. Sadly, many conference participants presenting about their front-line HIV prevention work are unclear if their jobs and programs will still exist in the months ahead.

Medicaid services, housing, and the AIDS Drug Assistance Program (ADAP) are other areas facing funding reductions that will slow the nation’s response to HIV/AIDS, and the overall impact of budget reductions on the social safety net will be especially hard on those living with HIV or vulnerable to infection.

Advocates note that funding cuts mean we can neither maintain existing services nor deploy desperately needed innovations to tackle the root causes fueling HIV, particularly in hard-hit communities. Thus, leaders at the conference are prepared to insist that the National HIV/AIDS Strategy must not only articulate clear, measurable and achievable strategic goals, but also hold lawmakers accountable for appropriating adequate economic resources for program expansion and implementation.  

Putting the National Back into the National HIV Prevention Conference

The timing of the conference the first major Obama Administration gathering on HIV, as well as the high visibility of healthcare reform and the National HIV/AIDS Strategy as potential game-changers has brought uncommonly broad attention and participation to the National HIV Prevention Conference. The coming days will reveal possible challenges and opportunities in our struggles against the domestic epidemic; what’s clear is that the way ahead will not be easy and require shoring up the “pillars” of treatment, care and justice even as we push for desperately-needed innovations in HIV prevention.

We will be keeping you posted as the conference progresses.