PI Perspective #45
April 2008 View PDF En
español
Project Inform considers its role in
a national effort to
move the US beyond
managing the HIV epidemic to eliminating it
by Dana Van Gorder
In February 2008, Pfizer invited a substantial group of Executive
Directors of the nation’s HIV/AIDS agencies to gather at
their Research & Development headquarters in Groton, Connecticut.
The meeting had two principal goals: for us to hear from Pfizer
about the hope and challenges that characterize the search for
increasingly effective treatments for HIV infection; and to consider
how the United States will continue to finance the cost of HIV
care and treatment.
I was given the great opportunity to lead a panel of HIV healthcare
finance experts in a look at current and future funding issues
for the Ryan White Program, Medicaid and Medicare. The panel also
provided me with the opportunity to share in a conversation taking
place at Project Inform about how, in years to come, the nation
will move beyond managing the ongoing epidemic to truly controlling
and ending it.
Today, there are some 1.2 million HIV-positive Americans.
In the coming months, the CDC is expected to revise its estimate
of the number of people who become newly infected each year from
its current rate of 40,000 to perhaps 60,000 or more. In so doing,
estimates of the total number of HIV-positive Americans may also
increase significantly.
Some 17,000 Americans die each year as a result of HIV. And so,
if we maintain our current response to the epidemic, there will
be at least 1.63 million HIV-positive people in the nation in 2018.
Nearly
two-thirds of HIV-positive people will need to turn to publicly
funded programs to pay for care, treatment and social services.
Today, the cost to the federal government alone of care and social
support for HIV-positive people is $13 billion. Project Inform’s
Public Policy Department works tirelessly and effectively to advocate
for the protection and expansion of all public programs that provide
care and treatment to the most vulnerable people living with HIV.
And yet we know all too well that current spending is inadequate
to assure comprehensive, quality care for even the existing patient
load. Among those currently in care and treatment for HIV, many
are receiving inadequate services as a function of who they are
and where they live.
The CDC estimates that fully 25 percent of HIV-positive Americans
do not know their HIV status because they have never been tested
or have not been tested recently enough. And an estimated 20 percent
of people who do know that they are HIV-positive are not currently
receiving care or treatment.
If, then, we had a meaningful national
strategy to help the 45 percent of HIV-positive people to enter
care who are not currently receiving it; if we were to provide
all existing HIV-positive people with quality care and support
services; and if we add 430,000 people to the rolls of those who
will need HIV-related treatment and social services, what would
be the true public cost of the care and treatment of HIV in the
United States in 2018? Logic suggests that the answer is at least
a staggering $19.5–$26 billion a year.
At this cost, does
the political will exist to take the measures necessary to truly
control the HIV epidemic? Can we ignite a second movement in this
country to create that political will? If we truly want to rid
the nation of this scourge, we will have to.
A key topic of conversation at the Pfizer meeting was the current
plan to develop a National AIDS Strategy. Project Inform wholeheartedly
supports the goal of creating the Strategy, and we are honored
to be a part of the first organizing meeting for the effort taking
place in New York this coming April. For us, an effective Strategy
will go beyond addressing the many needs and goals that would enhance
current efforts to address HIV/AIDS. The Strategy should truly
be strategic, comprising a focused and detailed public health plan
that describes how we will control and then eradicate HIV domestically.
The Strategy should answer the following questions:
Exactly how will we assure that all HIV-positive
Americans currently unaware of their HIV status are tested for
HIV, and that all Americans are routinely tested for HIV in the
future?
How will we ensure the entry of all HIV-positive
people into quality, affordable healthcare who choose to be in
care and treatment, and how will we eliminate disparities in healthcare
and clinical outcomes for women, people of color and low-income
people with HIV?
How, through national healthcare reform, by enacting
the Institute of Medicine’s recommendation that the Ryan
White Program become an entitlement program, or by some other means,
will we guarantee access to comprehensive, quality care and treatment
for all HIV-positive Americans?
How will we eliminate barriers to
the research and development of additional therapeutics for HIV
disease, with an emphasis on those that go beyond controlling HIV
replication to an actual cure for HIV infection?
How will we reduce
by at least three-quarters the number of Americans who become infected
with HIV annually through enhanced behavioral prevention and a
major effort to prevent HIV using biomedical approaches? What will
be the cost of this effort, and how will it be financed?
One thing is painfully clear about the challenge that HIV/AIDS
advocates face in assuring adequate future funding for the care,
treatment and support services needed by HIV-positive people. If
we do not dramatically slow the rate at which additional people
are becoming infected with HIV each year, we cannot possibly hope
to finance the total cost of addressing HIV in the United States.
Project
Inform has not historically been involved in HIV prevention related
activities, except that our support of HIV-positive people entering
care and treatment clearly helps to reduce overall community viral
load and with it the likelihood of HIV transmission. But today,
we are discussing ways in which to add to our existing portfolio
of vital advocacy activities meaningful support for biomedical
approaches to HIV prevention — that set of strategies that
will bring HIV treatment and prevention together to further reduce
the incidence of HIV.
Among the possibilities Project Inform is
considering for advocacy of biomedical prevention are the following.
To actively support efforts to:
- increase testing among individuals at high-risk for HIV infection
and encourage them to enter treatment in order to preserve their
health and avoid transmitting HIV to others;
- encourage all HIV-positive
people to consider early treatment for HIV with these same benefits;
- determine
the possible effectiveness of Pre-Exposure Prophylaxis (PrEP)
in preventing HIV transmission and an expansion of Post-Exposure
Prophylaxis (PEP) in preventing HV infection, as well as advocate
for the public financing of these prevention strategies;
- develop
and deliver effective and affordable microbicides, both vaginal
and rectal;
- encourage the widespread detection and treatment of
sexually transmitted infections, including herpes in HIV-positive
individuals; and
- although it is not precisely a biomedical prevention
activity, assure the expanded availability of syringe exchange
programs throughout the United States.
As Executive Director, I (Dana Van Gorder) look forward to keeping
the readers of PI Perspective well informed both as Project Inform
makes decisions about its leadership of biomedical HIV prevention
and as the effort to develop a National AIDS Strategy proceeds.
And I welcome your thoughts about how this agency, and the nation
as a whole, can create a more muscular movement to advance our
nation from managing the HIV epidemic to eradicating it. Please
.
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