This article is part of a
special series this week focusing on HIV and AIDS in the United
States.  Rewire is partnering with CHAMP, the AIDS Foundation of Chicago, the HIV Prevention
Justice Alliance, and other organizations to highlight issues on domestic HIV and AIDS policy during this week of the National HIV Prevention Conference
in Atlanta, Georgia.  See the first piece in this series by Julie Davids and David Munar, The AIDS Crisis in the United States: Wlll the Obama Administration Meet the Challenge?  

ATLANTA – Speaking at the
Obama Administration’s first national HIV summit this week, top public health
leaders and community activists agree that a paradigm shift in HIV prevention
approaches is needed to make progress reducing HIV transmission in the
U.S. 

According to advocates and other experts,
the U.S. Centers for Disease Control and Prevention (CDC) must work
with partners to develop and implement a strategic scale-up of comprehensive,
combination HIV prevention strategies in order to achieve population-level
decreases in HIV transmission.  The aims of a new approach must
focus on averting as many HIV infections as possible. And it must expand
successful interventions, invest in research and evaluation, and address
social drivers such as lack of housing, mass imprisonment, poverty and
marginalization. 

There were tantalizing hints at this
week’s conference that CDC may be ready to seek significant changes
in federal prevention policy and programs, a shift that would require
strong leadership to inspire political buy-in and increased resources. 
Meanwhile, the new leadership at CDC faces steep challenges contending
with an unprecedented economic crisis and competing national priorities
that could jeopardize progress to slow the spread of HIV in the U.S.

In a seven-page booklet, distributed
to all delegates attending the 2009 National HIV Prevention Conference,
CDC asserts that "the science is clear: HIV prevention can and does
save lives."  The document, entitled HIV Prevention in the
United States: At a Critical Crossroads, makes the case for HIV
prevention and articulates CDC’s vision for leading the fight.

The arguments in the report are not
entirely new.  As in past reports, CDC describes the dire nature
of the epidemic in the United States and asserts CDC’s vigilance tackling
HIV incidence.

However, some participants at the conference
noted new, refreshing areas of emphasis. CDC’s report, which is going
through the government process for online publication in the next few
weeks, describes the hundreds of thousands of infections – and millions
of health expenditures-averted to date.  The report describes
the diverse and complex distribution of the epidemic and the many critical
issues a more robust approach will need to include.

"People don’t know what prevention
is, what they’re getting for their dollar, and why we need to do more,"
explained Terry Butler, a communications specialist with the CDC. 
"While we know the value of prevention, there’s a lot of misperception
that prevention is not making a difference – the value of prevention
in terms of lives and dollars saved."

AIDS advocates attending the conference
observed that the new report comes on the heels of CDC’s significant
set-back in not securing one-time HIV and STD prevention funding in
the economic recovery plan passed by Congress earlier this year. 
Despite a proposal by the U.S. House of Representatives to invest $335
million in HIV and STD prevention work,
conservative media pundits ridiculed the proposal and Senate members
removed the allocation from the final spending package. 

Meanwhile, struggling state economies
have triggered deep budget cuts for public health and HIV prevention
programs across the country.  Several speakers at this four-day
conference – presenting innovative HIV prevention activities – acknowledged
fear their programs and jobs will not be sustained in the weeks and
months ahead.

In his opening remarks, the new Division
of HIV/AIDS Prevention (DHAP) Director Dr. Jonathan Mermin didn’t
shrink from describing the challenges posed by the nation’s economic
recession.  He described data compiled by the National Alliance
of State and Territorial AIDS Directors (NASTAD) showing $84 million
in HIV-related funding cuts among states surveyed. 
A total off 55% of health departments reported funding reductions for
HIV prevention.  Importantly, the survey conducted earlier this
year does not even include the estimated $31 million in cuts resulting
from California’s state budget crisis.

CDC’s new booklet details the widening
funding gap at the federal level.  While CDC’s HIV prevention
budget has remained relatively stable since 2002, at $750 million annually,
the purchasing power of the budget has declined by nearly 20 percent
as a result of inflation.  Additionally, the report describes the
CDC’s professional assessment, calculated in 2008, that an additional
$877 million (a greater than 100 percent increase) is needed annually
to achieve a 50 percent reduction in yearly HIV infections in the U.S.

Mermin, a long-time AIDS clinician
and CDC staffer who spent the length of the Bush Administration in Uganda
and Kenya, has pledged to launch a new strategic planning process for
CDC’s Division of HIV/AIDS Prevention (DHAP) this fall as a component
of the National HIV/AIDS Strategy.  He said it will draw upon the
work of the External Peer Review of DHAP’s programs and structure
initiated this Spring.  Individuals involved with the external
review say they already see evidence of their recommendations integrated
into Mermin’s remarks defending the cost-benefits of HIV preventions
and justification for a larger investment in HIV prevention.

For example, Dr. Mermin expressed in
his welcoming remarks the need to look at the "social context, including
where people living, poverty, homophobia, race/ethnic bias, gender inequality,
housing status, and HIV stigma," all factors believed to contribute
to elevated risk for HIV acquisition.  He also called for a deeper
investment in combination HIV prevention strategies to bridge different
approaches "in multiple disciplines, including biomedical, behavioral,
and community and structural interventions."

The HIV Prevention Justice Alliance
(HIV PJA) secured a meeting with Dr. Mermin on the
closing day of the conference to discuss ways to collaborate with CDC
on efforts to mitigate HIV-related social determinants.  Among
the HIV PJA’s demands is CDC’s commitment to develop a framework
that begins to shift the focus of federal HIV prevention from predominantly
individual, behavior-change models to interventions addressing the social
and structural components fueling HIV transmission for entire groups
of people. 

But beyond the mere complexity of such
an ambitious undertaking, HIV PJA fears current economic conditions
will undermine even core public health functions from being delivered,
much less new forward-looking plans on root drivers of risk and HIV
acquisition.

Graphically Simplifying a Complex
Epidemic

HIV Prevention in the United States
includes just two graphs, but they both speak volumes about how
CDC may hope to inspire an increased investment and focus on HIV prevention.
One charts the growing numbers of people living with HIV during a period
of relatively stable HIV incidence (albeit at a rate that we learned
a year ago is much higher than previously thought).

According to Rich Wolitski, Deputy
Director of DHAP, the chart  "encapsulates a lot of challenges
and tough decisions facing us," as it indicates that more HIV-positive
people are in need of prevention resources even as the need for primary
HIV prevention for those who are negative remains.

The second breaks down the 2006 incidence
estimate by race/ethnicity, risk group and gender for the most affected
subpopulations, and thus has distinct, descending bars for white men
who have sex with men (MSM), Black MSM, Black heterosexual women, and
so on. As explained by CDC spokesperson Terry Butler, this breakdown
is part of an effort to "better communicate where we are in the epidemic.
The data’s been out there but it’s clearer this way."

After years of euphemistic coding and
strategic de-linking of information on different populations (for example,
much talk of "African American and gay men" but little of "African
American gay men"), these analyses are helpful tools even in clarifying
the realities of the epidemic for conference attendees in the thick
of prevention work. Throughout the conference, CDC has also been gathering
feedback on a possible online tool that will also help a broad range
of people visualize the incidence data broken down to this level of
detail.

The Need for a Big, Good
Idea

On Monday, HHS Secretary Kathleen Sebelius
spoke boldly about the need for an emergency response to the epidemic:

"In 2005, the CDC reported that
in five major cities, almost half of all African-American gay men were
HIV-positive… Think about that.  Imagine if it were half the straight
white women in Atlanta.  Wouldn’t we be calling this a national emergency? 
Shouldn’t we be?  That’s how we at HHS are treating it.  So we’re
experimenting with innovative new ways to reach these groups – from
a new online banner campaign that targets gay African-American men to
partnering with groups like the Black Women’s HIV/AIDS network."

While greeted by loud applause for
her recognition of the racial and social injustices, the Secretary’s
examples of innovation under-emphasize the many activities at the federal,
state, and local levels needed to heighten the response to HIV/AIDS
among gay men of color.  Thankfully, in dozens of presentations
and a CDC listening session on responding to HIV among Men who Have
Sex with Men, participants described the need for programs and services
designed to address the diversity of gay men at risk for HIV. 
A speaker from Massachusetts, for example, described the disproportionate
number of HIV-positive gay men who have spent time incarcerated. 

The discrepancy between the progressive
analysis and rather standard actions (online banner ads? Partnering
with community networks?") is reflective of some of the post-Bush
CDC initiatives in which long-awaited core activities are perhaps over-lauded
for lack of more radical approaches.

For example, conference participants
spoke of CDC’s new "Act against AIDS" advertising initiative as a decent start
to spark a national dialogue about HIV/AIDS but cautioned, however,
that the campaign cannot be viewed as taking the place of expanded HIV
prevention services needed by people at risk and living with HIV or
strategic structural interventions.

Treatment and prevention integration
dominated many of the discussions this week with advocates and federal
officials anticipating clinical trials will likely show that pre-exposure
prophylaxis with HIV medications can effectively, though not completely,
prevent HIV acquisition. However, the health education, medical and
social systems implementation and financial challenges that would come
with such a breakthrough would be formidable, and comprised the subject
of a day-long meeting here on Sunday.

The concept of reduced "community
viral load" as population-based HIV prevention (where greater numbers
of HIV-positive people on treatment achieve undetectable viral load
and are rendered significantly less infectious) is another bold idea
gaining prominence.  Implementing greater treatment and prevention
integration on a large scale, and in the face of significant budget
reductions, remains a daunting task and will likely require greater
coordination and collaboration between different government departments
and agencies to, among other things, pool resources. 

Tough Choices, But New Opportunities?

The new booklet speaks quite plainly
about the need to prioritize prevention work.

Advocates and Congress alike have criticized
CDC officials for a lack of transparency and a reluctance or inability
to provide clear and timely information about how they set priorities
and spend the agency’s funding.

In one of the final conference sessions,
CDC unveiled a new resource allocations model that is being designed
and tested to better determine program priorities. And the booklet makes
it quite plain that "difficult choices" will have to be made, with
"resources… directed to the populations at the highest risk and
to the strategies that are the most cost-effective in reducing HIV transmission."

As explained by Wolitski, the "crossroads"
referred to in the publication’s title ("At a Critical Crossroads")
alludes to the imperative to make difficult, strategic choices in an
era of increased need and diminished resources.

"We’re at a point of having to
ask these questions. We are doing the external review, a strategic plan,
there’s the national HIV/AIDS strategy and health care reform. A lot
of things today are changing. We have to look at the data and variables,
and assess how what CDC does fits in a broader framework of providers,
private insurance, medical care systems and so on. That’s why the
tough choices are now so salient."

New CDC Director Thomas Frieden, former
commissioner of New York City’s health department, is no stranger
to embracing controversy in the face of what he feels is in the best
interests of public health. Advocates note his past efforts supporting
access to condoms, syringe exchange and – incurring the wrath of some
advocates — pushing for legislative changes to allow for HIV testing
without written informed consent or counseling. But his presence at
the podium was limited to an introduction of HHS Secretary Sebelius,
far from showing his hand or sketching out a vision of change.

Last year, the National Center for
HIV/AIDS, Viral Hepatitis, STD, and TB Prevention held a consultation
to consider the adoption of a social-determinants framework. While its
Director, Dr. Kevin Fenton, has pushed for such a framework, it remains
unclear whether new leadership at CDC will embrace a model that posits
factors such as poverty, homophobia and mass imprisonment of African
Americans and Latinos as likely drivers of the epidemic – or if they
would actually move from a modeling to significant action.

It’s widely speculated that any re-thinking
of CDC policy must reduce dependence on pre-packaged "boxed interventions,"
which have failed to meet the nation’s HIV prevention needs but been
the mainstay of funded programs. Thus, some speculate that community-rooted
prevention workers could be shunted aside rather than retrained under
a new vision of comprehensive HIV prevention. Advocates have begun to
speak out to demand that, if changes do come, those leading HIV prevention
efforts in our communities will be given the opportunity for training
and support to integrate and bolster new efforts, but this was not addressed
in Atlanta this week.

The National AIDS Strategy to the
Rescue?

Throughout the conference, there was
much talk of the potential capacity of the National HIV/AIDS Strategy
(NHAS) being coordinated by the White House Office of National AIDS
Policy as a tool for turning tough choices into big, new ideas for prevention
progress and inspiring re-investment in reducing incidence.

The placement of noted CDC researcher
Greg Millett as a Senior Policy Advisory for the NHAS has been lauded
as a step in the right direction. ONAP held a well-attended input session
at the conference to launch development of the NHAS, with dozens of
people testifying on their priorities for the plan, and Mr. Crowley
spoke on a plenary session devoted to inter-governmental collaboration.

The NHAS is, in and of itself, a big,
new idea in the domestic epidemic. The challenges of a truly implementable
strategy are formidable, but fully consistent with the need for CDC
to devise a more strategic and rigorous approach.  Only through
bold, new leadership to chart a new, strategic path is there any chance
to confront stubbornly persistent HIV incidence in our country.