HIV prevention advocates hope a new White House long-term strategy and a turning political tide will help stop new cases of the disease.
The Obama administration announced July 30 it will use new science along with national and community efforts to lower the number of new HIV cases by 25% and reduce the death rate among people with HIV by 33% by the year 2020.
Those goals and an outline on how to achieve them are part of the “National HIV/AIDS Strategy for the United States: Updated to 2020.”
“It seizes on the rapid shifts in science and policy as we've learned more about this disease,” the president said in a video describing the updated strategy. “And it focuses on making sure that every American, no matter who you are, where you live or how much money you've got, can get access to life-extending care.”
The strategy notes how “providing new, sterile syringes and other injection equipment to persons who inject drugs should be part of a comprehensive HIV prevention strategy.”
Dr. David Satcher, director of the Satcher Health Leadership Institute at Morehouse College and surgeon general under Presidents Bill Clinton and George W. Bush, said that politicians continue to ignore evidence that has “unequivocally” shown how needle exchanges reduce the spread of HIV infection without increasing the use of drugs.
Some are “still not ready to say that people with addiction disorders need help more than punishment,” Satcher said.
An HIV outbreak among drug users in rural Indiana earlier this year was contained after Republican Gov. Mike Pence, a needle-exchange opponent, changed his stance. He declared a public health emergency and allowed a needle exchange to operate in Scott County, where the outbreak was focused. There are 175 confirmed cases there, according to recent numbers.
It appears Republicans in Congress may also be softening their anti-needle exchange position somewhat. Buried deep in the $153 billion labor, health and human services funding bill for fiscal 2016 is a portion that appropriates $3.6 billion for the Substance Abuse and Mental Health Services Administration. There is a passage proposing that communities with rapid increases in cases of HIV and hepatitis C use federal funds to support a syringe exchange—but they couldn't use the money to buy syringes and needles.
“We're happy that has the potential to pass,” said William McColl, director of health policy for Washington-based AIDS United. He added that he thinks it was the Indiana outbreak that caused some in Congress to rethink their position.
Ernest Hopkins, director of legislative affairs for the San Francisco AIDS Foundation, also thought that the Indiana outbreak helped cause the shift in Congress.
“It's not perfect, but for most places it will provide sufficient flexibility to fund programs,” Hopkins said of the appropriations bill. “Once people get that data in their heads we may be on the road to complete elimination of the ban.”
Hopkins agreed and said he liked how the updated White House strategy looked at how the “social determinants of health” create barriers to accessing needed care.
“This document, for the first time, puts meat on the bone of the conversation of a comprehensive continuum of care that includes housing and exposure to job training,” Hopkins said. “You have to address their entire life. You can't just focus on their HIV. You have to understand their needs to get them engaged and stay engaged.”
The White House strategy update also gives prominence to new drugs used for pre-exposure prophylaxis, known as PrEP, that can reduce the rates of infection among high-risk populations. The Food and Drug Administration approved the first of these drugs, Truvada, in July 2012.
McColl noted that PrEP drugs are not vaccines but a pills that need to be taken daily. He called it “a real strong piece of the puzzle,” and it illustrates how the strategy update has gathered all the research of the past five years and packaged it in a document that provides useful, actionable information.
“Not only are people who get infected living longer, they have an almost zero rate of transmission,” he said. “That's a real sea change from the first strategy.”
Hopkins agreed that PrEP can be a major tool in the fight against HIV, but said the administration has yet to come out with clear guidelines on who will get it and how it will be paid for.
Hopkins added that the strategy's new focus on black and transgender women was a positive development, but he disagreed that there is complacency in the fight against HIV/AIDS.
“The reaction to a HIV-positive diagnosis is still as devastating as it always was,” he said. “It's still a very devastating and stigmatizing diagnosis.”
McColl, however, said there are some people who engage in risky behavior with the attitude “if I get HIV, I'll take pills and I'll be fine.” But he said the message has gotten out that being on a lifetime pill regimen “is not exactly great.”
“We lost some of our focus,” he said, adding that more HIV public service announcements are needed and that school-based education continues to be threatened by forces demanding that abstinence is the only anti-HIV strategy that can be taught to students.