The White House released the National HIV/AIDS Strategy ( NHAS ) on July 13, 2010 to address the diverse growing needs of people with AIDS in the United States. Since the start of the HIV/AIDS epidemic, an estimated 575,000 Americans have lost their lives to AIDS and more than 56,000 people in the United States become infected with HIV each year.
President Barack Obama, together with the Office of National AIDS Policy ( ONAP ) , committed to developing NHAS with three major goals in mind: reducing HIV incidence, increasing access to care and optimizing health outcomes, and reducing HIV-related health disparities.
Senior Policy Advisor at ONAP, Greg Millett, took a few moments to chat with Windy City Times about NHAS and ONAP while in Washington, D.C.
Windy City Times: There are an estimated 56,000 new HIV infections in the United States each year. What provisions does the Office of National AIDS Policy ( ONAP ) seek to implement to prevent the number from rising even more in the next five years?
Greg Millett: That's a good question. You know ... you're correct that there are about 56,000, or 50,000 or so, new cases that take place each year, per CDC's estimates, and CDC's going to be coming out with newer estimates a little later this year. In terms of trying to prevent the number of infections from rising, you know, a lot of it is, actually, if we just keep the status quo, the number of infections is pretty much going to stay the same, because they've been staying the same for the last 10 years, but where they might rise, though, it won't be in the next five years, but perhaps in the next 10 years, is the fact that there are more people who are living with HIV because there's more effective medications. People are living longer, and they're living more productive lives. Though, with more people living with HIV, it also means that there are more opportunities for HIV transmission. So there've been other individuals at CDC and others who've been modeling out that over the next 10 years and longer, that if things remain the status quo, it means that we're going to see a rise in new infections, something we haven't seen over the past 10 years.
WCT: How does the organization seek to minimize the potential rise in infections?
Greg Millett: In order to really try to minimize that, what ONAP has proposed in the National HIV/AIDS Strategy, is to do several things that we haven't necessarily always done in our prevention response. One of them is to target the populations at greatest risk for HIV infection. Over the last 30 years, we have done a good job, but not necessarily the best job. In some ways, we democratized risk for HIV, and we know that not everybody is at equal risk of becoming HIV-positive in the U.S. and men who have sex with men, African-Americans, Latinos, and drug users are more likely to become infected. But we haven't always prioritized those populations. And without doing that, it's made it easier for us to lose focus in terms of the epidemic, and for some of the infections and epidemics that are taking place in those populations to continue.
Another thing we haven't done is that we haven't really utilized those interventions that we know work. In many ways, there's been an emergency response to the HIV epidemic from the '80s, where we're really trying to do everything possible to minimize the number of infections and to take care of people who are infected with HIV. But we really haven't slowed down and taken a collective deep breath to evaluate, "Okay, among all of these tools that we have, what actually works in preventing HIV?" And that is something that we tried to do with the National HIV/AIDS Strategy, by taking a look at all the accumulated scientific evidence, and saying, "Well, this part of our prevention response are things that we know work at preventing new infections." And then there are other things that we're doing that don't work. And if they don't work, why, in a resource-limited environment, are we spending time on those interventions, when we could actually be placing that money in those things that do work?
And then the last thing that we were looking at in terms of the National HIV/AIDS Strategy to prevent the number of infections from rising, is that for those things that work, we wanted to make sure that there's actually a population-level effect. So there are some things that work, but the effect is really just preventing HIV among one individual. And then there are other things that work, but the effect is preventing HIV among multiple individuals or even a larger population. And what we're looking for is the small number of things that we can do that work in populations at highest risk for HIV, but would produce mass effect, and not just in preventing one infection. Preventing one infection is important. That's something that is laudable. But that's not going to meaningfully impact the epidemic. We need to prevent multiple infections in a population. So that's a third thing we're looking for it to do.
WCT: The National HIV/AIDS Strategy ( NHAS ) has three major goals in place: reducing HIV incidence, increasing access to care and optimizing health outcomes, and reducing HIV-related health disparities. How will the new healthcare law affect these three major outlined initiatives?
Greg Millett: Honestly, I think it will affect it in dramatic ways. One thing that's become very clear in the HIV/AIDS world, particularly over the last year, year and a half, is that HIV care is also HIV prevention. So, when people who are living with HIV are in care and they have access to medications that improve their health outcomes, those medications also make them 92% less likely to transmit HIV to someone who is uninfected during unprotected sex. That's huge. Care is prevention.
And in terms of people living with HIV, what the new healthcare reform law will do, the ACA will do, is quite a few things that are incredibly important. People living with HIV are likely to be underinsured, or to have no insurance, compared to other populations. And some of that is due to pre-existing conditions that we have with insurance companies. And what the ACA healthcare reform law will do, or already has done, is that it's really prevented insurance companies from preventing those who are the sickest of the sick from getting insurance. So now, people living with HIV can get insurance, whereas beforehand they would have been prevented from doing so because of pre-existing conditions.
The other thing that's very important in terms of the healthcare reform law is the fact that it expands the number of people living with HIV who do not have resources who have the ability to enroll to receive care. So previously, people who had very low resources would be able to use the Ryan White Care Act ( Ryan White ) , which was really the care of last resort. But there were still individuals who were not necessarily getting the care that they needed who might have been marginally above the requirements, income requirements, for Ryan White. What the new Medicaid law does is that it dramatically expands the number of low-income individuals who will be able to access care, by actually going beyond the income requirements where they currently are. And we know, as I mentioned beforehand, getting all those individuals into care not only has meaningful outcomes for their quality of life, but also outcomes in terms of reducing the possibility of infection to others.
WCT: ONAP hosted 14 HIV/AIDS community discussions throughout the United States beginning in 2009. How were those initial 14 cities chosen ( for instance, we notice that Atlanta, Los Angeles and New York were cities visited but Seattle and Chicago were not ) ?
Greg Millett: One thing that became very clear when Jeffrey S. Crowley, Director of the Office of National AIDS Policy, came into office was that there seemed to be this recognition from the domestic HIV community that their voices needed to be heard. They felt in some ways that their voices hadn't been heard in some of the preceding years, where the focus really went from domestic HIV to international HIV. And it was important to work on international HIV, because there's a lot of need that's there, and there have been some fantastic things that have taken place, but there were some people who were affected domestically who believed that in some ways their needs were ignored or their voices weren't heard.
So what was very clear was that we wanted to pull together 14 community discussions where we were able to actually get as much meaningful input on what people would like to see in a National HIV/AIDS Strategy as possible. And we really wanted to make sure that there was going to be geographic representation, and representation of different epidemics. For example, in parts of New York City, it used to be primarily an injection drug using epidemic. In Atlanta, you have an epidemic primarily among African-Americans. In Los Angeles, you have an epidemic primarily among Latinos. In Minnesota, you have an epidemic among immigrants, you know, immigrants from various parts of Africa. And then in the Southwest, there are all sorts of needs in terms of an epidemic among Native Americans. And then on the West Coast and San Francisco, there is an epidemic among gay and bisexual men.
We didn't only want the regional diversity, but we also wanted to get the diversity of the various epidemics that are taking place in the United States, and to hear the voices of people who are representing each one of those epidemics. And we also wanted to hear, just as importantly, epidemics that are taking place in rural areas of the United States, as well as urban areas, and epidemics that are taking place in the South, as well as other different parts of the U.S. Because usually, you might find some things that might be taking place a little bit different. And we did. There were some places where, you know, living with HIV wasn't as heavily stigmatized, and people were very eager to come out about their HIV status in front of us, in front of hundreds of people during these community discussions. And then we would go to other places where HIV was incredibly stigmatized, and no one would ever mention that they were HIV-positive, even though we knew that there were people living with HIV in the room. So, you know, that in and of itself told us a lot about some of the regional differences that are taking place in the U.S. But the thing that was amazing about the community discussions is that, even though we went to different places, we heard a lot of the same themes across each one of these different communities and different regions. And that really helped us in pulling together the National HIV/AIDS Strategy.
And for those regions that we weren't able to get to, we actually hosted a place on the White House website, where people could submit to us their recommendations to add to the National HIV/AIDS Strategy. And even when we looked at those recommendations, we saw a lot of striking similarities with many of the things that we heard while we were on the road during the community discussions. And we ended up publishing all of this in a report, summarizing what we've heard, in April of last year.
WCT: When Ryan White was diagnosed with AIDS at age 13, his family turned to the CDC for guidance during multiple court trials because so little was known about the disease at that time in 1984. Is the CDC still intricately involved in court battles surrounding AIDS or has that become less the case with more studies being released over time surrounding the disease?
Greg Millett: You know, I'm not aware of CDC being involved in any court cases dealing with HIV, though CDC of course is still heavily involved in really trying to make sure that the American public is educated about HIV. Which is extremely important because there are actually data com
