HIV Politics: Yes, We Still Can

An Interview With Mark Harrington

July 7, 2014

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You come from ACT UP. What should activists be doing about this in terms of the CDC? Is there a place for other activists to be doing something?

Yeah. The CDC has never been very responsive, and I think it needs to feel the heat about the fact that we're failing huge parts of our community. Do you know that the Helms Amendment is still law in this country? And that it prohibits the use of federal funds to promote what Jesse Helms would have called that "disgusting" homosexual activity? But it puts limits on what government agencies can say and do about HIV prevention among gay people and transgender people.

What happened years ago, when it felt like the federal government was going to lift this ban on using federal dollars to fund needle exchange?

They did lift it for two years.


They lifted it, and now it's back on. Why did that happen?

Because the Republicans took over the House, and because Obama was willing to sacrifice the lives of injection drug users to get a better deal in that particular budget cycle. It was one of his most craven, cowardly moves. Nobody forced him to sign it.

When we look back on Obama, when he's no longer in the White House, are we going to compare him to Reagan?

When Hillary Clinton was secretary of state, the PEPFAR [President's Emergency Plan for AIDS Relief] program was able to more than quadruple the number of people on protective therapies globally, with a budget that was actually going down. It went down by 12%. So PEPFAR was extraordinarily effective. They launched that AIDS-free generation initiative when Hillary was there. Globally, the momentum that was already there with PEPFAR continued under Obama. His National AIDS Strategy is just pathetic -- it's so much worse than most of the countries that we're giving PEPFAR assistance to, in terms of its lack of ambition.

The other problems with the plan, the strategy, include the fact that it's more of a blueprint for what the federal government should be doing than what everybody should be doing to end the epidemic. It doesn't really have as much of a role for states, counties or community organizations who are still in society. I mean reducing new infections by 25% is just not only an unsexy goal; it's not an acceptable goal. We know that communities have been able to reduce incidence by more than 50% with PEPFAR assistance. So why aren't we trying to do that here at home? Because he doesn't want to spend the money?

But who's leading the charge in D.C. around HIV issues if we have a president who's not really done what we thought he was going to do? Who are our allies in D.C.?

The AIDS community is pretty fragmented and full of silos where people work on issues that they work on. The harm reduction people work on harm reduction; the housing people work on housing; treatment people work on Ryan White; and prevention people -- I don't really know what they're doing, but they're already in Washington.

One of the things that we noticed when we started our prevention initiative at TAG was that there are a lot of groups that say they're doing HIV prevention programs, but there's not a lot of people that are working on policy around HIV prevention, or what it should be. They're perfectly happy to take the $900 million in CDC grants to do whatever they're doing -- which, nobody knows what it is. You can get a list of the CDC grants. It's obviously not enough to make a dent in the epidemic.

Some people talk about this idea of HIV prevention justice, which looks at things like economic justice, racism, sexism and homophobia as social drivers, instead of looking at individuals' behaviors as the only way to look at prevention. I don't even know how you put money into social determinants of health, other than just having workshops and training to talk about it. What do you think about that?

I have no idea whether or not that makes any difference to the outcome of the epidemic. I certainly know things need to be addressed for their own sake -- getting people out of prisons and back into the community -- doing something needs to be done for its own sake. But that's going to be work of many decades, and it's going to be really, really hard. It's going to be hard to reintegrate people back into the community.

We have a chance to save thousands of people right now. We're not going to get rid of homophobia, racism and economic inequality in five years. But we can make a serious dent in HIV transmissions in the next five years.

What do you think the next five years should look like?

It's believed that they've done that in San Francisco and Washington, D.C., over the last six to 10 years, and so it's worth looking at what they've done and seeing whether it's true, first of all, and secondly, whether it's scalable to other very different epidemics, where they don't have the same combination of programs and communities and political will that they had in those two cities.

It appears that some places have gotten down incidence by as much as 40% over a five- to six-year time period, which is pretty close to that tantalizing number of 50%. You know, set a goal of bringing down national infections by 50% in five years, and then we'll get the resources to do it. That would be more motivating than a pathetic little 25% goal.

We should start looking at what it would take to end the epidemic and then work our way backwards from there and say, "How quickly can we do it? How rapidly can you bring incidence down? How rapidly can you bring up testing, linkage, referral, retention, sustained treatment engagement and successful treatment outcomes?"

Because there's no reason not to try to do all these things as quickly as possible, and using some of the levers of health care reform to try to enable that to happen. It's just that our community suffers from a lack of ambition, because so many people are worried about their own agency, its own survival and the next grant. They're not thinking about the big picture, which is that we really want to put ourselves out of business. We want to be able to end the epidemic in our lifetime and say, "Well, that really sucked. But we want to bequeath to our nephews, nieces, kids and grandkids a world where they don't have to grow up worrying about this disease that's life-changing, life-threatening, that requires never-ending treatment and always requires vigilance to prevent more transmission."

This transcript has been lightly edited for clarity.

Copyright © 2014 Remedy Health Media, LLC. All rights reserved.
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