July 7, 2014
Longtime activist Mark Harrington, the executive director of Treatment Action Group (TAG), explains to TheBodyPRO.com why the U.S. National HIV/AIDS Strategy has been a letdown, what the current state of HIV policy looks like and what's actually needed to make a dent in the epidemic.
When you think about 2014, is there anything, in terms of HIV care or treatment, that you're looking forward to, interested in or excited about?
Well, I think we need to really beat the shit out of the White House on their shitty targets for their National AIDS Strategy. Let me just give you an example. AIDS strategy is supposed to address the health disparities that characterize the U.S. It's one of the three big areas. One of the areas was, increased proportion of high-risk groups that are having virological treatment success is like 25% -- for MSM (men who have sex with men), blacks and Latinos. MSM have much higher rates of HIV suppression than blacks and Latinos at baseline. More of them are in care, or they get into care earlier, etc.
The White House targets actually start with this shitty baseline for blacks and Latinos, and they only put in 25% more by 2015. So their targets for all three of those groups don't converge; they actually keep the same disparities in 2015 that they had at baseline, only with a higher rate of viral suppression so that gay men go from 40 to 48%, and blacks from 32 to 40%, and Latinos from 36 to 44%. How can you say you're addressing disparities if the disparities are still as big in percentage terms at the end of your strategy as they were at the start? If you are going to address disparities, you have to put more resources into where services are worse, which means you have to put more into getting, for example, blacks to have a suppressed viral load, or MSM to have less new infections.
Their plan does the opposite. It takes things as they are and just adds these random percentages. And we know from the treatment cascade that we should be at, like, 90 to 100% virally suppressed to really stop the epidemic. So, getting gay men to 48% suppressed, that still means 52% of them won't be, which means that they're not even trying to do a moderate approach to the epidemic.
What's going on with our AIDS czars -- which, it is worth noting, is a political position? Why can't we keep anybody in that position?
I think it's fairly thankless. It doesn't have a lot of power. And everyone is always bitching to you about things. It's not a very appealing thought. Obama never put another dollar into AIDS care, or AIDS prevention.
What's going to end up happening?
[We'll need to] meet the goals of the National AIDS Strategy without new money. And the new money that will exist is now going to be new money that comes from ACA [Affordable Care Act] rollout and Medicaid extensions. But that's only going to happen in states that are doing ACA rollout and Medicaid extensions. So the health disparities will get even worse, because cities and states that are doing well will do better, and the poor in the South and many in the Midwest will do worse because they don't have any ongoing care.
Let me tell you another factoid about the White House report. This report is from 13 jurisdictions -- 11 states, and two parts of states -- so that means 37 states didn't report into that data.
So when you read the fine print it's like, well, it includes California -- only San Francisco -- New York, but not New York City. Well, in New York, 80% of the cases are in New York City. But they didn't have the data for 2009 because New York City wasn't preparing it yet. By 2011, they'd gotten it up to 17 jurisdictions reporting CD4 and viral load [data]. And California has added Los Angeles. Now California has San Francisco and Los Angeles, but not the rest of the state. And New York has added New York City, and Kentucky has joined.
It's like we're really only getting a picture from about a quarter of the epidemic, as far as viral load and CD4. And then the White House is acting like that's representative nationally, when we know that most likely a lot of the places that have really big epidemics aren't even reporting any yet. So the health disparities are likely to be even worse than what we think they are.
The White House said incidence is going down, but the CDC [Centers for Disease Control and Prevention] report said incidence in gay men and Latinos is going up. The CDC, at least they'll report on data and gaps in data. So, in order to find out whether what the White House said is true or not, you'd have to read the White House report, two CDC-backed reports, and then a whole host of other CDC surveillance reports that are mentioned in the notes. Then, if you want to know the numbers about housing, or Ryan White retention care, there's often not a data source for what they're saying. They're claiming that more people are in housing, but we don't know where that claim comes from because there's no reference.
What is your opinion of Obama in terms of any kind of leadership on AIDS?
Well, his AIDS plan was premised upon a false premise, which is that we could get much better results without spending any more money. So it's based on a fundamental flaw, which is that you're going to make modest improvements in the epidemic without investing more in it. The whole CDC prevention approach is based on getting more people tested and into care earlier. It's the whole treatment-as-prevention approach.
We must have seemed pretty radical and avant-garde a few years ago when we were pushing really hard for government agencies to adopt it as a meaningful target, but it leaves out an entire area of people that sort of were HIV negative to begin with and are still HIV negative. Forty percent of new infections come from people in the first year of infection who don't know their status. Then that 40% isn't going to be affected by treatment because they're not in care yet.
There's no national, state or local campaigns around prophylaxis, fourth-generation testing, early detection of HIV infection or acute seroconversion illness. There's no concerted prevention effort in the wings. The amount of spending that we're doing on prevention is the same as it was under the presidency of George H. W. Bush, in 2014 adjusted terms. And we're getting the same results that we got under George H. W. Bush, which is 50,000 infections a year, a number that seems to be more or less refractory to the vast expansion of treatment, and the fact that effective treatment is available now that wasn't available through the first six years of the '90s.
Something is clearly not happening with treatment-as-prevention. It is clearly not a panacea. And yet, it seems to be the anchor of the CDC's prevention [plan], and they're not really doing anything for primary care physicians, to help the people who are HIV negative now to stay negative.
The head of the CDC used to be the health commissioner of New York City.
Yeah, under the Bloomberg administration, which was hostile to the AIDS community. Tom Frieden was a public health official who really never did anything to try to work with the community when he was here. It was a very top-down, vertical approach to public health.
So now he's in charge of the CDC.
Yeah. It's not wrong for the CDC to promote treatment-as-prevention as part of a coherent national response; it's just not going to be complete. And it's not going to be comprehensive.
We [at TAG] are trying to get them to create a combination prevention cascade that would be a suite of interventions that would be tailored for each key population with a particularly high risk of getting infected and would probably introduce part of the central prevention benefits through ACA that would have to be required to be given by all health care providers.
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