As the AIDS epidemic turned 20 in 2001, Helene Gayle, M.D., M.P.H., then the head of the Centers for Disease Control HIV/AIDS division, made a bold promise: To reduce the number of Americans newly infected with HIV -- then believed to be 40,000 a year -- by half in the next five years.
That didn't happen. Dr. Gayle moved to the Gates Foundation, graduating to the global stage, and a comprehensive national strategic plan to combat HIV/AIDS never materialized. With no clear plan, HIV continued its quick-fire spread, particularly among Blacks, in big cities and in the South. Every year 56,000 Americans are newly infected with HIV, nearly half of them African American.
But when the federal government finally unveiled the first ever National HIV/AIDS Strategy, Dr. Gayle wasn't sweating that it came about five years later than promised. At the XVIII International AIDS Conference in Vienna over the weekend, she had one word for the long-awaited document. "Hallelujah."
Dr. Gayle, now the head of the Presidential Advisory Council on HIV/AIDS, as well as several of the Obama administration's top AIDS advisors, spoke to a group of African-American journalists on Saturday to discuss the HIV epidemic in the United States and deconstruct the new strategy. Those in the room largely believe that the Bush's administration's emphasis on the global AIDS epidemic -- and neglect of the problem at home -- helped drive up the numbers of new infections. His President's Emergency Plan for AIDS Relief, known as PEPFAR, has spent billions of dollars to provide anti-retroviral medicines and medical care to millions of people infected with H.I.V. in poor countries across the world, but he neglected to adequately support efforts to end the domestic epidemic. Obama has redirected the focus back home.
"Part of my career in HIV has been with feet in both worlds, international and national," said Dr. Gayle, who currently also runs the international anti-poverty organization, CARE. "I pushed for PEPFAR. But as we've focused so much on global epidemic -- and we should since that's where most infections are. But focus on the epidemic here has been minimized. So after a lot of work over the last three decades, it's good to finally have the strategy."
Or as Congresswoman Barbara Lee put it, "what a difference a president makes."
The 45-page plan, endorsed by the President when it was released last week, has been boiled down to three straightforward goals:
Reduce the number of people who become infected with HIV.
Increase access to care and optimize health outcomes for people living with HIV.
Reduce HIV-related health disparities.
As outlined, the new strategy aims to reduce new infections by 25 percent over the next five years and also promises to focus more attention and resources on populations at the highest risk for HIV infections -- gay and bisexual men, black men and women, Latinos and substance abusers. Black men and women represent only 13 percent of the population, but account for 46 percent of people living with HIV. Among blacks, gay and bisexual men are at the greatest risk for HIV infection followed by women. Sixty-four percent of all women living with HIV/AIDS are black.
In interviews with African-Americans involved in HIV/AIDS work scattered throughout the conference center here in Vienna most applaud the new strategy, with reservations. Serious reservations. They are concerned less about the plan itself than about its implementation. The president has instructed various government agencies to work together and provide a blueprint for putting the strategy in action. The due date for a detailed report is December 10 -- 150 days.
"We applaud the release of the strategy, but have concerns about the implementation plan," says C. Virginia Fields, president and CEO of the National Black Leadership Commission on AIDS.
"The African American implementation steps are extremely weak. The data puts the community in a health crisis with respect to HIV. It talks about compiling and assessing the strength and weaknesses of some of the existing programs and trying to decide what are the best programs that work. No! We are too far into this epidemic, 30 years almost now, with too many African Americans impacted for that."
Dazon Dixon Diallo, founder and president of the group SisterLove, says she is particularly concerned about the southern states. "I am in Atlanta, Georgia, which puts me in the Deep South, and most days we think of ourselves more closely aligned with those in the global south when it comes to HIV," she said.
"While I'm very thankful to have the strategy, it worries me that we are releasing it almost at the same week as states like mine are continually adding people to ADAP waiting lists. These are newly diagnosed people who may have very severe needs."
ADAP, the AIDS Drug Assistance Program, is a government program that provides medication for those who can't afford it. As of July 16, nearly 2,000 people were on waiting lists for treatment. The vast majority of those live in southern states, where HIV stigma, lack of health care and poverty are most severe.
Money was on the mind of most everyone asked about the new strategy. Neither the plan itself nor the accompanying federal implementation document specify how any of the ambitious goals will be paid for.
"The big elephant in the room is 'show me the money,'" said Phill Wilson, CEO of the Black AIDS Institute. "The question is what do you do in an environment where we have economic stress." The United States currently spends $19 billion a year on domestic HIV prevention, treatment and care and isn't expected, at this point, to up the ante.
The new plan emphasizes redirecting old funds, rather than getting new money. "We have to work smarter when it comes to the resources," said Dr. Kevin Fenton, director of the CDC's National Center for HIV/AIDS. "In these tough economic times, we have to think outside the box."
After the Sunday panel on the U.S. strategy, hundreds of protestors marched through the streets and into the convention center shouting "Obama lies, million die," angry that the president isn't planning to increase international HIV/AIDS relief. The activists staged a die-in and delayed the kick off of the conference. Representing the 33 million infected with HIV throughout the world, most attendees in Vienna aren't thinking about the epidemic in the U.S. -- or its money problems.
Barbara Lee insisted that there was plenty of money to go around for HIV. "You can't tell me that there are no funds for this when we've funded two wars to the tune of a trillion dollars and provided tax cuts to the rich," Lee said. "I'm not going to accept that there's no money to fund this. We can find money."
Linda Villarosa directs the journalism program at City College in New York. She has covered the International AIDS Conference five times.