Last week on The Colbert Report, during an interview with National Institute of Allergy and Infectious Diseases Director Dr. Anthony Fauci, Stephen Colbert remarked about the AIDS epidemic, "I thought we were done with that one." The audience laughed at the joke, but Colbert's fictional character was speaking to the reality that AIDS is today much less present in the public mind.
A sense of urgency has been replaced with complacency, even though AIDS remains a devastating, and worsening, epidemic in the hardest hit communities in our country. Two salient facts: the rate of 56,000 annual new HIV infections has not fallen during the past decade, and at least one-third of Americans living with HIV/AIDS are not receiving lifesaving care.
The good news is that the Obama Administration has recently taken decisive steps to refocus efforts to tackle our domestic AIDS problem. In July 2010, the President released a National HIV/AIDS Strategy that sets ambitious goals by aiming to reduce HIV infection rates, increase access to AIDS treatment, and reduce the profound racial and other disparities that have been the signature of America's AIDS epidemic from the beginning.
On paper, at least, the response to AIDS in America already looks better. Whether improved outcomes actually materialize now depends on how the Strategy is implemented by federal, state, and local governments, as well as community and private providers. In many ways, however, the National HIV/AIDS Strategy is a challenge to the status quo, and its success depends on people's willingness to do business differently: to collaborate better, redistribute existing resources, find new money, and, in some cases, change what their agencies do.
Plans released by the White House this past February call for a whole list of smart, Strategy-related reforms. First, there are several proposals from the Centers for Disease Control and Prevention (CDC) for using funds more effectively.
Millions of HIV prevention dollars would be redirected from small-scale approaches to interventions with broader community impact. Funding formulas would be revised to put more resources where the epidemic is most severe. And the work of planning bodies would be reviewed to ensure they are allocating resources appropriately.
Each of these proposals presents challenges. For example, greater emphasis on community-level impact means many providers will need to reinvent how they approach HIV prevention. Planning groups and public health departments will need to reassess resource allocations to ensure that programs for groups at elevated risk of infection, including gay men (particularly African-American gay men), African American and Latina women, youth, and others, receive financing that is proportionate to their share of the epidemic.
Second, the Strategy places new emphasis on epicenters: the 12 jurisdictions that account for 44 percent of all people living with HIV/AIDS in the U.S. This "12 cities" approach could be a leading edge of health systems reform because it promises to support local planners in identifying gaps and then mapping out a more coordinated and effective response. But it's yet to be seen whether "12 cities" lives up to its potential or devolves into another set of rigid bureaucratic requirements.
To be successful, "12 cities" will need sustained funding, a new spirit of collaboration across multiple agencies, forceful federal leadership providing a clear vision of the initiative's core goals, and enough flexibility in funding and reporting to allow local and state planners to be creative.
Third, the Strategy lays the groundwork for a paradigm shift in HIV prevention. Research in the last several years has established that providing quality treatment to people living with HIV reduces the amount of virus in their system, making them less infectious. San Francisco and other cities are studying whether focusing on community viral load (the amount of HIV circulating in the community) can help track who is and is not benefiting from treatment, and eventually reduce new HIV infections through better treatment delivery. The early signs are promising, and the CDC has plans to help cities utilize this community-level prevention tool.
This new approach could be a game changer in the epidemic, but success depends on doing a much better job of reaching people who want and need HIV treatment, and finding the money to do that. It depends on more efficient health systems that can effectively link people to the care they need. And it means new roles for community-based providers, some of whom will be challenged to adjust their work to focus more on HIV testing, linkage to care, and support with treatment adherence. The new paradigm must not lead to divestment in critically important community-based services, but it will mean that, in some cases, those services will need to be transformed.
Finally, with a more strategic approach in place, there has never been a better case for dedicating new resources to the fight against AIDS. HIV prevention has been chronically underfunded since the beginning of America's epidemic, and thousands of Americans wait in line to benefit from the AIDS Drug Assistance Program (ADAP).
With states facing draconian cutbacks in public health, the federal financing role is more important than ever. Congress must pass the modest new domestic HIV investments proposed in the President's fiscal year 2012 budget request, and do better in areas like ADAP and housing. Congress also needs to enact a proposal by the White House to give Secretary of Health and Human Services Kathleen Sebelius authority to create a funding pool to promote the National HIV/AIDS Strategy goals. Without new resources, the promise of recent scientific breakthroughs, such as pills and microbicidal gels that prevent HIV infection, will remain unrealized.
It is possible one day that Stephen Colbert's comment about AIDS won't be a laugh line. We could be "done with this one" with a combination of smarter approaches, prudent new investments, and thoughtful application of new research findings. The President has called for a new direction in the domestic AIDS crisis. Now Congress, states, local communities and all of us must seize this opportunity and end the AIDS epidemic in America.