U.S. Presidential Candidates' Health Care Plans -A Call for Leadership
By Susan Blumenthal, M.D. and Melissa Shive*
It's fitting that the official theme of World AIDS Day this year is "leadership," given that the 2008 Presidential primaries begin next month. This convergence of the elections with today's spotlight on global HIV/AIDS brings into focus the importance of U.S. Presidential leadership in combating the AIDS pandemic in America and around the world. Two weeks ago, UNAIDS released its 2007 AIDS Epidemic Report, providing the most recent statistics on the spread and impact of the pandemic. While there was a downward revision in the prevalence and number of deaths from previous estimates, AIDS remains a leading cause of death worldwide, particularly in the developing world, where in Swaziland, Botswana, and Lesotho, 25% of people are HIV positive and the average life expectancy in some of these countries is less than 38 years of age. There has also been a resurgence of the disease in the United States, the United Kingdom, and parts of Western Europe. In light of this news and with health care ranking as the most important domestic issue to American voters in the 2008 Presidential elections, it's of concern that so few of the Presidential candidates have described their plans for leadership in the fight against HIV/AIDS.
The Pandemic
The HIV/AIDS pandemic has inflicted the single greatest reversal in human development. -- 2005 United Nations Development Report
In its 26 year history, HIV/AIDS has caused immense human suffering, economic damage and loss of lives both in the United States and around the world. The disease has widened health care disparities, decreased quality of life, and robbed millions of people of their lives worldwide. During the hour it takes to watch our favorite television program, a staggering 285 people in the world contract HIV. Globally, 25 million people have died from this disease since the beginning of the epidemic. According to a recent report from UNAIDS, there are currently 33.2 million people infected with HIV--resulting in a significant decline in life expectancy in those countries most affected by the illness, particularly in southern Africa. New frontiers of the epidemic include Asia and Russia where the virus is spreading unchecked.
In recent years, attention has been focused on global AIDS, but the disease remains a significant public threat in the United States, where it has become a forgotten epidemic. Consider this: every 13 minutes, an American is newly infected with HIV, and 10% of them are children and adolescents under 24 years old. More than 500,000 Americans have died from the illness in the past quarter century; moreover, in the 30 minutes it takes many people to commute to work, AIDS steals the life of another American.
In addition, the epidemic's disproportionate impact on racial and ethnic minorities and women is increasing. Analyses of national household survey data in the United States revealed that over 2% of African Americans are HIV positive--more than any other group. Survival rates after an AIDS diagnosis are also lower for African Americans than for any other racial or ethnic group. Among Latinos, there are 27.8 HIV/AIDS cases per 100,000 people--more than triple the rate of Caucasians. Women as a proportion of cases in the United States have increased significantly since the beginning of the epidemic, tripling from 8% in 1985 to 27% in 2005, and globally, half the people living with HIV are female. Geographically in the U.S., although the numbers of cases are increasing in rural communities, this disease continues to be concentrated primarily in large, metropolitan areas, so that the ten largest metropolitan areas account for about half of cumulative reported AIDS cases.
Myths and stigma about HIV/AIDS also continue to persist. Since 1990, there has been no change in the percentage of people in the United States who mistakenly believe that HIV can be transmitted by kissing (37%), sharing a drinking glass (22%), or touching a toilet seat (16%). Additionally, according to a new global study from the MAC AIDS Fund, nearly half of respondents said that they would not be comfortable working alongside someone who was HIV positive; 59% of people living in India wrongly believe there is a cure available for HIV, and nearly 3 in 5 older adults in France do not realize that AIDS is fatal. These figures underscore the need for more effective education campaigns to increase knowledge as well as shatter the stigma that still surrounds this disease.
Advances in Treatment: Successes and Challenges
Over the past decade, there has been good news as a result of our national and international investment in AIDS research, thanks to the important advocacy and research contributions of organizations including amfAR, The Foundation for AIDS Research, the National Institutes of Health (NIH), the Centers for Disease Control and Prevention (CDC), and the Gates Foundation. The establishment of the President's Emergency Plan for AIDS Relief (PEPFAR), the Global Fund to Fight AIDS, Malaria and TB, combined with the work of the World Health Organization (WHO) and other organizations have brought advances in treatment of the disease to the developing world, substantially reducing AIDS-related morbidity and mortality and extending the lives of many people.
One of the first breakthroughs occurred in 1986, when amfAR, The Foundation for AIDS Research, awarded a grant to study proteases, which contributed to the development of a potent new class of anti-HIV drugs, protease inhibitors.12 The FDA approval of the first in this class of drugs--saquinavir--in December 1995 has since led to the discovery of highly active antiretroviral therapy (HAART) for AIDS. There are currently 30 FDA-approved antiretroviral (ARV) medications available for treating HIV/AIDS, allowing people who receive these drugs to live on average 13-14 years longer than those people who do not receive these medications. Additionally, as a result of medical advances, maternal-infant transmission has declined to 2% today in the United States. In total, research advances in HIV/AIDS treatment have resulted in at least 3.0 million years of life saved in America.
New treatments, however, are not cures and do not benefit all people with HIV. An estimated 42% to 59% of Americans living with HIV/AIDS are not receiving regular HIV care, and a recent study found that only 55% of people with HIV/AIDS in America who should be given antiretroviral (ARV) therapy were actually receiving it. The circumstances are worse in low- and middle-income countries, where fewer than 1 in 5 people who need ARVs are receiving them. Furthermore, for every individual who receives treatment, at least 6 more people will become infected with the HIV virus worldwide.
The September 2007 failure of the much-anticipated, multi-million dollar HIV vaccine clinical trial has refocused attention on the power of using cost-effective and relatively simple preventive measures to slow disease transmission. Evidence-based strategies such as education, male circumcision, increased availability of condoms, harm reduction, and birth control for HIV-infected women are relatively inexpensive measures that are immediately available and have a proven value. Even though these techniques are not perfect and do not possess the glamour of a technological breakthrough or "magic bullet," prevention remains a critical tool and strategy whose worth and power should be reiterated and where greater investments in research and education can yield life-saving dividends.
The Next U.S. President's Leadership in the Fight Against HIV/AIDS
The dramatic decline in mortality from AIDS in the United States coupled with the recent report from UNAIDS of lower numbers of infected people globally can lead policymakers, the public and the media to believe that AIDS is no longer a major public health hazard in the United States and that it is being conquered in the developing world. That belief is incorrect and perilous to the health of people in America and worldwide. Furthermore, there is an alarming trend toward decreased funding for HIV/AIDS research. Since 2003, the NIH budget has remained largely flat, falling behind medical inflation, and in 2006, it received its first budget cut in 35 years. These reductions in funding can only weaken the battle against this deadly virus; investment in cutting-edge research is essential to the fight against the HIV/AIDS pandemic to improve prevention, detection, and treatment of the disease.
For all of the reasons described above, the 2008 U.S. Presidential candidates must make the fight against HIV/AIDS a critical component of their health care proposals. Yet, of the seventeen declared Presidential candidates, only a few have detailed their plans to combat HIV/AIDS in the United States and worldwide. When nearly 25% of Americans infected with HIV are unaware that they are infected, when nearly two-thirds (63%) think domestic spending on HIV/AIDS is inadequate, and when nearly one-third believe that the U.S. is losing ground in the battle against HIV/AIDS, it is critical that the Presidential candidates share with the American public their proposals to fight this pandemic that threatens the health, economy and national security of our country and world.
More than ever, a comprehensive approach with proactive policies and strategies is needed. This begins with strengthening the efforts of the National AIDS Policy Office, appointing a Director and increasing its outreach efforts. A comprehensive approach means expanding national and global initiatives in the fight against AIDS and connecting the dots of development, including reducing poverty, providing education, and rectifying inequalities. It means fostering public/private sector partnerships and mobilizing citizens, businesses, philanthropists, scientists, health care providers, communities, and other governments to work together. It also means bringing innovation to the battle against this disease, including supporting and implementing evidence-based prevention, investing in new prevention technologies, education, and a vaccine that may help eradicate this illness in the future, developing improved treatments with fewer side effects, providing a range of services (such as housing), and addressing issues related to HIV testing as well as the needs of vulnerable populations (including women, minorities, youth, men who have sex with men, and incarcerated persons). The next President must importantly make it a priority to ensure access to quality health care for people with HIV/AIDS and for all Americans.
Throughout history, infectious diseases like AIDS have been major killers of people worldwide and therefore, decisive shapers of history. That is why it is essential for the 2008 Presidential candidates to detail their plans for eradicating this disease in the United States and globally now.
For more information about HIV/AIDS, visit amfAR, The Foundation for AIDS Research at amfAR.org.
*Susan J. Blumenthal, M.D., M.P.A. is the Senior Policy and Medical Advisor at amfAR (The Foundation for AIDS Research) in Washington D.C. She is also a Clinical Professor at Georgetown and Tufts University Schools of Medicine. Previously, Dr. Blumenthal served as Assistant Surgeon General of the United States and Deputy Assistant Secretary for Health in the U.S. Department of Health and Human Services.
Melissa Shive, a Fulbright Scholar and a recent Honors graduate of the University of Pennsylvania, serves as a Health Policy Fellow at the Center for the Study of the Presidency.
Kahn, Michael. "U.N. warns AIDS Could Spike if Countries Drop Guard." 20 Nov. 2007. Washington Post. 22 Nov. 2007. <http://www.washingtonpost.com/wp-dyn/content/article/2007/11/20/AR2007112000724.html?sub=AR>.; "UNAIDS/WHO AIDS Epidemic Update: December 2007." 20 Nov. 2007. UNAIDS. 20 Nov. 2007. <http://data.unaids.org/pub/EPISlides/2007/2007_epiupdate_en.pdf>.
Conference on Retroviruses and Opportunistic Infections; February
2005.