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COMMENTARY |
Jennifer Kates is with the Henry J. Kaiser Family Foundation, Washington, DC. At the time of writing, Richard Sorian was with the Institute for Health Care Research and Policy, Georgetown University, Washington, DC. Jeffrey S. Crowley is with the Institute for Health Care Research and Policy, Georgetown University, Washington, DC. Todd A. Summers is with Progressive Health Partners, Washington, DC.
Correspondence: Requests for reprints should be sent to Jennifer Kates, MPA, MA, Kaiser Family Foundation, 1450 G St, NW, Suite 250, Washington, DC 20005 (e-mail: jkates{at}kff.org).
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ABSTRACT |
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 TOP ABSTRACT INTRODUCTIONTHE US EPIDEMICTHE GLOBAL EPIDEMICCONCLUSIONReferences |
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Numerous policy challenges continue to face the United States in the third decade of the HIV/AIDS pandemic, in both the health and foreign policy arenas. They include long-standing questions about care, treatment, prevention, and research, as well as new ones introduced by the changing nature of the epidemic itself and the need to balance demands for limited resources.
These challenges concern the United States not only in its role as a world leader in combating a global epidemic, but in its decisions and focus at home, where the epidemic continues to take a toll.
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INTRODUCTION |
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TOPABSTRACTINTRODUCTIONTHE US EPIDEMICTHE GLOBAL EPIDEMICCONCLUSIONReferences |
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The policy challenges facing the United States in the third decade of the pandemic are both long-standing—such as questions about care, treatment, prevention, and research—and new—including the challenges introduced by the changing nature of the epidemic itself and the need to balance demands for limited resources. The United States must meet these challenges both at home, where the epidemic continues to take a toll, and on the global front, where US leadership is needed to help combat the epidemic.
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THE US EPIDEMIC |
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Reducing New Infections
Efforts to raise awareness about HIV/AIDS and change risky behaviors have helped to slow the number of new HIV infections in the United States from more than 150 000 per year in the mid-1980s to 40 000 today. Yet the United States has continued to experience about 40 000 new infections each year since the early 1990s.5 The recent stabilization in the number of AIDS cases and deaths is also cause for concern.
A key aspect of HIV prevention is the frequent collision between politics and public health science. Prevention interventions have historically been mired in controversy, owing in part to the fact that HIV transmission involves sex and drugs, subjects with which many—policymakers included—are uncomfortable. This discomfort, and the absence of a national consensus, has affected the use of proven strategies for reducing the number of new infections, including targeting at-risk populations and those who are HIV-positive with tailored, culturally specific interventions6; reducing stigma, given that stigma may contribute to risky behavior and affect individuals' willingness to get tested or seek care5,7–10; integrating prevention into the clinical care setting11; and implementing syringe exchange as part of comprehensive prevention programs for injection drug users.12 There is also a need for continued research to develop new behavioral and clinical prevention strategies, including topical microbicides and vaccines.
Increasing the Number of People Who Know Their Status
About 400 000 to 500 000 people with HIV/AIDS in the United States remain undiagnosed, untreated, or both, and are therefore not receiving the treatments that could forestall disease progression or the prevention supports needed to avoid passing the virus to others.2 Many continue to face economic barriers to care, lacking insurance coverage to help them afford the high cost of HIV care, which can average as much as $20 000 a year. Increasingly, HIV affects those who are poor, are outside the workforce, and have a history of barriers to access. Even among individuals who have some resources, the high cost of HIV care can quickly exhaust their assets and leave them impoverished.13
As a result, people with HIV/AIDS increasingly rely on the public sector for care, primarily Medicaid, Medicare, and the Ryan White CARE Act.14 One major barrier to Medicaid coverage is a catch-22 in eligibility—most low-income people with HIV must wait until they become disabled by AIDS to be eligible for coverage of treatments that can prevent disability.
Strategies for addressing these issues include increasing the number of people who know their HIV status by providing more information to the public and at-risk populations about voluntary HIV counseling and testing; using new testing technologies, such as rapid testing, to better target those most at risk; furthering efforts to reduce stigma and discrimination; and increasing access to care and coverage for people with HIV/AIDS through expansions of public and private coverage. For example, Congress is considering the Early Treatment for HIV Act, which would address Medicaid's catch-22 by creating a new state option to expand Medicaid coverage to lowincome people with HIV who are not yet disabled.15,16
Addressing the Impact of HIV in Minority Communities
HIV/AIDS disproportionately affects racial and ethnic minorities, as it has since the beginning of the epidemic. HIV is the leading cause of death for African Americans between the ages of 25 and 44 years and the third leading cause of death for Latinos in this age group.17 People of color now represent the majority of new HIV infections (74%) and people living with AIDS (62%).1
The increasing concentration of the epidemic among minority Americans is due to many complex factors, including social inequalities related to income and race and stigma associated with being gay or bisexual, which exists within minority communities as well as in the larger society. These contextual forces may operate at the individual level to increase high-risk behaviors or at the societal level by compromising community infrastructure for responding to the epidemic. There is a critical need to better understand where and why these disparities occur, what factors affect receptivity to prevention messages and health care access, and whether public programs, particularly Medicaid and the Ryan White CARE Act, are adequately serving people of color. Understanding the views of minority leaders and communities toward HIV/AIDS is essential to an informed response.18–20 The Minority HIV/AIDS Initiative, adopted by Congress in 1999 after much community pressure, has been one attempt to enhance community capacity to respond to HIV/AIDS.21
Addressing Rising Drug Costs
Spending on prescription drugs is one of the fastest growing components of US health care spending,22 and spending on HIV-related therapies is no exception. Because access to medications is critical for people with HIV/AIDS and these drugs are expensive, concerns have been raised about rising expenditures and the price of prescription drugs. Policymakers are faced with several questions: Are there mechanisms for purchasing drugs at lower prices, such as purchasing in bulk or through rebate programs? Should government be involved in limiting or controlling drug prices? Should the public and private sectors' respective investments in drug research be considered in determining drug pricing? Are there ways to use existing resources more efficiently, such as purchasing or continuing private insurance coverage for people with HIV?
Stimulating Research and Development
Despite significant public investment and progress in HIV research, there is still no cure for HIV and no vaccine against the virus, and available treatments, while effective for many, do not help everyone and often have severe side effects. There is a great deal to learn about how to use existing pharmaceuticals safely and appropriately; about long-term toxicities of the multiple medications that are being prescribed for people living with HIV; and about the development of drug resistance. Priority research areas include vaccine development, prevention, microbicides, and therapeutic research.
Policymakers are faced with a complex array of decisions and choices concerning research and development: What is the role of the federal government in conducting therapeutics research vis-à-vis private pharmaceutical and biotechnology companies? What is the best way to allocate public research dollars for basic science research vs clinical research? Are public dollars—or public policies—leading to research that can answer some of the questions about long-term toxicities, resistance, and so forth? Since barriers prevent private firms from aggressively conducting vaccine research, should federal policymakers fund this research directly or provide incentives for private research (e.g., through tax credits)?
Maintaining Attention to the US Epidemic
After 2 decades of fighting the HIV/AIDS epidemic in the United States, it is not surprising that there may be some signs of "AIDS fatigue." For example, although Americans still rate AIDS as a top health concern for the nation, the proportion who see it as the number one health problem has declined over the past few years.8 In addition, a recent report on the role of private philanthropy in responding to the epidemic found that while philanthropic support of global AIDS efforts is on the rise, support for domestic efforts has not grown.23 Yet as the US epidemic continues to exact an increasing toll on racial and ethnic minority communities, maintaining attention to the epidemic at home remains critical, even as the global response gains attention.
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THE GLOBAL EPIDEMIC |
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Identifying Appropriate Forms of US Assistance
The United States allocates funding and other resources used to address the global epidemic in several ways, including direct financial assistance to other countries, support for multilateral organizations such as the Joint United Nations Program on HIV/AIDS (UNAIDS), and broader forms of development assistance. This assistance goes toward a variety of activities, including direct prevention, care, treatment, and support services and, increasingly, impact mitigation efforts that address the larger societal consequences of the pandemic.
To date, the bulk of US foreign assistance in the fight against the global pandemic has been in the form of bilateral assistance to other nations. While the level of spending and other resources made available is clearly a fundamental component of the US response, it is also important to assess the mechanisms by which resources are allocated and their effect on recipient countries and programs. These mechanisms include US agency activity; direct assistance through government-to-government agreements and bilateral aid; contributions to multilateral programs; loans to developing countries; debt relief; and direct assistance to nongovernmental organizations. For example, since foreign debt is one of the major barriers facing developing nations' ability to respond to the epidemic, grants and debt relief may represent more viable options than loans.27
Shaping the Global Fund to Fight AIDS, TB, and Malaria
Total resources for addressing the HIV/AIDS epidemic in the developing world are estimated to be at least $7 to $10 billion annually.28 In April 2001, UN Secretary-General Kofi Annan issued a call to action to create a Global Fund to fight HIV/AIDS as a mechanism for mobilizing and coordinating additional resources toward this goal. The scope of the fund was expanded to include tuberculosis and malaria and plans for the fund began later that year.29 The first round of grants were announced in April 2002. The United States has pledged $300 million to date and has earmarked an additional $200 million for fiscal year 2003, which is awaiting congressional approval.30
The US government has played a critical role in shaping decisions concerning the fund, working with other governments, research and community organizations, foundations, and other private sector players. Continued leadership from the United States is needed to address ongoing challenges including mobilizing larger and sustained contributions (and articulating the appropriate role of US commitments in this regard); expediting disbursements without sacrificing oversight and accountability; establishing executive leadership and appropriate staffing; and clarifying the role of the Global Fund in the context of other global AIDS efforts (the fund is intended to represent new resource commitments, rather than funding redirected from other health and international development efforts).29,31
Balancing Priorities
Research, care and prevention are integral components of an effective global or national HIV/AIDS strategy, and understanding the often complex relationships between them is critical. To date, the majority of US government spending on HIV/AIDS in developing countries has been for prevention, with few resources allocated to care.32 As the United States seeks to promote an integrated approach to the global pandemic, it will need to look at ways to foster public–private partnerships that support prevention and care, including the provision of antiretroviral therapies (to prevent mother-to-child transmission and to treat those who are living with HIV) and research in developing countries.
The issue of health care infrastructure is fundamental to these considerations. Definitions of infrastructure include such elements as the availability of health centers, facilities such as laboratories, and trained personnel; roads, equipment, supply systems, and water; security; and stability of government. There has been some reluctance on the part of the United States, other nations, and the private sector to provide increased or new support for certain interventions in developing countries because of concerns about existing infrastructure. There is a need to improve the understanding of the definition and role of infrastructure in delivery of prevention and treatment interventions in resource-poor settings and to identify ways to support infrastructure enhancements. It will be important to gain experience in implementing infrastructure development initiatives, assessing the level of infrastructure needed for different types of interventions and insuring the capacity of indigenous institutions.
Promoting Access to Treatment
The last couple of years have witnessed important progress in removing barriers to access to treatment for people living with HIV in developing countries. Nonetheless, the cost of antiretroviral and other medications far exceeds what is affordable for most individuals in these countries, raising concerns about the need to balance intellectual property rights protections with greater access to medications and propelling the discussion into the realm of US and global trade policy. Within this context, several strategies are being explored to enhance access to treatment, including the purchasing of generic drugs, bulk purchasing, parallel importation, compulsory licensure, and tiered pricing. In addition, UNAIDS and individual nations have worked with several pharmaceutical manufacturers to forge price reduction arrangements for antiretroviral and other HIV-related medications.33
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CONCLUSION |
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There are no easy choices. Yet, as UNAIDS' Peter Piot recently noted, "the AIDS epidemic is different from any other epidemic the world has faced, and as such, requires a response from the global community that is broader and deeper than has ever before been mobilized against a disease."35 The United States continues to be in a position to provide critical leadership to such a response.
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Acknowledgments |
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Footnotes |
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Accepted for publication March 18, 2002.
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References |
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2. Fleming PL, Byers RH, Sweeney PA, Daniels D, Karon JM, Janssen RS. HIV prevalence in the United States, 2000. In: Proceedings of the 9th Conference on Retroviruses and Opportunistic Infections; February 24-28, 2002; Seattle, Wash. Abstract 11, Oral Abstract Session 5.
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5. HIV Prevention Strategic Plan Through 2005. Atlanta, Ga: Centers for Disease Control and Prevention; 2001.
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7. Centers for Disease Control and Prevention. HIV incidence among young men who have sex with men—seven U.S. cities, 1994–2000. MMWR Morb Mortal Wkly Rep. 2001;50(21).
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9.
Valdiserri RO. HIV/AIDS stigma: an impediment to public health. Am J Public Health. 2002;92:341–342.
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11. Institute of Medicine. No Time to Lose: Getting More From HIV Prevention. Washington DC: National Academy Press; 2000.
12. Evidence-Based Findings on the Efficacy of Syringe Exchange Programs: An Analysis for the Assistant Secretary for Health and Surgeon General of the Scientific Research Completed Since April 1998. Washington, DC: US Dept of Health and Human Services; 2000.
13. Financing HIV/AIDS Care: A Quilt With Many Holes. Menlo Park, Calif: Kaiser Family Foundation; 2000.
14. Federal HIV/AIDS Spending: A Budget Chartbook, FY 2000. Menlo Park, Calif: Kaiser Family Foundation; 2000.
15. Early Treatment for HIV Act of 2001, 107th Cong, 1st sess, HR 2063 IH and S 987 IS (introduced June 5, 2001).
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Kahn JG, Haile B, Kates J, Chang S. Health and federal budgetary effects of increasing access to antiretroviral medications for HIV by expanding Medicaid. Am J Public Health. 2001;91:1464–1473.
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18. Friday JC, Lee DH, Lillie-Blanton M, Weinstock B, Kates J. A survey of black elected officials on HIV/AIDS in the African American community. Minority Health Today. April 2002(suppl).
19. African Americans' Views of the HIV/AIDS Epidemic at 20 Years: Findings From a National Survey. Menlo Park, Calif: Kaiser Family Foundation; 2001.
20. Latinos' Views of the HIV/AIDS Epidemic at 20 Years: Findings From a National Survey. Menlo Park, Calif: Kaiser Family Foundation; 2001.
21. About the initiative. Available at: http://www.omhrc.gov/omh/aids/about/abt_toc.htm. Accessed March 6, 2002.
22. Prescription Drug Trends: A Chartbook Update. Menlo Park, Calif: Kaiser Family Foundation; 2001.
23. Funders Concerned About AIDS. Voices from the field: remobilizing HIV/AIDS philanthropy for the 21st century. 2001. Available at: http://www.fcaaids.org/spotlight/010622.html. Accessed May 6, 2002.
24. AIDS Epidemic Update. Geneva, Switzerland: UNAIDS; 2000.
25. AIDS Epidemic Update. Geneva, Switzerland: UNAIDS; 2001.
26. Children on the Brink. Washington, DC: US Agency for International Development; 2000.
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28. Fact Sheet: HIV/AIDS Financing Gap. Geneva, Switzerland: UNAIDS; February 2002.
29. The Global Fund to Fight AIDS, Tuberculosis, and Malaria. Available at: http://www.globalfundatm.org/. Accessed March 6, 2002.
30. HHS budget for HIV/AIDS increases 8 percent [press release]. Washington, DC: US Dept of Health and Human Services; February 4, 2002.
31. The Global Fund to Fight AIDS, TB, and Malaria: Successes and Challenges. Washington, DC: Center for Strategic and International Studies; 2002.
32. USAID combatting HIV/AIDS: a record of accomplishment [press release]. June 22, 2001. Available at: http://www.usaid.gov/press/releases/2001/fs010420.html. Accessed March 6, 2002.
33. UN efforts broaden availability of antiretrovirals: accelerating access initiative moving forward; 72 countries worldwide express interest [press release]. Geneva, Switzerland: UNAIDS/WHO; December 11, 2001.
34. Global Spending on HIV/AIDS: Tracking Public and Private Investments in AIDS Prevention, Care, and Research. Menlo Park, Calif: Kaiser Family Foundation; 2001.
35. Hearings Before the Committee on Foreign Relations of the United States Senate, 107th Cong, 2nd sess (February 13, 2002) (testimony of Peter Piot, "Halting the Global Spread of HIV/AIDS: the Future of US Bilateral and Multilateral Responses").
This article has been cited by other articles:
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| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
