2011 marks the 30th year of AIDS. "The View from Here" is a special year-long series to mark the anniversary. Advocates, doctors, researchers, politicians, philanthropists, educators, public health professionals, journalists and celebrities are answering the same set of questions each month.
This month, we feature two of the nation's top strategists when it comes to devising and implementing new ways to stop the spread of HIV: Jeffrey Crowley, director of the Office of National AIDS Policy and Senior Advisor on Disability Policy at the White House, and Dr. Grant Colfax, director of the HIV Prevention and Research Section in the San Francisco Department of Public Health AIDS Office.
1. We’ve learned a lot in 30 years. What do we have yet to learn?
Crowley: How to manage change and maintain support for HIV programs as the epidemic evolves and as it becomes increasingly concentrated in certain communities. In times of economic distress, we need to make sure our responses match the best evidence about what works and are appropriately targeted to have the biggest impact. And, we must do this at a time when many people do not want to think about HIV. We’ve maintained a strong national response to HIV as the epidemic enters its fourth decade. We must still keep learning, however, how to do more, do it better, and keep broad sectors of the American public committed to fighting to end the HIV epidemic.
Colfax: What do we have yet to learn?: Much. How do we develop an effective vaccine? Will the day come when a cure is a realistic expectation for the millions already living with HIV? How do we most effectively scale-up interventions we know work, including testing and treatment, so that they have a population-level impact on reducing HIV incidence? How do we effectively mobilize the resources and social support for changing the underlying drivers of the HIV epidemic, including racism and homophobia?
2. What was your deciding moment, when HIV/AIDS became an important issue in your life?
Colfax: There was no one specific moment: as a gay man coming of age in the mid 1980’s, HIV/AIDS was the defining issue in the community. My decision to attend medical school and focus professionally on HIV research and prevention emerged not only from the experience of having lost so many friends to the disease, but also because it was clear that there was so much more we needed to know and do to effectively combat the epidemic.
Crowley: I had several. I was just realizing I was gay when I was 16 years old…in 1981. I was that nerdy kid that read the newspaper everyday and I remember seeing the scary news reports of gay men dying of some strange disease. A few years later I did a college internship at the National Institutes of Health (NIH) where I lived in the hospital as a volunteer for about three months. I remember seeing gay patients with Kaposi’s sarcoma lesions who looked very ill. And, I remember when I didn’t see them and one knew that meant they probably weren’t still alive. A few years later in the late 1980s, I was a Peace Corps Volunteer in Swaziland. It is a wonderful country in southern Africa where it was predicted that HIV prevalence would rise dramatically. It seemed fanciful at the time because we didn’t see any people that we knew were living with HIV. Today, Swaziland has the highest HIV prevalence rate in the world. All of these experiences had an impact, but like so many others, it is the personal reality that so many of the most important people in my life are living with HIV that sustains my commitment.
3. With ever-increasing public health issues to contend with, why should anyone prioritize HIV/AIDS?
Crowley: HIV remains a very serious condition that threatens the public health. As a nation, we must respond to a range of health threats and there are always competing priorities. Nonetheless, there are factors that make HIV unique and particularly challenging and that demand a strong public response. These include the high level of stigma and discrimination faced by people living with HIV and the communities at greatest risk for HIV. These same communities often have the biggest barriers in accessing effective prevention and health care services. Further, our investments in HIV research and lessons about how to provide prevention and care services also continue to translate into gains for HIV and numerous other conditions. The biggest reason to prioritize HIV is because our collective efforts can make a big difference. Through the National HIV/AIDS Strategy that President Obama released last year, we have a vision and a roadmap for making significant progress against HIV through strategic and concerted collective action.
Colfax: How can we afford not to prioritize HIV/AIDS? Globally, 33.3 million people are living with HIV, and there are 2.6 million new infections each year. Infection rates in the United States have remained stable over the past decade, at about 50,000 new infections annually. Yet we know how to prevent the disease, and treatment is more effective than ever. Effective HIV prevention and treatment greatly reduces the risk of other diseases such as TB. Decreasing HIV-related morbidity and mortality in turn results in healthier communities and allowing for increased focus on other public health issues, including cleaner water, housing, vaccination, or other STD treatment. In the United States, as HIV increasingly becomes a manageable, chronic but infectious disease, the question is how do we integrate HIV prevention in treatment in the broader context of healthcare reform, and ensure the HIV expertise is represented within what will hopefully be a more integrated healthcare system.
4. What keeps you up at night?
Colfax: How do we get the important things right? We now know testing and treatment are the cornerstones of any effective HIV/AIDS strategy -- but will society support the financial and social resources to scale up widespread testing and treatment efforts? Thirty years into the epidemic, one-fifth of persons living with HIV in the United States are undiagnosed. When people are diagnosed, it is very late in the course of the disease, after much damage is done. We have the tools to end the epidemic: the question is, does the United States prioritize health equity sufficiently to meaningfully address the epidemic in populations where HIV continues to spread: gay men, especially gay men of color; injection drug users, and transwomen?
Crowley: President Obama is deeply committed to responding to HIV here at home and around the world. During the time-limited period that I have the privilege of serving in this Administration, I want to make sure that I am helping to ensure that we are doing everything we can to implement the National HIV/AIDS Strategy—and that we will be able to look back on this time and see, through measurable outcomes, that the work we are all doing has made a difference.
5. Three decades into the epidemic, what gives you hope?
Crowley: The level of support I receive from so many people living with HIV and from others in the HIV community. When I travel across the country, I frequently meet people who tell me that they support the work that President Obama is doing on HIV and they support the work of my office, so I have to feel encouraged. I believe that many people recognize that we have a rare moment of opportunity. Recent research advances, the enactment of the Affordable Care Act, the implementation of the National HIV/AIDS Strategy, and other positive policy changes all combine to create a lot of positive energy within the HIV community.
Colfax: We’ve made faster progress in understanding, treating, and preventing HIV than any other disease in history. There are many victories, built on the foundation of community-based activism that catalyzed scientific and public health efforts. Breakthroughs include the emergence of combination therapy; the massive reduction in US perinatal transmission due to widespread testing and treatment of pregnant women; the recent breakthroughs in using retroviral therapy to prevent sexual transmission; the first cure as a result of a stem cell transplant. My hope is that we will live to see the day where HIV is rare, when it does occur is readily treated and cured, and that the lessons learned from this epidemic will be applied to addressing other epidemics and health disparities.
What do you think? What thoughts would you share with these two hugely influential fighters in the war against HIV? Join the conversation by commenting below...
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