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The recent bad news out of San Francisco and New York City that new HIV cases are rising among certain populations is an uncomfortable reminder to clinicians that the battle against HIV rages on. The good news is that the fiscal year 2001 federal budget increases were fairly hefty, topping 10% in some cases, and there was an injection of $350 million targeted specifically to prevention and treatment in racial and ethnic minority communities.
Also positive was the nearly $240 million increase in the FY2001 budget for assistance to other nations struggling with the AIDS epidemic. This increase more than doubled the FY2000 figure. (For a summary of FY 2001 spending, click here.)
Unfortunately, the epidemic appears geared for a rebound in industrial nations that have made great progress in improving life spans and quality of life among HIV-infected people. The worse-case scenario is this: As patients continue on antiretroviral therapy for years, their viral loads often begin to climb, and the virus eventually finds ways to thwart the medications. Combined with increasing HIV infection rates among those most at risk of infection, there may be a simultaneous national increase in new HIV infections, AIDS cases, and AIDS deaths in the next decade.
The stage has been set in San Francisco and New York City. New York’s HIV infection rate among young African-American men who have sex with men (MSM) has climbed to 33%, according to city health department data. In San Francisco, the rate of new infections per year among MSM has doubled since 1997, from 1.04% to the current rate of 2.2%. (See "San Francisco notes HIV rise in MSM population," in this issue.)
San Francisco’s latest data on new HIV cases should be a sobering wake-up call to clinicians and public health officials across the country, says Mike Shriver, AIDS and HIV policy advisor to San Francisco Mayor Willie I. Brown, Jr. "If other jurisdictions and other cities were smart, and they are, they’d look at what’s happening here and say, You know, we’re not going to wait until it gets as bad as it is there before we act, because every time they start a trend, we follow it,’" Shriver says.
Some AIDS activists say they are most concerned about whether the new presidential administration will continue to make AIDS treatment, research, and prevention a national priority. "People start to say, Why should we have to continue spending money on prevention?’ And we say it’s because prevention is an ongoing activity," says Tanya Ehrmann, director of public policy for AIDS Action in Washington, DC. "Prevention isn’t telling somebody one time to not have sex or to not use drugs and then just walking away and expecting we won’t have increases in new infections," Ehrmann says.
"It’s a different world now because of the success of protease inhibitors, and we need to develop new prevention messages that incorporate and recognize this," Ehrmann adds. People who are diagnosed with AIDS today may live longer than they would have a decade ago, but it doesn’t mean people are no longer dying from the disease, Ehrmann says.
One of President Bush’s first announcements was that he would discontinue foreign aid to international organizations that perform or promote abortions. The restriction could affect some health agencies that provide HIV prevention and treatment services in sub-Saharan Africa and other developing regions. This action, coupled with hints that President Bush may reverse President Clinton’s executive order permitting parallel importing of AIDS drugs into sub-Saharan Africa, raised hackles among AIDS activists.
The San Francisco AIDS Foundation was so concerned about how President Bush’s administration would treat HIV/AIDS issues that less than a week after the inauguration, the organization sent the president a list of HIV priority guidelines and recommendations. "It is something we felt compelled to do now, because during the course of the presidential election, health care — and, specifically, HIV/ AIDS — were barely mentioned at all," says Ernest Hopkins, director of federal affairs for the foundation.
The foundation’s concerns were heightened when they learned that their package could not be delivered to the National Office of AIDS Policy because the office had moved and there was no forwarding address, Hopkins says. "The last administration called AIDS a national security issue, and the president embraced it," Hopkins says. "AIDS is destabilizing nations all across the world, and we feel like the president and the people around him need to be made aware of HIV."
The foundation’s letter to President Bush, which is available on the foundation’s Web site (www.sfaf.org/policy/recommendations/index.html), calls to his attention that this year the HIV pandemic marked its 20th anniversary of the first diagnosed case in the United States. "Presidential leadership in addressing this public health crisis both nationally and internationally remains critical," states the letter, which is signed by both Hopkins and Fred Dillon, the foundation’s policy director.
The foundation’s letter included requests for the following items:
AIDS Action also wrote President Bush, urging him to let stand the previous administration’s executive order that allowed parallel importing of AIDS drugs in Africa. "Sub-Saharan Africa is in the midst of the worst plague the modern world has ever seen," writes Claudia French, executive director of AIDS Action. "Twenty-five million men, women, and children are living with HIV/AIDS in Africa. The cost of their treatment can be two to three times higher than the average GDP of some African countries, and easily outpaces the health budgets for many African nations."
AIDS advocacy groups are poised to react if the administration moves to reduce HIV/AIDS funding for prevention, treatment, or services. "We have great concerns about potential funding levels for AIDS programs in this environment of budget cuts and increased defense spending," Hopkins says. "Our fear is that those will be the only priorities that we actually see in the revised budget that we expect in early spring. And if that’s the case, then we’ll have to do even more work with Congress to get the numbers where they need to be."
Shriver, who is open about the fact that he is HIV-positive, says he remains optimistic that President Bush will continue the previous administration’s advocacy of funding for HIV/AIDS programs. "I have to believe, because it’s my life on the line, that this president will continue to make sure we stay in the leadership [position] we are in and not damage HIV programming in this country," Shriver says. "His father signed the Ryan White Care Act into law, and don’t forget the American with Disabilities Act."