by Nayvin Gordon
The scientific Public Health approach to preventing and controlling sexually transmitted diseases has been well established for some 70 years. Why is it then that the HIV epidemic, which began in the US in 1981, has continued to infect over 38,000 people a year, declining only 8% from 2010-15? What was the role of the government as “guardians of the public interest”? The Supreme Court ruled in 1905 that there is a governmental and societal interest in preventing the spread of disease. The historical record demonstrates that the US Government has, for political and financial reason, not only refused to take the necessary well known steps to end the HIV epidemic, they have also cut funding to the major institutions responsible for bringing the epidemic to an end.
Today the HIV epidemic rages across the nation, disproportionately affecting black and Latin people. There are a total of 1.1 million victims of HIV/AIDS in the US, of whom 43% are black, and the rate of new infections for blacks is 8 times that of whites and 2.5 times that of Latins. Heterosexual contact is also a more common route of infection in black men than white men, 35% vs 14%, and is the most common mode of transmission among black women. Drug use accounts for only around 10% of cases.
Within four years after the HIV epidemic began, a blood test was developed. There is now effective treatment available for HIV, which not only reduces morbidity and mortality, but prevents transmission. Treatment should be administered as soon as the diagnosis is made, preferably as early as possible after infection. Nonetheless, 14% of those infected are unaware of their diagnosis – much higher in the young- and only 49% are effectively treated as of 2016. Once again, the rates are grossly racially skewed. HIV death rates (deaths for which HIV was indicated as the leading cause of death) are highest among blacks; in 2015, blacks had the highest age-adjusted HIV death rate of 7.9 per 100,000, compared to 1.1 per 100,000 whites.
A sustained medical prevention policy would include: universal screening, partner identification, treatment and prevention. But a Public Health strategy also would require providing housing, substance abuse and mental health care, living wages and employment, which all help to prevent HIV. Incarceration contributes to HIV as well by limiting the number of men in neighborhoods and narrowing the pool of partners. Criminalizing HIV transmission or outlawing gay sex creates enormous fear and shame, driving people away from testing and treatment. Strategies to address all these issues could have been put into effect if priorities and funding had allowed an expanded Public Health workforce to take the necessary actions to end the epidemic. Tragically this was not allowed to happen.
During the 1980’s, while the HIV epidemic accelerated, the administration under President Reagan was focused on making cutbacks in federal health spending. Huge cuts to the Public Health Services were made as extra billions of dollars were poured into a massive military buildup. In New York State activists had to fight for an HIV partner notification law (1999), a key component for eliminating sexually transmitted diseases and crucial to protecting the Public Health. In 2008-9 cuts were made to public health funding as billions more were given to bail out banks and corporations. In 2018, there were $1.3 billion in cuts to Prevention and Public Health Funds as $1.5 trillion in tax cuts was given by the Trump Congress to bankers, corporations and the rich.
Globally close to 38 million people live with HIV, primarily in sub Saharan Africa, due to limited access to care, poverty, and homelessness. Large numbers of children (1.8 million) live with HIV/AIDS acquired through childbirth and breastfeeding. In 2017, 940,000 people died, a actual decline in mortality due to funding for testing and medications from PEPFAR, the President’s Emergency Program for AIDS Relief, and the Global Fund for AIDS, Malaria, and TB. Activists around the world have demanded housing, low cost, generic medication, and debt relief in countries where the International Monetary Fund demanded loan repayment that pulled funding from education and health care. They also organized against policies that attack sex workers and people who are LGBT.
The grim reality is that for 30 years HIV has been infecting thousands of new victims every year, and to this date, a complete public health prevention strategy for combating HIV has not been introduced as a comprehensive national program or international program. The Institute of Medicine declared in 1988 that the American Public Health System had fallen into disarray. Another way to conceptualize these failures is to understand that the global economic system has been shown to place corporate profits and war above protecting the public from disease, especially the most vulnerable. It is time to think about an economic system that puts the people’s health first.
Dr. Nayvin Gordon is a California Family Physician. He can be reached at firstname.lastname@example.org