December 1, 2016

World AIDS Day 2016: More of the Same for AIDS, Inc.

With the usual “feel good/aren’t we incredible” glad-handing gathering of AIDS, Inc., politicians, government employees, and funders, along with the usual platitudes of “heroes”, the DC Department of Health and Mayor Bowser unveiled DC’s “bold” new plan to end the HIV/AIDS pandemic. “90-90-90-50” is the title of this latest go at things – essentially using the right words about innovation and change, claiming to have gotten input from the “entire community” (not so much), but fundamentally, bureaucratically and institutionally maintaining the status quo. Other than housing, there was not a whiff of an acknowldedgment that we need a syndemic approach to HIV, but the epidemic model is the one that continues to rule. 

For sure there was good news to report. No mother-to-child transmissions in the District for the 3rd straight year. A continuing decline in new diagnosis. Advances in prevention – specifically PrEP and the expansion of its use to include the heterosexual community (although by the look of the posters in the room, this community consists of young black women – so much for being creative about stigma).  But when it comes to truly being creative and innovative, this was severely lacking.

“90-90-90-50” means simply this: within the next few years, 90% of all people with HIV will know their status; 90% of those diagnosed will be in care; 90% of those in care will have suppressed viral load; and there will be a 50% drop in HIV transmission.  To look at how incredibly unimaginative this is, simply look at the first goal: 90% of all people with HIV will know their status. In order to do this, a broad net will need to be cast over all those who should be tested for HIV. When asked about what innovations will be used to accomplish this, the director of the DC DOH talked about the on-going testing in emergency rooms and that all licensed medical and mental health providers are required to take 3 CE’s every two years on HIV. That’s it. Not very creative and, in fact, not very effective. ER testing, for example, is nominally effective at catching HIV and, at that, most of those are “late-progressors”. We need to do better.

The CDC has been recommending that all medical providers test all clients between 15 and 65 since 2006 but still there are entire schools in DC where students are not offered an HIV test simply because they are schools that cater to the more affluent. But by stating a goal of “90% of those with HIV will know their status”, DOH can maintain the system that prefers to target groups rather than go large – something like “90% of all DC residents will know their status”. This would go a long way to not only getting the first goal, but also of ramping up education, changing stigma of who should get tested, and breaking down barriers to testing by fostering truly innovative approaches that include PrEP and self-testing. The latter, for the record, got not even a mention despite the fact that self-testing has been identified by the World Health Organization as an effective tool to reach people who might not otherwise test.

So another World AIDS Day passes, and AIDS, Inc. gets another day in the spotlight. But nothing is changing at the upper levels. As is the case with so many things these days, grassroots efforts are the real keys to innovation and real change.