• Wasting time in HIV prevention

    Election night 2008 was a promising moment for public health. The Bush era had brought political acrimony, managerial problems, and under-funding had brought severe morale problems to the alphabet soup of federal agencies concerned with population health and safety-net care. It was therefore a powerful relief to greet new leadership under a presidential administration and House majority notably sympathetic to public health.

    The past 50 months have brought worthy accomplishments in tobacco control, child obesity, substance abuse, and in much else. It’s still been tougher sledding than many of us had hoped. As general concepts, population health and prevention attract universal rhetorical support. Yet as practical measures in a political fight for scarce resources in hard times, public health has proved distinctively vulnerable in Congress and across the states.

    The Centers for Disease Control and Prevention and other federal public health agencies have faced flat or declining funding. With almost surgical precision, the lowest-income states with the worst population health outcomes resist the Affordable Care Act (ACA)’s most important public health provision: its Medicaid expansion. Meanwhile, ACA’s Prevention and Public Health Fund, originally slated at $15 billion, remains the target of repeated cuts, congressional criticism, and conspicuously tepid White House support.

    HIV/AIDS provides a hallmark example of the opportunities we are allowing to slip away. It’s by no means the most neglected public health problem. It’s merely one area in which the human consequences of such neglect are particularly acute.

    Almost 640,000 Americans have died after being diagnosed with AIDS. Remarkable treatment advances have reduced the death toll. Yet 20,000 Americans living with HIV still die every year, an annual death toll that exceeds the rate of U.S. combat deaths in Vietnam.

    The HIV prevention effort is also falling short. The annual number of new HIV infections has remained basically unchanged since the early 1990s, with roughly 50,000 Americans newly infected every year. The number of new HIV infections among men who have sex with men is slightly higher today than it was twenty years ago. At this rate, striking proportions of sexually-active gay and bisexual men will be infected.

    The Obama administration offers a good national strategy. Yet the money isn’t there to really execute what must be done. Stuck in artificial crises such as the current sequester mess, our policy process seems unable to focus on real public health problems. Meanwhile, we let opportunities to help slip away.

    More here from me with some wonky graphs, at the Washington Post’s Wonkblog section.

    @haroldpollack

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    • On a related note, not only does the sequester cut 9% of the CDC’s budget, but it also mandates that the CDC can’t prioritize all of the cuts, so that substantial part of the cuts have to come out of epidemiological field work rather than low-priority things like advertising disaster awareness. http://hyperplanes.blogspot.com/2013/04/impact-of-sequester-on-public-health.html

    • “B.C. has experienced a marked decrease in HIV/AIDS morbidity and mortality since the implementation of HAART in 1996. This has been associated with a nearly 60% decrease in new HIV diagnoses, to the current level of 301 cases diagnosed in 2010.” http://cfenet.ubc.ca/tasp

      With a population of about 4.4 million, the equivalent new infections in the U.S. would be less than half (21,500/year) of the 50,000 new cases referred to above. The B.C. Centre for Excellence in HIV/AIDS has the funding from the province and an “eradication” strategy. Safe injection site for IV drug users in Vancouver, needle exchanges throughout the province, routine testing offered to in-hospital patients to identify undiagnosed cases, aggressive taxpayer-funded treatment (to reduce risk of viral transmission), and targeted strategies for the homeless, mentally-disabled, and substance-abuse communities in Vancouver and Prince George.