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EndingAIDSinAmerica: MeetingtheChallenge 1987 • • • • • 41,000Dead;71,000LivingwithHIV AIDSQuiltfirsttimeonNationalMall FirstAntiretroviralDrugApproved– AZT FirstpublicSpeechbyPresidentReaganonAIDS ACT-UPFounded:AIDSCoalitionToUnleashPower 1988 HIV&AIDSOverTime:OurLegacy IntroductionofHighlyActive AntiretroviralTherapy (HAART) 198919831986198919921995199820012004200720102013 = LifetimeTreatment Cost$379,668 50,000NewInfections TreatmentCostsofHIV = LifetimeTreatment Cost$18.9Billion = $94.9Billion Insurance Coverageof Nonelderly Adults withHIV 2009Pre-ACA HIV= A Disease of Disparities HIVDiagnosesTrends2005-2014 ByRace HIVDiagnosesTrends2005-2014 ByModeofTransmission HIVDiagnosesTrends2005-2014 ByRaceamongMSM LifetimeRiskofHIVDiagnosis intheUnitedStates(CDC,2016) LifetimeRiskofHIVDiagnosis intheUnitedStates(CDC,2016) CDCEstimated2014NewHIVInfections BlackMSM 11,207 9,012 WhiteMSM 7,057 LatinoMSM 4,657 BlackHeteroWomen 2,113 BlackHeteroMen OtherMSM All subpopulations accounting for 1,000 or more of 2014 infections 2,105 LatinaHeteroWomen 1,282 WhiteHeteroWomen 1,115 0 2,000 4,000 6,000 8,000 10,000 12,000 HIVwithinTransCommunities “Transgender communities areamongthe groupsat highestrisk forHIV infectionin theUnited States.” A2008meta-analysisof29studiesfocusing ontranswomenintheUnitedStatesfound: 27% MTFtestedHIVPositive 11% Self-reportedknowingtheywereHIV+ AmongAfricanAmericans 56% MTFtestedHIVPositive, 31% Self-reportedknowingtheywereHIV+ RatesofAdultsandAdolescentsLivingwithDiagnosedHIV Infection,Year-end2013—UnitedStatesand 6DependentAreas N=950,811 Total Rate=355.9 Note.DataincludepersonswithadiagnosisofHIVinfectionregardlessofstageofdiseaseatdiagnosis.Alldisplayeddatahavebeen statisticallyadjustedtoaccountforreportingdelays,butnotforincompletereporting. Incomeaswellasracepredictwhoismorelikely todiefromHIV (Levine,2007) (Singh,2013) NHASVision: TheUnitedStateswill becomeaplacewherenew HIVinfectionsarerareand whentheydooccur,every person,regardlessofage, gender,race/ethnicity, sexualorientation,gender identityorsocio-economic circumstance,willhave unfetteredaccesstohigh quality,life-extendingcare, freefromstigmaand discrimination. Source:UNAIDS/Lohseetal/Hoogetal/Mayetal/Hoggetal HPTN052– TreatmentasPrevention Graphic developedby: RodgerAet al.HIV transmission riskthrough condomless sexifHIV+ partneron suppressive ART. PARTNER Study.21 st Conference on Retroviruses and Opportunisti cinfections, Boston, abstract 153LB,2014. ChangeinARVTreatmentGuidelines Basedonnew researchfrom NA-ACCORD cohortofHIV+ people,life expectancy of HIV+adults initiating therapytoday isapproaching thelife expectancy of thegeneral population. DHHS2012Guidelines: ARTis recommended forallpeople livingwith HIVtoreduce theriskofdisease progression. WHO2013Guidelines: ARTis recommended aspriorityforindividuals at<350CD4,forindividuals at>500 CDC,andforallpeople livingwithHIV andwithactiveTB,co-infected with Hepatitis andevidence ofliverdisease, andsero-discordant couples. StagesofCare– TheUnitedStatesTreatmentCascade 100% 1,201,100 86% 1,032,800 61% 725,302* 40% 478,433 37% 441,661 30% 361,764 HIV-Infected DiagnosedLinkedtoHIVRetainedin Care HIVCare Source:CDCVitalSigns,US2011;EarlyRelease11/25/14 OnARTSuppressed viralload PrEP is a new prevention method in which people who do not have HIV take a pill a day to reduce their risk of acquiring the virus. When taken consistently, PrEP has been shown to reduce the risk of HIV acquisition by up to 92% Impact on HIV & Current Challenges • • • • • • Norescissions, noabilitytoexcludebased onpre-existing conditions; Expansion ofnumbersofindividuals withinsurance, particularlythe poorvis-à-vis statesoptingintoMedicaidexpansion, Establishing abaseofessential health benefits; Expansion ofpreventative healthservices, includingtesting; Insurers currently facingchallenges linkedtoplacingallHIVdrugsin specialtyand/ortoptiers,increased co-paysandsmaller networks– challenges beingworked out. Transparency offormularies &networks ofcare. AmericanKnowledge&Attitudes (Washington Post/KaiserFamilyFoundation2012Survey) • 61%ofAmericans believeAmericans don’thaveaccesstoHIVtreatment; • 50%ofAmericans nevertestedforHIVdespite CDCrecommendations • 34%ofAmericans identifysharingadrinkingglass,touchingatoiletseator swimminginpoolasriskofHIVtransmission • 20%wouldbesomewhatorveryuncomfortable workingwithsomeone who hasHIV;and44%similarly wouldnotwantanHIVpositivepersonpreparing theirfood. NotJustPopulation-at-large,butalsoProviderAttitudes LimitingSuccess:ParticularlyforTransPopulations OurAsks OurAsks 1.InsuranceandCoverage 2.Housing 3.Education 4.Decriminalization 5.Research The Facts Massachusetts: From2000to2011,the numberofHIVinfection diagnosesdecreasedby44% andthenumberofdeaths amongpeoplereportedwith HIV/AIDSdecreasedby41%. ACA+RWP= FasterprogresstowardsanAIDS-freeGeneration. The Asks • EnforceACA nondiscriminationmandates; • Enactlawstoreducediscriminatorycost-sharing for HIVmedications; • MaintainfederalcommitmenttoMedicareand Medicaid,withemphasisonsupportforlate-comer statestoexpandMedicaidandstillgarnerthreeyearfullcoverage. TheRyanWhite HIV/AIDSProgram • Servesanestimated536,000Low-IncomePeopleAnnually (nearlyhalfofallindividualslivingwithHIVintheU.S. • Isasafetynet/payeroflastreset- criticalincoveringthe uninsuredandelementsnotcoveredunderinsurancethat areneededforengagement&retentionincare. • Lastauthorizedin2009&Expired(notsunset)in2013 • Reauthorizationwillbeneeded,butmoretimeneededfirst toseeimpact/needsrelatedtoACA. TheRyanWhite HIV/AIDSProgram • TheRyanWhiteProgram(RWP)isacritical componentofthenationalpublichealthresponse toHIVinfectionanddisease. • Whilereauthorizationmaynotbeready,fulland continuedappropriations areneeded. STABLEHOUSING TheFacts • Alifelinefor peoplelivingwith HIV • Oneofthe greatestunmet needsof Americansliving withHIV/AIDS • HOPWA Enacted1990 FY16$335Million STABLEHOUSING Theasks ModernizeFormula– Ratherthancurrentapproachofallocatingbased on cumulative AIDScases,newformulashould betieddirectlyto number ofindividuals currentlyliving withHIV,povertylevel, andhousing costs. IncreaseFunding – Provide a$40million increasetoHOPWA attime of modernization toclosegaponneed,andtoensure modernization getsmore equitable resources toareas withgrowingepidemics, while otherareasarenot destabilized. TheFacts • Lessthanhalfofallhighschoolsandonly20%of middleschoolsintheU.S.provideallofthe16 topicsidentifiedbytheCDCascriticalsexual healtheducation. • Youngpeopleunderageof25accountedfor20% ofallnewHIVinfectionsin2014and68%ofall chlamydiacasesin2013. TheAsk • SupportcontinuedauthorizationofthePersonal ResponsibilityEducationProgram(PREP)forFY20162020,andincreasedfundingforTeenPregnancy PreventionInitiative(TPPI)andDivisionofAdolescent& SchoolHealth(DASH)inFY2017 • Eliminatefederalfundingforabstinence-onlyprograms, asproposedinthePresident’sbudget • Co-sponsorRealEducationforHealthyYouthAct TheFacts • 33statesandtwoterritorieshaveHIV-specificstatutes thatapplyonlytopeoplelivingwithHIV; • InU.S.,morethan1,000peoplelivingwithHIVhave facedchargesunderHIV-specificstatutes; • Longsentences,evenwherenorealriskof transmissionhasoccurred,havebeendocumented. • Criminalizationislimitedtothosewhoknowtheir status,andassuch,couldinhibitsomefromseekingto learntheirstatus(anti-publichealth). TheAsk Supportand/orCo-SponsorHR1586 sponsoredbyRep.BarbaraLeeandS2336 sponsoredbySenatorCoons TheRepealofExistingPoliciesthatEncourageandAllow LegalHIVDiscrimination)REPEALAct. – Requiresafederalreviewofstatelaws,policies,andregulationsrelatedto HIVCriminalization.Won’tchangestatelaw,butwillhopefullyinfluence. AIDSBudget&Appropriations Ø InvestmentinResearch,Care,Preventionand Housingcriticaltobendingthecost-curveof newinfections(eachpreventedHIVinfection saves$377kinfuturetreatmentcosts) Ø EnsureBudgetRequestsfromAIDSBudget andAppropriationsCoalitionaresupported Ø NIHBudgetfallshortof$100millionincrease promisedforHIVresearch the End of AIDS “Weareonscientifically solidgroundwhenwesaywecanendtheHIV/AIDS pandemic,”Dr.Fauci said.“TheendofAIDSwillnotbeaccomplished, however, withoutamajorglobalcommitment tomakeithappen.Wehaveahistoric opportunity— withscience onourside— tomaketheachievement ofanAIDSfreegenerationareality.” - 2012Int’lAIDSConference