Answering the wake-up call on HIV, AIDS

LATE LAST month, George W. Bush signed into law an extension of the President's Emergency Plan for AIDS Relief - a bill that committed $48 billion to the global initiative. This is a major success story for Bush. US efforts have clearly resulted in better access to care and treatment around the world; so far under the program, 1.4 million people have received life-saving drugs, over 6.6 million received care and services, and the establishment of critical prevention programs headed off an estimated 157,000 infant HIV infections.

Despite this commitment abroad, though, the federal government is missing opportunities to protect its own citizens against a deadly and serious threat.

Last weekend, the Centers for Disease Control and Prevention announced that the number of annual new HIV cases in the United States is 40 percent higher than previously reported. This was not news for AIDS experts and those living with HIV. Reports from around the country over the last year indicated that the CDC has long underestimated the impact of the epidemic in the United States.

Part of the problem is that the planning and coordination that US officials demand of other countries is not occurring in the United States.

Internationally, there was an agreement at the United Nations conference on AIDS in 2001 that all countries would create national plans that coordinated services and set specific health outcomes with timelines. In that spirit, the United States establishes bilateral agreements with key recipients of US funding - that is, those countries with the worst epidemics. They are required to draft national plans and regular progress reports against established outcomes.

In 2002, for example, Botswana committed to providing free HIV treatment to all citizens who need it, and the country's progress toward that goal has been measured systematically - not just reported anecdotally. And by 2007, more than 90 percent of those who needed treatment were receiving it.

But the United States does not have such a plan to address its own epidemic.

The federal government's approach to problems has been to create new programs. Officials rarely take the time to determine whether a program fits within an overarching strategy or addresses gaps in current programs. The country is left with a Byzantine maze of programming the ends up being less than the sum of its parts. Currently the federal government lists 30 HIV/AIDS programs in six different government departments and over 20 agencies. There is no coordinated strategy. And there is no clear, standard measure of how effective a given program or intervention might be.

In the absence of such measures, ideology creeps in. If data led the way, abstinence-only prevention programs, which studies show are ineffective, would not siphon off precious resources. And the federal government would establish a syringe access program, because similar efforts by states have proved effective in preventing infections.

The lack of planning has serious consequences. Previous studies have documented that 50 percent of those infected with HIV in the United States are not in medical care, and 25 percent of those living with HIV are not aware of their status. Between 2001 and 2006, New York City reported a 33 percent increase in the number of new diagnoses among gay men under 30. In locales where HIV among black Americans is heavily concentrated - urban centers and the Deep South - infection levels among blacks approach those reported in the most heavily affected countries in Africa. The top cause of death for African-American women ages 25-34 is AIDS. In our nation's capital, one of every 20 residents is reported to be HIV-positive.

The CDC's report is a wake-up call. The next president must focus attention on the crisis at home. Not only do we need a commitment to prevention programs, a significant increase in funding for care and treatment, better access to testing and counseling, and a way to address racial disparities, but we also need a national AIDS strategy that establishes specific and measurable outcomes, timetables, and accountabilities.

We know what causes AIDS; we know how it is spread; we have the tools to prevent it. The United States should lead the way toward ending this epidemic across the globe.

Rebecca Haag is president and CEO of the AIDS Action Committee of Massachusetts and executive director of the AIDS Action Council in Washington.