Dissent in the House
by Rep. Nancy Pelosi (D-CA)
Don’t be fooled—Tom Coburn’s bill is about testing, not prevention.
In the absence of a cure, we must have effective HIV prevention to save lives. Thanks to our significant investment in prevention research, we know what works in HIV prevention. Our policies should be based on science, not politics.
The controversy over the HIV Prevention Act of 1997, recently introduced by my colleague from Oklahoma, Rep. Tom Coburn, gives us the opportunity to make important distinctions about future directions for HIV prevention. We both agree that we need to do more to prevent the further spread of the epidemic. But we have very different visions of how this goal can be achieved.
For the last 10 years I have been in Congress, I have worked for increased funding for AIDS research, prevention, patient care and support services, particularly housing. Since 1993, I have been working on legislation to improve the effectiveness of our HIV prevention programs. Likewise Rep. Connie Morella (R-MD) has been a leader in Congress on concerns of women and AIDS for many years. This year we have joined forces to offer a bipartisan, comprehensive HIV-prevention bill. We are joined by 112 of our House colleagues to promote targeted HIV prevention.
Recently, I asked the Congressional Research Service to do a side-by-side comparison of our bill with the Coburn bill. The agency reported that the task was impossible because, other than their titles, the bills have absolutely nothing in common. The Pelosi-Morella bill is about prevention. The Coburn bill is about testing.
Our bill provides funds to state and local health departments for a variety of prevention programs. Priorities for interventions and target populations are set at the local level in partnership with HIV-prevention planning groups. We also promote better coordination and planning as well as establish new outreach services for women.
My reaction to the Coburn bill is that it misses the point. The bill is based on a belief that the traditional public-health measures have not been adequately used to prevent the HIV epidemic and that such approaches have been blocked by a powerful coalition of homosexual and civil-rights groups.
The Coburn bill is not an approach that would improve the effectiveness of HIV-prevention programs. Instead, it would eliminate anonymous HIV testing and require that the names of all people in the United States infected with HIV be reported to the federal government. This expensive approach would be a step backward by diverting resources from more effective efforts in HIV control. Critics call the bill “Coburn’s List.” How would such a list prevent the spread of HIV? Theoretically, the federal government could follow up on reported cases with contact tracing and partner notification of all sexual and needle-sharing partners, thus ending the spread of the disease. However, as pointed out by the National Governor’s Association in opposing the Coburn bill, it would be foolish to divert all of our prevention resources to this one approach while ignoring the results of hundreds of millions of dollars invested by the National Institutes of Health (NIH) in prevention science. And research studies have demonstrated that comprehensive HIV-prevention programs based on this science work.
The Coburn bill would block the federal share of Medicaid payments to states unless each state enacted seven specific laws or regulations. For example, hospitals would be required to inform funeral-service practitioners if a body is know to be HIV infected. What does this have to do with HIV prevention? The Centers for Disease Control and Prevention (CDC) is unaware of a single case of occupational HIV infection in the funeral industry. Nonetheless, New York state alone would be required to pass such a law or lose over $10 billion in federal Medicaid funning. This is a sledgehammer approach.
The rape provision in the Coburn bill would permit testing without consent of persons accuses, but not convicted, of sexual offenses. The rational is that the victim has the right to know, and, if the rapist turned out to be HIV positive, the victim could be monitored for signs of illness and have access to early treatment. While Tom Coburn would like to frame the issue as the rights of rapists versus the rights of the victims, the real issue is what can be done to prevent infection? Again, science, not politics, should lead.
Research on preventing seroconversion in those newly exposed to the virus indicates a 79 percent reduction in risk using “post-exposure prophylaxis,” and antiretroviral regimen that typically involves a four-week course of therapy. CDC recommendations—based on research not among rape victims but solely among health care workers pricked by needles—are that treatment should begin within 72 hours of exposure, but ideally within 4 hours. Coburn’s bill would not allow rape victims to know their attackers’ HIV status within this time frame. Our bill would pay for post-exposure prophylaxis if recommended by CDC guidelines.
The Pelosi-Morella bill would provide needed services to address the psychological burdens caused by the frequent fear of contracting HIV or STDs from an assailant. Our focus is on enhanced services for the victim regardless of whether an assailant has been identified or apprehended. In addition, confidential services would not be contingent on the assault being reported to the police.
Let me also respectfully disagree with my colleague from Oklahoma on two other important prevention related policy issues—needle exchange and “abstinence only” education.
The NIH has recently released a consensus statement indicating that HIV transmission could be reduced by 30 percent or greater through needle-exchange programs. The NIH director has urged that prohibitions on the use of federal funds for needle-exchange programs be dropped. I agree. Scientists estimate that as many as 11,000 new infections with HIV could be prevented in the United States by the year 2000 if we implemented comprehensive needle exchange programs. Some politicians appear willing to ignore this science and sacrifice these people’s lives, and the lives of their families, to make a political point.
Likewise, NIH researches indicate that “abstinence only” education increases the risk of HIV infection because if abstinence fails, young people have not learned alternatives to protect themselves. Thus, “abstinence plus” programs, including instruction on condom use, are recommended. This investment of $50 million each year for programs that will increase HIV infections is taking place while programs that work are not being funded.
I support the recommendation of the scientists and I urge my colleagues to do the same. Because the Coburn bill is based on political rather than scientific consideration, it would set back HIV prevention efforts. Because it follows the science, the Pelosi-Morella bill would be a step in the right direction.
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