After holding a series of nationwide townhall meetings to gather information from the community, the White House released its first National HIV/AIDS Strategy in July. What has been the reaction?
We've been very pleased with the reaction. The community feels rightfully like it's theirs. I think many people feel like they have ownership, which is very gratifying.
What was your personal feeling?
When I got the job [as director of the White House Office of National AIDS Policy (ONAP)], quite frankly I felt like my whole job was to manage expectations because there's so much we need to do and no way to please everybody. I felt like the real challenge was to set some clear priorities that give us a vision for going forward.
Professionally, it's the opportunity of a lifetime, and I feel really proud that the administration enabled us to put out a strategy like this.
What was President Obama's reaction to meeting the community at the White House reception after the strategy's release?
He gets energized when dealing with [the American public]. It would've been easy for him to say, “I don't have time for this,” but I think his presence shows that he is very committed to [HIV/AIDS].
I also think that he really enjoys getting out of the bubble as they call it, and just engaging directly with people. Clearly it was an electric night, so how could he not feed off the positive energy of everybody present?
Is this a historic moment for HIV/AIDS in America?
I always want to be cautious about calling anything that we do historic, but I do think that we [the ONAP staff and the President's Advisory Council on HIV/AIDS (PACHA)] have a commitment to involving people with HIV [on a level that hasn't happened before].
This isn't about the Obama administration as much as it is about the country moving forward together. This isn't a federal strategy; this is a national strategy. Hopefully, people will see what their role can be in helping us move forward.
The strategy aims to lower new infections 25 percent by 2015. One of the criticisms I've heard is that the strategy isn't aggressive enough. We haven't flatlined infection rates in 30 years, so doesn't it feel pretty aggressive?
Yes, I actually do believe that 25 percent is both realistic and quite aggressive. I wish that we could set a goal for 50 percent or 75 percent and believe that we could realistically get there, but I don't believe it helps anybody to set a really high goal that we don't even come close to achieving. [Even] if we don't meet 25 percent, we can still make major progress.
The strategy aims to combine the efforts of federal, state and local health organizations. How will that be monitored?
When we released the strategy, a presidential directive was given to executive agencies to take action. In particular, the Department of Health and Human Services is going to come up with an operation plan that's going to pull together all the things that all the various agencies are going to do.
[The DHHS] can flush it out because they are the ones who are going to directly fund state and local health departments. Also, PACHA has a very significant role, both in supporting implementation and monitoring implementation, even [down to the level of] community-based groups.
In our federal system, we don't tell states what to do. We've given them a vision [so] that they can see what their role is. Hopefully, people will talk to their state and local officials and say, “You need to come up with your own plan to implement this strategy.”
Is part of the strategy to highlight best practices?
We have committed to a new level of reporting. In the presidential memorandum, [the president] directed me and ONAP to report to him annually on our progress. For me to develop this report, we're going to be relying on all the reports from all the other departments and the agencies across the governments.
What you suggest is great, because it's not just about what's our progress in AIDS metrics. When there are good lessons, we want to make sure that people can learn from other people's successes.
Will we see significant funding increases for HIV/AIDS?
When President Obama came into office, we had flatfunded prevention for about a decade. We have increased HIV prevention in our last two budgets and announced new prevention funding through the Prevention and Public Health Fund.
Everybody will [always] say we need more money, but I think that we are showing at least in these tight, difficult times that HIV is a priority, and you can expect that to continue.
Similar things have happened on the care side through the Ryan White program and others. Certainly, we need to recognize the very significant resources we are bringing to the care system through the Affordable Care Act*, so I think we are very committed.
The presidential memorandum directs the executive agencies to ensure that when they are developing their budget proposals that they are looking at the recommendations and the priorities of the strategy, so that their budgets reflect the priorities in the strategy.
I'm assuming those reports will take into consideration that much of health care reform doesn't kick in until 2014.
Within the strategy, we have been very clear that we need to bridge the gap. Even in 2014, the Affordable Care Act won't solve every problem, but it will make a lot of other problems easier and give us some breathing room to think about what we need.
We certainly expect that the Ryan White program will continue after health reform is implemented, but in the short term we have some challenges. But I would also say that these aren't challenges that are for the federal government alone to solve. There's a role for state and local governments, private funders and community-based organizations.
What can the community do to support the strategy?
We've laid out a vision. A lot of people look at the strategy and say, “What's my role in this?” I don't think that people should sit back and wait for me to tell them what to do. I think they should look at the strategy and [recommend] how they can help. We hope that a lot of activity takes place at the local level and the state level to really move us forward.
Do we need legislation to secure some of the ideas related to the strategy?
Some of the issues that we dealt with in the strategy were linked to laws passed in different times. We want to make sure that policies support evidence-based approaches. There's a role for Congress to take a look at some of those issues.
Is treatment or prevention emphasized more in the strategy?
I think they're [both] important. I would say, though, that certainly in the area of HIV incidence, the steps that we need to take to increase our prevention efforts are probably the areas where I think we're giving the most forceful vision of what we need to do.
We're focusing on the communities at greatest risk and really scaling up evidence-based practices. We also need to be willing to say [that in] some of the things we are currently funding, maybe the evidence isn't so strong, so in a time of scarce resources we really need to focus on the evidence-based practices.
I'd also say the issue of reducing health disparities [is important]. These disparities exist, and we need to make major strides in [addressing them]. The way we do that is we improve our prevention efforts, we get people into care. To some extent, they all sort of blend together.
We've struggled to clearly identify who has HIV/AIDS in America. Are surveillance and testing part of the new strategy?
I think we can say that we have one of the best surveillance systems in the world, but it's still under stress. We need to continue to invest in our surveillance system to make sure that it gives us the best data possible. We have $30 million of new prevention funding—some of that is going to support the surveillance system.
Our surveillance system on its own doesn't tell us everything we need to know. We need to make new investments in behavioral surveillance and other things that allow us to look at smaller samples of the population.
We believe that testing is very important. To me, testing is not about the number of tests. It's about the number of positives we identify.
We do want to routinize testing. Everybody should know his or her HIV status. But some populations need to be tested more regularly than others. We have limited resources. We can't pretend that we could offer HIV tests multiple times a year to everybody in the country, but maybe we can for some populations that are high risk.
This strategy is not about me or the White House deciding all these tough policies. We've set a direction. The community does have a job to push us, but they also shouldn't expect that every question is going to be answered within the first 150 days [after the release of the strategy].
By focusing on groups at high risk, are we stigmatizing HIV/AIDS? In other words, if it's a “gay” or “black” disease, won't the general public believe it can't happen to them?
I understand those concerns, and I think they're real. But this country has [come] a long way in the past 30 years in how it deals with and understands gay and bisexual men. We probably couldn't have the honest conversation 30 years ago that we can have today.
People understand that gay men are driving this epidemic, but we can still expect the general population to care about them.
The strategy cites data from the Kaiser Family Foundation that say roughly half of the people in our country of 300 million people know someone with HIV. Unfortunately, that's the extent that HIV is permeating society, but it [could also lead to] something that's hopeful.
We know that when people know someone with HIV, they are more committed to the fight. I understand the concerns, but I think there is just more to be gained by being honest about the challenges we face and addressing them in a direct way.
* This article has been revised to reflect the following correction: The correct name of the law referenced in Crowley's response to the question on funding increases is the Affordable Care Act.