January 20, 2001

Re: The AIDS Agenda

Hail to the chief, as they say. You are now our 43rd president, but if your record leaves many HIVers doubting that their concerns will get any traction in your administration, POZ dares you to prove them wrong. Although the Republicans still control Congress, the narrowing of their majorities (particularly in the 50-50 split Senate) is an Rx for gridlock -- a mixed blessing because while little may get done, at least any attempts to roll back the progress made on behalf of HIVers may be stymied.

While AIDS was hardly mentioned in the campaign, it's imperative that you make curing the disease and ending its spread a priority. As the Presidential Advisory Council on HIV/AIDS underscored last September in its final report to your predecessor, "there is no threat to the global community that demands more urgent leadership and response.... Ultimately, it is an issue not of resources but of will that keeps us from stopping" the epidemic. Whether you keep or kill funding for the council or the Office of National AIDS Policy and AIDS czar, you can do one thing for which the three previous Oval Officers lacked nerve: Take the council's findings seriously.

No great expense or exertion is required to set an AIDS agenda. Start by reading the council's report, "No Time to Spare" (your own aides can find it at www.cdcnpin.org). And to make it even easier for you, POZ has polled some AIDS experts to outline some first steps. We'll begin with those most likely to be rubberstamped by a "compassionate conservative" administration and end with those that call for you to take a courageous stand.

NO-BRAINERS
(#1) Protect funding for treatment. After all, it was your dad who (finally, in 1990) signed the Ryan White CARE Act.

With no congressional action at all, you could (#2) streamline the Medicaid eligibility requirements for HIVers seeking Medicaid by issuing waivers, an area that your Health and Human Services nominee Wisconsin Gov. Tommy Thompson pioneered (see "Puppet Master," this page). Susan Dooha, a welfare specialist at Gay Men's Health Crisis, points out that the paperwork is pointlessly painstaking and requires annual recertification. "People with HIV should be given a pass on these stigmatizing, finger-pointing home visits, as well as the limited-eligibility requirements," she said.

You must lead Congress to action on the urgent issue of drug pricing. "Nearly every major Western democracy has some form of price controls for drugs," said the Consumer Project on Technology's Jamie Love. But even if you won't try to persuade Congress to institute limits, you should follow the advice of Robert Fogel, a Chicago lawyer who was a member of Clinton's AIDS advisory council. "The federal government is a large-enough consumer of pharmaceuticals to exert leverage to force lower prices," Fogel said, noting that (#3) combining federal and state purchasing power would increase bargaining clout with Big Pharma. Threatening to withhold reimbursement for overpriced meds could result in dramatically lower negotiated prices. Ask Congress to give you the authority to do this.

Finally, go global with the fight against AIDS by calling for full funding for such (#4) public-private research partnerships as the Global Alliance for Vaccines and Immunization and the International AIDS Vaccine Initiative, and at least $100 million a year to develop HIV-preventing vaginal and rectal microbicides. You should take the lead in canceling the debt to the U.S. of the poorest, most AIDS-devastated countries permitting them to develop healthcare infrastructures. And without waiting for Congress, use your current authority under the Bayh-Dole Act to make a raft of AIDS meds developed with U.S. taxpayer dollars available for production immediately by poor countries or nonprofit drug manufacturers.

TOUGH STUFF
Here at home, nothing is more critical than (#5) launching a national campaign of AIDS education and prevention. Every hour, two Americans aged 13 to 15 are infected with HIV. As Jamie Fox, executive director of AIDS Action, said, "the president needs to use the bully pulpit to talk about AIDS prevention. Let's get over our neopuritanical nonsense about this, because it's life or death." Take this advice to heart and sign an executive order, requiring any provider receiving federal subsidies or tax credits to make HIV prevention a part of its patient contact -- defined in a report prepared for the Office of National AIDS Policy by the AIDS Alliance for Children, Youth and Families as the need "to provide comprehensive sex education in schools and to provide condoms for sexually active teens." Go up against the "family values" crowd in Congress to appropriate money for this critical work.

Then there's the second (and even more controversial) leg of prevention: (#6) clean needle exchange and single-use syringes. According to the U.S. Surgeon General's review of this issue last October, half of all new infections are caused by sharing dirty needles, as are three out of four AIDS cases among women and children. And he found that (as study after study have shown) clean needles "do not encourage the illegal use of drugs."

Without Congress' lifting a finger, you could implement a key recommendation in a Institute of Medicine of the National Academy of Sciences report: (#7) Change the allocation formula for HIV prevention funds so that communities with high rates of new infections get the money they need. The current system, known as proportionality, "rewards the reporting of AIDS cases rather than the prevention of new infections."

Catherine Hanssens, an attorney with the Lambda Legal Defense and Education Fund, urged that you should (#8) make federal funding for prisons hinge on a just standard of care for HIV positive inmates and on effective prevention programs, including condom use. Controversial? No doubt. Compassionate? Absolutely. The AIDS advisory council agreed that U.S. Public Health Service Guidelines for Use of Antiretroviral Agents should be applied, insuring that the latest life-extending drugs get to HIVers in prison.

OR ELSE...
Mr. President, this short list shows that you have the power to take action now, on your own -- regardless of what a deadlocked Congress may do -- that would save tens of thousands of lives here at home and millions abroad. But be warned: As you have reached into previous Republican administrations for a vice president and cabinet nominees, so HIVers and their advocates are ready to return to the activism required during your father's and President Reagan's terms. History will judge you a leader or an ostrich. It's up to you.