Articles, Blog

Ending the HIV Epidemic: A Plan for America

December 18, 2019

Hi. Ending the HIV epidemic, a plan for America,
is the focus of the 2019 US Conference on AIDS for Washington DC. The opening plenary session just ended and
I’m delighted to have some of my HHS partners here with me. I’m Kaye Hayes, Principal Deputy Director
of the Office of Infectious Disease HIV/AIDS Policy at HHS and also the Deputy Director
of the Presidential Advisory Council on AIDS. I’m delighted to have colleagues here, Dr.
Anthony Fauci, Director of the National Institute of Allergy and Infectious Diseases at NIH,
Dr. Laura Cheever, HRSA’s Associate Administrator in the HIV/AIDS Bureau, which brings and manages
the Ryan White HIV/AIDS program and Rear Admiral Michael Weahkee, Principal Deputy Director
of the Indian Health Service. Welcome again to each of you. Our colleague Dr. Robert Redfield, Director
for the Centers for Disease Control and Prevention was also here today and presented. He had to depart for another meeting, but
we will join him sort of virtually in this conversation later I want to sort of tee it off with some questions
and I want our colleagues here to share what they’ve heard today, what they presented today. And I’m going to start with Dr. Cheever. Great, so today I was specifically discussing what
we needed to do to get the 400,000 people who are not in care into care. Of those about 250,000 have been diagnosed
and often they were linked to care but are no longer in care. So what do we need to do differently to get
those people in care? Clearly we spent a lot of time talking about
the importance of housing. Housing is healthcare that we need to engage
in housing, but also there are important issues around stigma and discrimination, racism that
need to get addressed. Certainly the issue, it’s not simply taking
a pill once a day and getting a pill into every mouth. We know it’s more than that. And today the community really brought to
us that there’s an important part of community mobilization that needs to be a part of this
response. Thank you. And Rear Admiral Weahkee, What were some of your thoughts and reflections
from your presentation and sharing with the group? Well, thank you. And the Indian Health Service is excited about
this opportunity to end the HIV epidemic in Indian country and we’ve really focused a lot on the issue of
partnership and the importance of community voice in developing our program. So one of the items that I spoke a lot about
was consultation and confer. We have in our authorizing law for the Indian
Health Service, the requirement to consult with tribes and in our urban Indian organizations. However, what I heard today was the need for
[inaudible 00:02:51] and more specific inclusion of tribal community member voice in these
convenings. So we’ll be doing that through a round of
listening sessions. We partnered with the National Indian Health
Board and the National Council of Urban Indian Health to hold listening sessions throughout
Indian country so that we can gather that and better inform our programs moving forward. Thank you. I think it’s so important because our agency
partners are sharing what their agencies will be doing and I think that’s critical as we
have these discussions. And Dr. Fauci, I know you had your interview. What would you like to share with our audience? Well, the point that I made in the discussion
during the interview was that today, in 2019, we have the tools that if implemented properly
and aggressively, that we have the tools to end the epidemic. Literally whenever we want to end it. It’s just a matter of implementing. It’s not that easy, because we have to reach
members of the community who are not easily accessible. There’s a lot of stigma still around. We need to overcome stigma, but it is doable. It’s no longer just aspirational. It’s doable. We have treatment as prevention, which if
implemented properly, would prevent the spread from one person to another. We have pre-exposure prophylaxis, which is
highly effective in preventing the acquisition of HIV. You put those two things together, you implement
them in a very aggressive, committed way and we can get there. So that was really the message that we can
get there. But we need the community and the point that
I made and all the other speakers made, it wasn’t only the point that I made is that
this is the audience that really needs to hear that, because they are the ones that
are going to be partners with us in the implementation of the program. I think that’s so key what Dr. Fauci just
said that what we heard through the presentations and you could hear it echoing in the audience
and our partners, is that it’s this community. It’s a community collective participation. So when I tee off to some other things, I
want to tell our viewers as we unfold this plan that you the ending the HIV epidemic plan,
what are some of the specific things you think we can we can start with? Dr. Fauci we can start with you on this one. Well the plan is to essentially get people
who are generally out of care and not either infected or living with HIV, not knowing it
or living with HIV in a healthcare system that’s inconsistent. Because if you look at the overwhelming majority
of transmissions that occur, they occur from either a person who has HIV and doesn’t know
it or who has HIV and is not in a consistent health program that would bring down the viral
level to below detectable. If you can access those people then we’re
we’re we’re halfway or more there to where we want to be. Now that may sound as something you could
easily do. The difficulty is that was brought out not
only at the conference but also in our plan is that if you look at the demography in the
United States, it isn’t homogeneously spread with regards to persons with HIV or at risk
for HIV. We have geographic hotspots as we call it
and we have demographic hotspots or at high risk. We need to concentrate on them and that is
involving, we know now 48 counties plus the District of Columbia and San Juan, Puerto
Rico. Seven states with rural intensity of HIV transmission. Then you have the demography, you have mostly
African American men who have sex with men, African American women, transgender persons
and others who are clearly at the higher risk and more vulnerable. Thank you for sharing that. Rear Admiral Weahkee from the Indian Health
Service what are some of your perspectives in that regard? I think one of the items that we’ll be focusing
on early is better data. So we have some funding that’s been identified
and will be set aside to support our national tribal epidemiology centers. So we want to provide those both in the geographic
hotspots and outside the geographic hotspots with the resources they need to improve the
data in Indian country. Also, we’ll be working to expand upon those
best practices that have been identified like Cherokee nations ending or eradicating Hepatitis
C initiative. We really want to promote those types of initiatives
and build upon them, replicate them throughout Indian country. And then finally with consensus building and
best practice sharing, we want to support a National Native HIV consortia or group to
bring together the voices and to make that free flow of information sharing easier for
native communities. Right, thank you. As we talk about launching the initiative
and we look to HRSA, Dr. Cheever, what are some of those specific activities that HRSA
will need to tackle? Well, I think Dr. Fauci really sort of set
this up for me in that we have about 250,000 people in this country who are diagnosed and
out of care. So among people that have come into the Ryan
White program, that’s about half a million people, which is half of all the people diagnosed,
those people have done very well. 86% of them are virally suppressed. So that’s great. We have 14% we need to be doing something
different for those 14%, but we also have 250,000 people know they have HIV are not
in the system. So the system has failed them in some way. So we need to be providing services differently. We know some things about those people that
are out of care. They’re much more likely to be homeless, as we’ve already discussed, having serious substance abuse or mental health
issues that need to get addressed that aren’t addressed in the system today. We’re not able to meet them where they need
to be met. Additionally, people that are in transition. So when people go from adolescent care to
adult care, they fall out of care. People that are in and out of jails and prisons
often lose continuity of care. So we need to figure out how to handle those
transitions differently to keep those people in care and to engage them. So it means providing services differently
than we’re providing them now. Thank you. I think that’s so important what Dr. Cheever
said about doing things differently. And it kinda is a great segue. So I kind of bring in Dr. Redfield into the
conversation, because he did have to leave. But that was one of the salient points that
he talked about was sort of this disruptive innovation that was discussed earlier. So I’m going to kind of bring him in this
conversation and then have you guys chime in as some of those points we’ve heard CDC,
Dr. Redfield talk about. He talked about a need for comprehensive
access to PrEP for all individuals. He talked about, again disruptive innovation,
and as Dr. Cheever mentioned, he talked about housing as a medical issue. And really thinking about the housing needs
of people living with HIV. Again, stigma is the enemy to public health
is one of the salient points discussed. And so jump in because those are some of the
things that were very consistent across the presentations and sections that you guys had. Well, let’s start off with the first one that
you mentioned. The idea of PrEP. So at the NIH, we funded four studies in Southern
Africa that looked at, if you preemptively go out and access people and put them on antiretroviral
drug, if they are living with HIV and bring down the level of virus to below detectable. You can save the life of that person and you
can prevent some people in the community from getting infected. But if you do that at its fullest, but look
at whether you actually effectively brought down the incidence of HIV, you don’t. You think you might have, but you don’t. You have to put PrEP into the mix. So if you really want to decrease the incidence
in a community, that community could be a village in Africa. It could be a city in the United States, it
could be a state somewhere. If you really want to bring the incidence
down, you’ve got to do both. You’ve got to get treatment for those who
are living with HIV and you have to provide PrEP for those who are at risk. Otherwise you’re going to do good things,
but you’re not going to bring the incidence down. That’s spot on. I think Dr.Redfield also talked about that
comprehensive approach to prevention. So PrEP is an important part of it. We’ve never had sort of a public health implementation
of PrEP in this country. So now is the time that we can do this through
the initiative. In this initiative, I think there are a couple
of different things we’re going to do. We’re going to have PrEP available through
community health centers throughout this country. In addition, we’re going to have them through
STD clinics and where people live. So we’ve heard a lot today from specific people,
from transgender people, from black, young, MSM, from black women and how do we have the right
messaging in communities that people understand they’re at risk and should be on PrEP. And I think going to be a big challenge. And we are working closely at HRSA with CDC
on how to get that information into community, into the hands of the people that need it,
so that they will understand that that PrEP is available and they should be accessing
PrEP. Right, because we heard that consistent message,
meeting people where they are. Right. I think that came across loud and clear in
the presentations today. Admiral Weahkee. Yeah, I, I think the real item that I want
to key in on to addressing social determinants of health. Dr Redfield mentioned housing specifically
and he also moved a little bit into economic development, job availability. These are issues within Indian country that
we focus on quite a bit. Transportation, lack of transportation in
rural America, availability of healthy foods. The list goes on and on and the issues that
we need to address in able to best serve our patients. Thank you. Now I always like to ask this question, so
we want to leave our viewers with like a takeaway message, so what’s that burning one message. I’m going to ask each of you. I’m going to start with you Rear Admiral Weahkee. What’s the burning takeaway message you’d
like to share with our viewers? For me, the power of partnership and the importance
of inclusion. Not just through formal consultation and confer
processes, but actually getting into the ground level and talking to the people who are engaged
in the work. Thank you. I would say it’s that the communities today
throughout this country are doing the things they need to do to end this epidemic and now
we need to scale up. There’s really innovative approaches that
are happening all over the country to make it work. Thank you. Dr. Fauci. It’s entirely possible and doable and I think
if we don’t do it, history is going to judge us very harshly for having squandered this
very, very important opportunity. Thank you. Thank you to our viewers for listening in. I want to thank our panel, Rear Admiral
Weahkee, Dr. Cheever, and Dr. Fauci for sharing your time, talent, expertise with our viewership. Have a good day and we look forward to hearing
from you soon.

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