The Political Perils of HIV Policy

Scientists and public health officials are in agreement. Treatment options and prevention drugs combined with testing could bring an end to the HIV epidemic in the U.S. in general and Michigan specifically within the decade.
"Other things [diseases] have had that over time, but it's always with an advent of a vaccine and we don't have a vaccine yet," said Katie Macomber, director of HIV/STD Programs for the Michigan Department of Health and Human Services. "The scientific advances from 1992 to today? Incredible."
Without a vaccine, and the cost of the drugs to treat and prevent HIV extraordinarily high, politicians are faced with finding a balancing act between budgets, costs and the public health. It's a tightrope act that could have catastrophic or exceptionally positive outcomes. The decisions made in the coming years will literally set the course for the future of the epidemic, agreed politicians interviewed by BTL.
The U.S. and the United Nations Joint Nations Program on HIV/AIDS (UNAIDS) has set an aggressive goal of identifying 90 percent of people living with HIV, connecting 90 percent of those with the virus to medical care and treatment and virally suppressing 90 percent of those in care. It's called the 90-90-90 Plan.
With scientific evidence mounting that those on treatment, and virally suppressed, can't transmit their virus to sexual partners, combined with the use of Pre-exposure Prophylaxis, which is up to 99 percent effective in preventing sexual transmission and 70 percent effective in preventing needle sharing transmissions, the landscape of HIV response has changed "dramatically."
But translating that excitement will require politicians to formulate new strategies to address HIV stigma in the law and in policy-making. Those strategies will require integration of federal and state efforts, particularly for funding.
State Rep. Jon Hoadley (D-Kalamazoo) is in his second term in the state House. He has been working in the GOP dominated House to bring attention HIV prevention, care and education needs — a daunting task. But he shares the optimism of public health officials and scientists.
"I will tell you I also believe there's a light at the end of this tunnel and I think it's coming sooner rather than later," he said. "The barriers we need to remove so we can get to the end of this tunnel includes education HIV prevention and treatment. Second, fully funding HIV treatment so there is no reason folks can't be 100 percent in proper medical care. Third, it's addressing the moral stigma that still evades so many folks when it comes to public policy and medical care, which is preventing folks from having an honest conversation on tools like PrEP. If we were able to then fully support the removal of these roadblocks, we actually could get to where we're trying to go."
One of the major obstacles facing lawmakers is the drive by national Republicans to repeal the Affordable Care Act. A key provision in that law expanded Medicaid access dramatically to communities most at risk for acquiring HIV and those living with the virus. In Michigan, the expansion made it possible for nearly 700,000 people to get health insurance coverage.
The Trump administration and GOP leaders have talked about rolling back provisions in the law which financed the expansion in most states. One proposal would be to provide a block grant, rather than real time financing for costs. The results could be a drastically scaled down Medicaid program.
"I'm very concerned about that," said former Senate Minority Leader Gretchen Whitmer. She's the presumed front-runner in the primary for the Democratic nomination for governor next year. Currently most of Michigan's HIV funding — prevention, treatment, health insurance — comes from federal dollars. Gutting one leg of that funding system is dangerous.
"It's crucial we draw down every dollar available into our state," said Whitmer. "That we empower a larger fighting capacity in negotiations with pharmaceutical companies so that we can get access for people at lower costs and that we educate the medical profession to write prescriptions."
That sentiment was shared by Hoadley as well as former Detroit Health Department Director Dr. Abdul El-Sayed, who is challenging Whitmer and others for the nomination in the Democratic 2018 gubernatorial race.
"I think HIV prevention pays for itself," El-Sayed said. "I think the current formula is sort of broken. I think we have, generally as a state, an issue with revenue as it stands."
Hoadley said he believes that the state has to reassess revenue generation in light of the ongoing work on rolling back taxes on "billionaires." He called for a progressive income tax in the state, which would require a constitutional amendment, but could pull in millions of additional dollars to state coffers.
El-Sayed said the state has to re-examine "gigantic cash handouts to large corporations." He said the issues of funding have to be bridged to become a bipartisan issue and "a matter of political priorities."
But Hoadley warns that work to make HIV funding a political priority will require a lot of "one on one" work with lawmakers. No one, he said, is coming into the state legislature with a burning passion and experience as it relates to addressing HIV. Complicating this, many in the legislature are like most Americans, operating on policy prescriptions for HIV but doing so with a knowledge base that is two decades old. Hoadley said in conversations he's had with lawmakers, in explaining the new science as it relates to treatment as prevention and PrEP, cause his colleagues to have aha! moments. But getting to the aha takes time.
For three years, Hoadley has been working with activists to modernize Michigan's HIV disclosure law. Right now, the law does not require intent to transmit the infection or behavior which has been demonstrated to transmit the virus. As a result, people have been sent to prison for sexual activity that posed no risk of transmission.
He said the movement is making progress, and state health officials have said they are working a parallel track to modernize the law independently of what Hoadley and activists are engaged in.
Both Whitmer and El-Sayed said they want to find ways to create funding programs for people who are underinsured or uninsured to access PrEP. Both mentioned drug assistance programs in operation in Washington and New York states.
For El-Sayed, the 90-90-90 goals from the UN need to be amended. He wants to see 90 percent of people at risk for HIV on PrEP.
"I know that's a really aggressive goal, but it's what we have to offer," he said. "And it's something that every time somebody who should be on PrEP is not on PrEP, that's a lost opportunity to prevent a transmission."