How Will the Next US President Combat the Global AIDS Crisis?
Bush, Gore Respond to IAPAC on HIV/AIDS Positions
From the September 2000 IAPAC Monthly
In a matter of weeks, US voters will go to the polls to choose a new
president. When the votes are tallied Albert Gore Jr. or George W Bush
will occupy the White House, taking on what arguably is the most complex
job in the world. The new president will face an AIDS pandemic that has
shifted dramatically since 1992, when the United States last ushered in a
new presidential administration.
During the last eight years, combination antiretroviral therapy has
given HIV-infected people in industrialized nations a new lease on life.
At the same time, however, gaps in treatment access between wealthy and
poor nations have grown into gaping wounds. The HIV crisis, now decimating
the African continent, threatens similar devastation in other impoverished
areas. The future of these nations will depend in some measure on policy
stances of the next US president.
The International Association of Physicians in AIDS Care (IAPAC)
pinpointed a series of critical HIV/AIDS-related issues that the next
president will likely face as his administration sets policy. In mid-June
2000, both presidential candidates were asked to respond to a
questionnaire compiled by IAPAC Monthly writer Rebecca Voelker.
Response of Vice President Albert Gore Jr.
Democratic Candidate for
President
Americans generally rank AIDS as one of the most urgent health problems
facing the United States. Where do you rank AIDS in public policy
priorities?
A1 Gore strongly believes HIV/AIDS is one of the most urgent foreign
and domestic public health and public policy priorities facing the United
States. In January 2000, A1 Gore chaired a session of the United Nations
Security Council on HIV/AIDS in Africa--the first session the Security
Council has convened to address a public health issue--where he stated his
conviction that HIV/AIDS is a great threat to national and global
security.
The Clinton/Gore administration has successfully increased overall
HIV/AIDS funding at the Department of Health and Human Services (DHHS) by
121 percent, funding in biomedical and behavioral research [at] DHHS by 89
percent, funding in prevention at the Centers for Disease Control and
Prevention (CDC) by 47 percent, and care and treatment under the Ryan
White CARE Act by 338 percent. Previous successful programs have been
bolstered by the $245 million Congressional Black Caucus (CBC) Initiative
to fight HIV/AIDS in African-American, Latino, and other communities of
color, and the $100 million Leadership and Investment in Fighting an
Epidemic (LIFE) Initiative to address HIV/AIDS in sub-Saharan Africa and
India.
The CBC Initiative focuses on technical assistance and infrastructure
support, increasing access to prevention and care, and building stronger
linkages to address the needs of specific populations. The LIFE Initiative
focuses on primary prevention, care for children infected and affected by
AIDS, home- and community-based care and treatment, and surveillance and
infrastructure development. The administration has also convened an
Interagency Working Group (IWG) on International AIDS under the leadership
of the National Security Council and the White House Office of National
AIDS Policy. A Gore administration would build upon the success of these
previous and new programs and implement the ideas developed in the context
of the IWG.
If elected, would you consider lifting the ban that prohibits
HIV-infected people from entering the United States?
A1 Gore supports the current administration's policy concerning
HIV-infected people entering the United States. Currently, people with HIV
may enter the United States to attend conferences, receive medical
treatment, visit close family members, or conduct business and may stay
for a maximum of 30 days as long as their visit does not pose a danger to
public health in the United States. Furthermore, HIV-infected people may
be admitted into the United States to attend certain "designated events,"
which are considered to be in the public interest, including international
sports events, and academic and education conferences--such as the XIII
International AIDS Conference in Durban, South Africa, which brought
together the world's leaders in research, prevention, care, and treatment,
including representatives from the administration. HIV-infected people who
seek admission to the United States as immigrants must establish the
required family relationship, and the possibility of the spread of the
infection must be minimal.
Thousands of Americans are infected with HIV but are unaware of their
status. Yet research shows that upon learning they are infected, most
people who are HIV-positive obtain treatment and begin immediately to
adopt safer sex practices. What measures should the US healthcare system
take to enable more Americans to know their HIV status?
Al Gore understands that testing cannot be separated from counseling.
It is important that all Americans be prepared through pre- and post-test
counseling to deal with the physical and mental consequences of the
results--negative or positive. Knowing your HIV status has individual and
community benefits. If you know that you are HIV positive, then you can
take better care of yourself and change your behavior to prevent infecting
others.
The Clinton/Gore administration has developed and/or implemented a
number of programs to enable and encourage more Americans to know their
HIV status. National HIV Testing Day (June 27), founded by the National
Association of People with AIDS, is an excellent example of a successful
public-private partnership. Another example is the "Know Your Status
Campaign" of the CDC. The CDC "Know Your Status Campaign" is relatively
new, but it has already demonstrated success. The administration is also
working to implement new testing techniques such as rapid testing and oral
testing. As president, Al Gore would work with public and private partners
to enable and encourage even more Americans to access confidential and
voluntary counseling and testing.
According to the US Centers for Disease Control and Prevention, at
least half of all new HIV infections in this country are in people under
the age of 25; most probably were infected as teens. Given that
information they receive during their teenage years can greatly influence
future behavior, do you favor programs in high schools that consist of
condom distribution and education on abstinence and prevention through
safer sex?
Some reports suggest that a quarter of all new HIV infections are in
people under the age of 21. Al Gore is deeply troubled that young people
are becoming infected. He supports a comprehensive strategy to prevent HIV
infection among youth, focusing first and foremost on abstinence
education. A1 Gore believes that local communities are in the best
position to know what strategies--including family planning services and
condom distribution--will work for their unique needs. That is why A1 Gore
would provide support to help local communities address their
needs.
Recent research has shown that high-risk sexual behavior is common in
the US military. Given the global deployment of US troops and the risk
that they could transmit HIV in countries where they are stationed, will
you support stronger HIV/AIDS prevention and education programs for the
military?
The administration has worked to develop and implement targeted
education and behavioral change programs in the US military. The
administration has also encouraged the Department of Defense to broaden
and widen military-to-military HIV/AIDS training in sub-Saharan Africa
under the auspices of the LIFE Global AIDS Initiative. A Gore
administration would continue to promote prevention and education in our
military and the militaries of more of our allies around the world.
Medicaid pays for a substantial amount of HIV/AIDS care in the United
States, yet the program does not currently provide coverage for those
individuals who would derive the greatest benefit from access to
antiretroviral therapy because eligibility is limited to those individuals
in whom the infection has progressed to AIDS. This policy ignores clinical
treatment guidelines that recommend early treatment with antiretroviral
drugs to suppress the virus. As president, what would you do to move
legislation to end this contradiction?
A1 Gore understands that it makes no sense to limit eligibility to
those individuals in whom the infection has progressed to AIDS. It makes
no sense for the individual because his/her health suffers, and it makes
no sense for the community because it costs the government and thus
taxpayers more to treat individuals later rather than sooner. This simple
analysis disregards the fact that healthy individuals are able to live
longer and healthier lives and be more productive for themselves and the
community.
Al Gore has led the efforts of the administration to work with states
to develop and implement Medicaid waiver projects, including the first
such waiver project in Maine. The Maine project will demonstrate that
Medicaid coverage is not only just cost-neutral, but cost-saving. As
president, A1 Gore hopes to be able to apply the expanded coverage to
Medicaid recipients across the country.
For years, needle exchange programs have been shown to reduce HIV
infection rates without increasing drug use in local communities. The
federal government now leaves it up to local authorities to determine
whether they will enact needle exchange programs, the result of which is
that many local authorities have not established these programs. Given
that many countries look to the United States for leadership on national
vs. local control issues, the next president must consider how US policy
affects public policy in other countries. Would you, as the next
president, favor federally sponsored needle exchange programs to help
reduce HIV infection in this country, recognizing that such action could
impact HIV risk reduction in other nations?
Public health and scientific research has demonstrated that needle
exchange programs are effective in that they decrease rates of HIV
infection, do not increase rates of injection drug use, and serve as
gateways to drug treatment programs. It is important that we work with
states and communities to enable access to programs for the treatment of
addiction. Al Gore believes local communities should continue to have the
option to use needle exchange programs as part of their comprehensive HIV
prevention strategies and that the federal government should not tie their
hands in this matter. He does not support attempts to restrict the options
of local public health officials on this issue, such as those that the
Republicans have tried to impose on the District of Columbia.
In 1997, President Clinton announced a goal of developing a safe,
effective HIV vaccine within 10 years. But even if the vaccine were
available tomorrow, the infrastructure needed for distribution--in poor
nations hardest hit by the pandemic--is not in place. What steps would you
take to build this infrastructure?
It has been a goal of the administration not only to develop a safe,
effective HIV vaccine within 10 years, but also to make sure that it is
applicable and accessible to persons around the world with different
clades, or strains, of the virus. The president announced the goal in
1997, and since then, the administration has taken a number of steps
toward achieving it. The administration has established a network of
domestic and international sites for clinical trials of candidate HIV
vaccines. On June 9, 1999, the president dedicated the new Dale and Betty
Bumpers Vaccine Research Center at the National Institutes of Health,
where the focus will be on HIV vaccine research.
On January 28, 2000, the president announced the Millennium Vaccine
Initiative. The initiative includes a new financial commitment to purchase
and deliver existing vaccines, including a proposed $50 million
contribution to the vaccine purchase fund of the Global Alliance for
Vaccines and Immunization; a call for the World Bank and other
multilateral development banks to dedicate an additional $400 million to
$900 million in low-interest-rate loans per year to expand immunization,
prevent and treat infectious diseases, and build effective delivery
systems for other basic health services; a significant increase in basic
research on diseases affecting developing nations, including a sharp
step-up in research critical to the development of vaccines for malaria,
tuberculosis, and HIV/AIDS; and a new tax credit for sales of vaccines for
malaria, tuberculosis, and HIV/AIDS to accelerate vaccine invention and
production. The tax credit would match every dollar paid by a qualifying
organization to buy a qualifying vaccine, and would represent up to $1
billion of additional funding for future vaccine purchases.
On March 3, 2000, the president met with public and private partners
including foundations, international organizations, nongovernmental
organizations, and the pharmaceutical companies to announce new
partnerships to develop and deliver vaccines for diseases including
HIV/AIDS, malaria, and tuberculosis for developing countries. The meeting
included donations by the four largest vaccine manufacturers of millions
of doses of vaccines worth more than $150 million and renewed commitments
to research and development on vaccines for HIV/AIDS, malaria, and
tuberculosis.
On May 22-23, 2000, Secretary of Health and Human Services Donna
Shalala convened a conference [entitled] Vaccines for HIV/AIDS, Malaria,
and Tuberculosis: Addressing the
Presidential Challenge at the National Institutes of Health. In the
meantime, until a safe, effective HIV vaccine is developed and produced,
the administration is working to build the necessary infrastructure. We
have learned a number of lessons about building infrastructure for
vaccination in our work with public and private partners to eradicate
smallpox and soon polio. A Gore administration would maintain and expand
efforts to apply lessons learned in smallpox and polio eradication to
activities under the LIFE, the Millennium Vaccine, and other national,
regional, and global initiatives.
Healthcare access--especially to drugs and, in the future, to
vaccines--is and will continue to be a salient issue, especially in
resource-limited countries most affected by the HIV pandemic. Certainly in
African nations and some other parts of the world, AIDS can be considered
a national emergency, a condition that appears to allow compulsory
licensing of drug products according to international trade agreements.
How would your administration address the issue of compulsory licensing or
any other mechanism to allow greater numbers of people with HIV/AIDS to
obtain life-saving and -enhancing drugs and, eventually, vaccines?
Many sub-Saharan African nations have declared HIV/AIDS a national
emergency, and some nations are exploring options under international
trade agreements, e.g., the World Trade Organization Agreement on
Trade-Related Aspects of Intellectual Property Rights, such as compulsory
licensing with the encouragement of the Clinton/Gore administration. The
administration has worked to increase access to healthcare and treatment
on the philosophical basis that public health policy and intellectual
property protection are mutually supportive.
On World AIDS Day (December 1, 1999), the president announced that the
Office of United States Trade Representative (USTR) and DHHS would develop
a cooperative approach on health-related intellectual property matters
consistent with the goal of the administration to help developing
countries increase access to drugs and, eventually, vaccines. On May 1,
2000, USTR issued a press release detailing the policy of the
administration on intellectual property and health policy.
On May 10, 2000, the president issued an executive order on access to
HIV/AIDS pharmaceuticals and medical technologies formalizing the policy
with respect to sub-Saharan Africa. A Gore administration would continue
to implement a similar intellectual property and health policy, as well as
continue to work with public and private partners including the
pharmaceutical companies to increase access to drugs and, eventually,
vaccines.
How have you been personally or professionally affected by the AIDS
epidemic?
Al Gore has been both personally and professionally affected by the
AIDS epidemic. A number of years ago, he met a young man named Camillo
Wing Lee at the NAMES Project in Washington. He was helping others make
panels for the AIDS quilt for friends and loved ones. Al Gore looked at
what he was working on, and then realized that he was working on his own
panel as well. He died three years ago. Al Gore has since seen the quilt a
number of times, and every time he is overwhelmed by the humanity it
represents--the loved ones lost, the potential never realized.
A number of people living with HIV/AIDS have been appointed to
positions in the government as well as to the Presidential Advisory
Council on HIV/AIDS (PACHA). In fact, to give just one example, Bob
Hattoy, who spoke so powerfully about living with HIV/AIDS at the 1992
Democratic Convention, has served at the White House and the Department of
Interior as well as on PACHA. Bob and others serve to remind the
administration what is truly important in the AIDS epidemic--the people
living with and still dying from HIV/AIDS. He hopes to be able to continue
to work on their behalf and in memory of those who have died of
HIV/AIDS.
We are united in the fight for research, care, and prevention. And we
will not stop until all who need it have access to the treatment they
need. We will not rest until we have a vaccine--and a cure.
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Response of Governor George W. Bush
Republican Candidate for
President
In lieu of responding to IAPAC's individual questions, Governor George
W. Bush submitted the following statement:
Thank you for your recent inquiry concerning my views on HIV/AIDS care
and prevention.
I fervently hope a cure for this horrible disease is found, and if
elected president I commit to do my part to combat this urgent health
problem. First and foremost, my administration will support significant
government-funded research aimed at conquering this disease. I also favor
a permanent extension of the research and development tax credit for
pharmaceutical companies who are currently conducting important research
on drugs to combat AIDS.
I support the National Institutes of Health (NIH) continuing their AIDS
research and have proposed doubling NIH's budget to propel additional
research. Effective prevention campaigns and also programs like the Ryan
White CARE Act are also effective means to respond effectively and
compassionately to people with AIDS.
AIDS is a disease that is ravaging communities around the world, but
infection rates are spiking most dramatically in Africa. The staggering
number of deaths every hour of every day of every year affects every
corner and every fabric of the African community. It is shocking to hear
that the average life expectancy there will soon drop below age 30, down
from 70, because of the increasing number of deaths due to AIDS.
It is even more staggering to hear that some nations in Africa will
experience negative population growth as a result of AIDS. Statistics show
that since the AIDS epidemic began, 11.5 million have died of the disease
in sub-Saharan Africa alone, accounting for 21 percent of all deaths in
the region, with malaria a distant second at 9 percent. More than 33.6
million people around the world are living with AIDS or [are] infected
with HIV, and over two-thirds of them, 23.3 million, live in sub-Saharan
Africa. About 5,000 people die of AIDS every day, and researchers predict
that number will grow to 13,000 by 2010. By comparison, about one-third of
one percent of the US population is infected, about 900,000 cases. The
African continent lacks adequate resources, both financial and medical, to
handle existing cases, much less the projected increase.
The ripples are larger still. A loss of life on this scale, aside from
the tragic human impact, also subverts economic growth and promotes
instability, which is especially important in countries that are just
starting to embrace and build upon economic and political reforms.
Conquering AIDS will be a priority in a Bush White House. Finding a
cure for AIDS, however, is not a goal that one person or even one country
can achieve alone. It is a monumental goal for the global community. With
an enemy as merciless as this disease, it will take all of our hearts,
minds, and strength to find a cure.
Thank you again for giving me the opportunity to share my views on this
important issue. As the campaign moves forward, I will always welcome your
thoughts and ideas.
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