The DC Gay and Lesbian Activist Alliance has released their 2008 Policy Agenda which includes a comprehensive section on HIV/AIDS reprinted below. The entire report is available on their website at: www.glaa.org.AIDS AND PUBLIC HEALTH
A. HIV and AIDS1.
IntroductionD.C. has the highest AIDS rate in the United States. It is comparable to the rates in sub-Saharan Africa. In 2002 the rate of reported AIDS cases in the District was 162.4 per 100,000 compared to 14.8 per 100,000 for the United States. In a local study of AIDS cases reported in year 2001, comparing the District of Columbia to cities with populations larger than 500,000, it was found that the District of Columbia had the highest rate, 119 cases per 100,000, of all cities included. This was the highest rate for AIDS in the nation for 2001.
9According to the “District of Columbia HIV/AIDS Epidemiology Annual Report” released in November 2007, almost 70 percent of all AIDS cases between 1997 and 2006 progressed from HIV to AIDS in less than 12 months after the initial HIV diagnosis, primarily due to late testing, compared to 39 percent nationally. While African-Americans are 57 percent of the District’s population, they account for 81 percent of new reports of HIV cases. While African-American women are 58 percent of the District’s female population, they account for 90 percent of new female HIV cases. Heterosexual contact is the leading mode of HIV transmission at 37 percent of newly reported infections, while nationally men who have sex with men lead new transmissions.
10Nationally, the HIV rate among non-Hispanic blacks between 19 and 24 is 20 times higher than among other young U.S. adults, according to a study in the
American Journal of Public Health.
11AIDS continues to be the leading cause of death for Black women between the ages of 24 and 34; Black youth represent over 56% of the new HIV/AIDS cases among youth in America; and nearly 50% of Black gay men in the U.S. may already be infected. Despite all of these alarming statistics, HIV/AIDS has only recently been treated as a serious problem in D.C. It was long ignored by D.C.’s politicians, government agencies, press and community.
Since treatments have improved significantly in the past decade, people with HIV are often finding that the disease is manageable. Consequently, many people are not open about their HIV infection and do not agitate to save their lives or the lives of their loved ones. However, the number of people with HIV/AIDS continues to grow. The demands on our public and private healthcare systems will only increase, and the government must get more serious in order to meet them.
Community participation is key to improving the District’s response to AIDS. The various planning bodies—including the Prevention Planning Group, HIV Health Services Planning Council, and the Mayor’s AIDS Task Force—should publish their meeting and minutes on the HAA website. Also, stronger efforts should be made to appoint community members to these bodies who are not board members, employees, or consultants of groups receiving funds, while existing conflict-of-interest provisions (such as in the Ryan White CARE Act) should be enforced.
2.
Reforms at HIV/AIDS AdministrationWe were pleased when the criminal cabal that ran HAA for many years was purged. There had been rampant fraud in contracting and retaliations against honest service providers and staff. The DC Appleseed Center issued a comprehensive report in 2005 that exposed many of the problems that GLAA fought to bring to light.
12The Appleseed report became a blueprint for reform, and report cards have been issued on the city’s progress. Financial and service audits need to continue.
The Council has resumed HAA oversight that was badly neglected under the former Health and Human Services Chair. GLAA had sought the breakup of that committee into two, and since it was done, oversight has greatly improved under Health Committee Chair David Catania, who held 8 hearings on HAA in the Committee’s first year, as opposed to 1 in 6 years previously. We hope that the reforms at HAA will continue and will be closely monitored by the Council and watchdog organizations such as Appleseed and DCPCA.
3.
Continued Challenges at HAAa. HIV surveillance has been changed to a names reporting system, but better privacy protections are needed. D.C. gave up on the Unique Identifiers that we used to protect people’s privacy after our hand was forced by the federal government. The Ryan White Reauthorization Act now bases allocation of funds on both HIV and AIDS cases. However, they will not accept unique identifier systems in counting HIV cases. Nonetheless, states, including the District, must report both HIV and AIDS cases to the CDC with a unique identifier.
The names-reporting system for HIV creates a de facto lifetime registry, which demands stronger privacy protections than we currently have. Our medical privacy laws do not allow for a private right of action, and no individual penalties for a government employee who violates the law. Any penalty would be paid by the D.C. government, and only if the D.C. government chooses to sue itself. Stronger laws are clearly needed.
b. Sero-positive surveys can improve the reliability of epidemiological data. GLAA supports the National Academy of Sciences’ Institute of Medicine (IOM) Report, which recommends “that the CDC create a national system to identify new HIV infections, enabling public health officials to track recent changes in the epidemic. Rather than trying to count every newly infected person, the surveillance system would provide data that would allow the CDC to estimate the number of HIV infected persons by testing a statistically valid sample of those at the highest risk.”
13The District of Columbia should adopt a sero-positive survey as recommended by the IOM, and should encourage the CDC to adopt the IOM recommendations to promote HIV prevention and surveillance.
c. Better program evaluation. HIV prevention programs receive tens of millions of dollars a year in D.C. but have failed to reduce the rate of new HIV infections. Significant studies need to be conducted on the effectiveness of HIV prevention programs. Every prevention program needs to be evaluated for effectiveness and new studies conducted to find programs and messages that work.
d. Housing. The District needs to make the most of funds from the federal Housing Opportunities for Persons with AIDS (HOPWA) program. An oversight hearing of the Committee on Health last December revealed that nearly 300 people are on the waiting list for housing. We can maximize our HOPWA dollars by prioritizing actual housing for PWAs when there are other funding sources for the support services that eat up a third of the District’s HOPWA funds.
4.
Testing for Sexually Transmitted DiseasesThe fact that HIV has been treated so differently from other infectious diseases has helped to perpetuate the stigma and contributed to its spread. HIV testing should become part of routine physical exams for adults and teens. 25% of people with HIV don’t inform their partners because they don’t know. This lack of knowledge is a leading reason for the spread of HIV.
Under proposed guidelines from the Centers for Disease Control and Prevention, patients would be tested for HIV as part of a standard battery of tests when they go for urgent or emergency care, or even during a routine physical. HAA is leading an effort to make HIV testing standard in all D.C. run health facilities, and encouraged in private facilities. Eliminating a special consent form would help normalize HIV testing and care. The test should be covered in a clinic or hospital’s standard care consent form. However, patients should be allowed to decline the testing, and should never be required to be tested except in D.C. jails, as noted below.
HAA should maintain anonymous testing sites and educate residents about the difference between confidential and anonymous testing. This is particularly important for non-citizens who are subject to deportation under the federal HIV immigration ban signed into law in 1993.
In June 2006, the D.C. Department of Health launched a campaign “to encourage all DC residents to demonstrate their shared commitment to stop the spread of HIV in our city by getting screened for the virus.” Unfortunately it was poorly executed and relatively few people were tested. The program should include funding for counseling and appropriate referrals for treatment.
HIV testing in D.C. prisonsPeople held in custody at the D.C. Jail should be protected from HIV transmission by means of automatic testing at intake and segregation of HIV positive inmates into a separate ward. To evaluate the practice, inmates need to be tested when they leave. Reducing or eliminating HIV transmission in the D.C. Jail will also reduce transmission to the partners of released inmates. Segregated HIV positive inmates must be provided all of the medical care and medication required, and not subjected to discrimination or stigmatizing treatment.
5.
Post-Exposure Prophylaxis (PEP)Post-exposure prophylaxis (PEP) for HIV should be provided at all D.C. emergency rooms, urgent care centers and health clinics. The availability of PEP should be publicized and included in student health classes. PEP needs to be started within 72 hours after exposure to HIV to be effective, so people must not be forced to wait for a doctor’s office appointment.
Studies in animals have shown PEP to be up to 100% effective if given within 24 hours and a course of medications is taken for four weeks. It failed half the time if taken three days after exposure or where the course was only for 10 days. HIV is found in the lymph nodes 2-3 days after transmission and after five days in the blood, which is generally seen as evidence of established infection.
6.
HIV Preventiona. Clean needle exchange. Given the clear evidence that syringe exchange programs (SEPs) help prevent blood-borne disease without promoting increased drug use,
14we celebrated when Congress finally lifted its ban on D.C. funding of SEPs in the Fiscal Year 2008 D.C. appropriations bill.
The District estimates that 9,856 residents inject drugs.
15From 1996 to 2000, 31.3% of AIDS cases were diagnosed in heterosexuals with a history of injecting drug use (IDU). An additional 6.5% were diagnosed as related to IDU through sex or childbirth.
16As we look forward to a District-funded SEP, we applaud PreventionWorks! (a 2008 winner of GLAA’s Distinguished Service Award) for operating a life-saving program for more than nine years solely on private donations. Kudos go to D.C. Councilmember Jack Evans for his longstanding leadership on this issue, to D.C. Congresswoman Eleanor Holmes Norton for her stalwart efforts in Congress, and to Congressman José Serrano (D-NY) for the key role he played in the appropriations victory. The continued ban on the use of federal funds for SEPs, which has been in place since 1988, remains a blot on the nation’s health care policy.
b. Condom distribution. The use of condoms is the safest and most effective prevention method for reducing HIV transmission. Condoms and water-based lubricant need to be widely and consistently available throughout the District. DC Appleseed reported that HAA missed its goal of distributing 600,000 condoms in 2004; only 290,000 were distributed. In 2005, the number fell to 125,000. An HAA initiative launched in February 2007 to distribute one million condoms also fell short. In September 2007, the District claimed to have distributed 650,000 condoms, but activist David Mariner wrote that “HAA is counting all the condoms they have given to local agencies, without regard to whether or not they have been handed out to actual people. Boxes and boxes of these ‘distributed’ condoms are actually in storage at local organizations.” HAA should change from its current haphazard approach and begin specifying distribution points at public health centers, hospitals, bars, nightclubs, and social service agencies, to permit better tracking. Lack of access to a condom should never be the reason for not using one.
c. Oppose criminal penalties for HIV transmission. Criminal penalties should not be used to address healthcare issues, as some have proposed. Imposing criminal penalties for knowingly transmitting HIV would have the unintended effect of harming HIV testing and prevention efforts by driving activity underground and encouraging more anonymous sex. It would also increase the stigma of HIV. HIV transmission is a public health issue and needs to be addressed as such.
B. Legalizing Medical Marijuana GLAA supports legalizing the medical use of marijuana when a patient’s doctor recommends it to combat some of the effects of AIDS, cancer, or other diseases. Initiative 59 passed by 69% and won in every precinct. The Council should oppose penalties against people who use medical marijuana or acquire it for their loved ones. The 1999 report
Marijuana and Medicine by the IOM found clear benefits of marijuana for the relief of pain and nausea and an increase in appetite. There is no reason to believe that legalizing medical marijuana in controlled situations encourages drug abuse. Alleviating pain and suffering must not be sacrificed to political posturing and demagoguery.
C. Women’s Health Needs There are many other medical issues of concern to our community. Lesbians are at particular risk of not receiving early diagnoses of breast and cervical cancers, based on lack of access to and sensitivity of medical providers to lesbian sexuality issues. The city must ensure that its health centers are staffed with people who are aware of and sensitive to such issues. The needs of women with HIV/AIDS must similarly be provided for.
D. Transgender Health Needs Transgender people in D.C. are disproportionately poor and unreached by our health care system. Incidence of HIV infection is greater than 25%. Prostitution is often a means of survival as discrimination and sex-transitioning keeps many out of stable employment. This is a serious HIV transmission vector that has been neglected by HAA because of the relatively small number of transgender people. HAA must make medical care for this at-risk population a priority.
Transgender people also face discrimination at shelters, in housing and in employment. Police routinely treat transgender people as prostitutes. The spate of murders of transgender people—9 in 2003—has created fear that has not been much eased by the official response. All of these problems have contributed to the further marginalization of transgender people, and limited their access and willingness to seek medical care. A comprehensive approach by the city is needed.
E. Tuberculosis, Hepatitis and Substance Abuse Drug-resistant tuberculosis (TB) and Hepatitis B and C need to be aggressively stamped out before they become more entrenched among people with HIV/AIDS and their medical care providers.
People with HIV are 40 times more likely to develop active, infectious tuberculosis if exposed to the contagion than are people with healthy immune systems. In 1994 the federal government began offering matching funds to states and territories to help them develop a limited Medicaid benefit for people who are infected with TB. The District should use these funds because current treatment is now funded by limited Ryan White or Alliance dollars. Also, these funds would be beneficial for keeping open the city’s cash strapped TB/STD clinic, which serves as a major point of entry for people newly diagnosed with HIV into the city’s health care system.
Substance abuse ranging from alcohol to crystal meth remains a serious problem in the District and contributes to the spread of HIV and other diseases. GLAA supports continued funding of targeted substance abuse treatment programs.
F. Domestic Partnership Insurance Availability for Small Businesses Many small businesses in the District have been unable to offer health insurance to the domestic partners of their employees because of the lack of insurance companies offering coverage to employers with fewer than 50 employees. In addition to putting small businesses at a disadvantage in attracting and retaining employees, the lack of access means that people who could have private insurance go uninsured. While D.C. has a low rate of uninsured, anyone without insurance eventually becomes a burden for the District.
On May 12, 2003, District Insurance Commissioner Lawrence Mirel secured an agreement from CareFirst Blue Cross to offer insurance coverage of domestic partners to employers who request it. Unfortunately, other insurers have not kept pace, limiting options for small employers. If other insurers do not extend domestic partner health insurance coverage to small businesses on their own, the District, at a minimum, should use its clout as a major customer to demand this coverage from insurers wishing to do business with the city. Additionally, the Council should pass legislation requiring insurance companies to extend domestic partner health insurance to all size businesses that request it for their employees.
G. Universal Health Insurance CoverageGLAA supports universal access to health insurance. We commend David Catania for introducing the “Healthy DC Act of 2008,” and we commend his colleagues for incorporating it into the budget. The bill’s requirement of health insurance coverage for all District residents will improve overall health, reduce the cost of medical care, reduce HIV transmission, and improve the health of people with HIV.
The Associated Press reports that an increasing number of states are rejecting ill-advised Abstinence-Only-Until Marriage funding; and rightly so. There is no scientific evidence that abstinence-only-until-marriage programs—those that censor information about contraception—are effective in preventing HIV or teen pregnancy. 
The analysis is available 
