[HARMRED] Speech from Paul Kawata @ Opening Plenary National HIV Prevention Conference
markkinzly at yahoo.com
Tue Aug 16 09:41:18 CDT 2011
Speech from Paul Kawata @ Opening Plenary
National HIV Prevention Conference
August 14, 2011
I want to thank the Centers for Disease Control and Prevention for giving me this opportunity. I've been writing a series of "musings" where I
ask the question "Are You Ready?" Our movement is going through a
transformation and I am concerned that some of us will be left behind.
The last time we faced this significant a change was in 1996 with the
introduction of Proteases Inhibitors. The impact of combination therapy
changed the landscape of our movement. Community based organizations
had to retool their services from those that take care of the dying into
services that support the living. Over the next 3 years we will have
to transform again, with the intersection of
1. Affordable Care Act
2. National HIV/AIDS Strategy
3. Treatment as Prevention (TasP)
Unfortunately, we are in an economic climate where Congress and the
President just cut $2 trillion in federal spending. It's the economics
that are going to make this discussion particularly difficult. Is it
reasonable to start new HIV prevention programs when state budgets are
being cut? A lack of funding will definitely impact our ability to
implementation the national AIDS strategy.
The irony is, we are at a moment in our movement's history where we could end the epidemic. Think about it for a moment, we could end this epidemic.
At the IAS conference last month, Dr. Julio Montaner discussed the data for HIV Prevention Trial Network Study 052. The study showed that HIV-positive individuals who started treatment
and got their viral load to undetectable, reduced the risk of HIV
transmission by 96 percent. I have to tell you, I cried. Who cries at a scientific presentation? Someone who has been fighting this epidemic
since the beginning, someone who believes we may be at the beginning of
There is something so perfect that on the 30th
Anniversary of this epidemic, we get the data that gives us a road map
to the finish. However, this was research performed in a controlled
scientific environment, now we have the responsibility to apply it to
real life. This is where this discussion gets difficult.
Over the next 6 months, you will be asked to take a hard look at the
impact of your prevention efforts. Some programs will need to be
retooled, but not everything. The CDC is calling this High Impact
Prevention (HIP). I know, another acronym, what's important to
understand is that Treatment As Prevention is a part of the CDC's HIP
Initiative. They work collaboratively to end HIV in America.
The new CDC FOA was the start of that discussion. How will you
incorporate 052 into your planning? More importantly, how will you
accomplish the promise of HIV prevention without new money? Planning to
implement 052 has to happen at the city, county and/or state level.
What works in one region may not work in another. Your plan will need
1. Identify HIV positive individuals who are not on treatment and to start treatment if it is medically appropriate
2. Work with HIV positive people who are on treatment, but not able to get their viral load to undetectable
3. Identify those who don't know they are HIV positive
It is goal #1: Identify HIV positive individuals who are not on
treatment and to start treatment if it is medically appropriate that
raises the most challenges. Is it medically appropriate to start asymptomatic HIV positive individuals on treatment?
When combination therapy first started, the side effects of those
original medications created significant problems. As a result, some
PWAs ended or delayed the start of therapy. Newer medications have
fewer side effects and are much easier to take; however, they still have
side effects for some individuals. This begs the question, Is it ethical to use the prevention benefits of treatment as a reason to start antiretroviral therapy?
Does that start us down the slippery slope were society/we use public health as the justification to trample on the rights of People Living with AIDS. Unfortunately, there are many examples from our history where this was true.
We know that criminalization of HIV transmission is not good public health, so should we understand that we cannot force people onto treatment.
That is why I continue to press for the leadership of People With AIDS.
We have to balance the 052 prevention benefits vs. an individual's
right to choose. Only with the co-operation, really I mean leadership of People Living with AIDS, will Treatment As Prevention work.
As you plan and implement your TasP strategy, certain guiding
principles should be observed. They are essential for protecting the
rights of PWAs and for ensuring the integrity of TasP.
Guiding Principles for Implementing TasP:
#1. Transparent Planning Process TasP is about lowering a community's viral load to reduce the transmission
of HIV. It requires the active participation of People with AIDS,
Healthcare Providers, Community Based Organizations, Health Departments, Federal Government, and the Pharmaceutical Industry. For this process
to work, planning and implementation must be:
2. Have Broad Community Input, particularly with PWAs
3. Promote Measurable ResultsTasP needs the cooperation of hundreds of thousands of PWAs. That is why transparency and community input are so essential.
#2. Can't Force People Onto Treatment Given the need for daily adherence to medications, forcing individuals onto treatment will not work.
We are asking our friends to make a lifelong commitment to stay adherent to their medications. Honest, upfront conversations about this commitment need to happen
before starting therapy. For a variety of reasons, treatment may not
work for someone at this moment in their life. This has to be OK.
#3. Commitment To Treatment Education & Treatment Adherence If we ask PWAs to make a lifelong commitment to be on HIV medications,
then we have a responsibility to educate about those medications. It's not reasonable to ask people to go on medications without giving them
the tools to understand those drugs, what may happen to their bodies,
and how it may impact their lives. Without treatment education, TasP is destined to fail.
Lack of adherence is probably the biggest barrier to achieving an
undetectable viral load. Removing structural and behavioral barriers to
treatment adherence are key to ensuring success.
structural change is to provide 90 days of meds instead of the
traditional 30 days. Not only is a 90-day supply cheaper, it is also
more convenient. We also need to push for innovations in dosing. A
monthly pill would revolutionize HIV treatment and adherence. I hear
that Dr. David Ho is trying to make this a reality.
#4. Mechanism For Payment If we put people on HIV medications, we must ensure that the resources are in place that gives access to these drugs for the rest of their life.
Starting and stopping medication is a sure way to develop resistance.
Our current system is not set up to handle an influx of PWAs
into treatment. Just look at the size of our ADAP waiting lists. TasP
may not be viable until the Affordable Care Actis fully implemented. Waiting until 2014 could mean 125,000 more Americans will be infected with HIV.
#5. Integrate Behavioral Health and Harm Reduction This recommendation is from my friends at the Harm Reduction Coalition. Mental health and addiction issues pose substantial challenges to HIV
treatment. All too often, behavioral health needs are under-recognized
or undertreated; especially outside of Ryan White-funded clinics.
Multidisciplinary care that integrates behavioral health remains all too rare, and as a result, many PWAs with these co-morbidities fall through the cracks.
#6. Regular Viral Load Testing Viral
load testing is an essential component to fully implement TasP. The
cost of this testing needs to be built into the provision of care. It
is not enough to just do CD4 counts. We need cheaper and more rapid viral load tests. At a minimum, the cost for viral load testing should be reduced due to a significant increase in the volume of testing.
#7. Stable Housing Activists like to say "Housing Is Prevention". If an individual does not have
stable housing, all other issues tend to fall by the way side. One of
the best ways to ensure compliance with HIV treatment is to support
stable housing for PWAs. The Ryan White Care Act and Housing
Opportunities for People with AIDS are an important part of stopping
All these reasons provide my rationale for why PWAs must lead the way.
There will be critical roles for CBOs, heath departments, healthcare
providers, the federal government and the pharmaceutical industry, but
it's going to take People with AIDS to end this epidemic. Personally, I think that's wonderful. It could be the perfect ending to this
So that's the Paul Kawata roadmap for
ending this epidemic. My team at NMAC and I hope to provide additional
tools to help you refine your work. Thank you for all that you do to
We can end the AIDS epidemic. It's in our grasp,
but it's going to require all of our leadership, vision and resources to
make this a reality.
Yours in the struggle,
National Minority AIDS Council
OUR CALLING IS THE PLACE WHERE OUR INNER JOY AND OUR INNER TERROR MEET
2 Thunder Hill
York, ME 03909
markkinzly at yahoo.com
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