Other Dragons at our Feet

The impact of the economic policies of a crazed administration on “Getting to Zero” and other necromancy at IAS 2017

Chad S. Johnson and Chris Romano

At IAS2016 in Durban, South Africa, we never truly anticipated being witnesses to the specter of an unprecedented economic and political unraveling of progress towards defeating this generation’s signature epidemic. The well-intentioned speeches, proclamations, and community building in Durban, realized on that idyllic Indian Ocean coast, now seem distant and naïve, as U.S. communities like Baltimore, Rochester, and the South Bronx fight against the threatened regressive policies of Washington.  As poverty and AIDS have come to be constant companions, without effective advocacy and scientific breakthroughs, scarcity and disease are settling in for an unwelcome, extended stay.

The 70s and 80s brought economic distress, drug wars, and the AIDS crisis, resulting in the South Bronx population plummeting by 57 percent from 383,000 to 166,000, one of the greatest population losses of a city not in a war zone.  The South Bronx is a key exemplar: a great place to live, boasting the Grand Concourse, The NY Botanical Gardens, Yankee Stadium, The Bronx Zoo, Fordham University and Arthur Avenue.  HIV rampaged through vulnerable communities, through the tenure of three NYC mayors, and funerals of tens of thousands of friends, neighbors and family members. Until the dedication of tens of millions of dollars from the Ryan White CARE Act, and the impact of billions in research, yielding the robust pipeline of therapeutics accelerated through the FDA at previously impossible rates, this borough was decaying fast. And these life-saving investments occurred despite murderous opposition in the name of harsh budget cuts and bureaucracy, and the intent of a masterful virus.  Regardless, there was hope for an end of the epidemic.

Then Donald Trump was elected President.

The first volley of the Trump Administration was to position to assassinate the Affordable Care Act. While the White House remains embroiled in one self-induced crisis after another, Paul Ryan, Mitch McConnell and their majorities are resuscitating the worst epidemic of a generation. The survival of people with HIV/AIDS hangs in the balance of back-room deal making on the Hill and a chaotic White House.

We knew if the improbable happened in the 2016 election, the ACA would be sacrificed. Now we know our President intends to go even further by eviscerating Medicaid, decapitating PEPFAR, eliminating US contributions to The Global Fund, and delivering mortal wounds to the NIH’s AIDS research.

It’s not surprising that six members of the Presidential Advisory Council on HIV/AIDS (PACHA) have resigned, with the URL for the hard-gained White House Office of National AIDS Policy (ONAP) going down on Inauguration Day.

Today, the Bronx is an epicenter of the AIDS crisis, characterized by narcotrafficking, incarceration within buildings abandoned by industrial landlords recouping insurance monies replaced by hopes of gentrification, culminating in the inglorious distinction of ranking amongst the poorest American communities. Despite all the evidence that impoverished people are most susceptible to contracting HIV, this Administration remains obsessed with demonizing the poor and retracting social safety nets, expecting patients to manage their medications in the face of chronic food insecurity and other elements of poverty.

 Out of the 19th World AIDS Conference in 2012, the slogan “Getting to Zero” became the feel-good phrase, without allowing for a fair measure of the implications of the CDC report that 3 out of 4 HIV+ Americans are unable to obtain undetectable viral loads.  And these statistics correlate   perfectly with estimates of food insecurity amongst AIDS patients.

Continued U.S contributions to the Global Fund have come into question with concurrent shortfalls in support from European countries and a looming fiscal cliff that Mike Weinstein at AIDS Healthcare Foundation warned about at the 21st IAC. Despite the tribulations of 2012 in D.C., the Global Fund announced the “20 by 20” Initiative, a monumental effort to place 20 million people with HIV in the developing world on antiretroviral therapy by the year 2020.

At the 9th IAS HIV Science Conference in Paris this July, we’ll have to define for ourselves and for future generations what “Getting to Zero” and “20 by 20” will mean in 2017. These initiatives demand accountability by a constituency aspiring to live despite this disease’s destiny being tied to discoveries for better drug development and saving substantial benefit programs for HIV patients.

Timothy Ray Brown’s letter on cuts to the NIH budget in June’s AIDS Research & Human Retroviruses is a start, as well as the condemnation by Treatment Action Group on May 24th of the proposed White House 2018 Budget Cuts for Health and Research. Therapeutic innovations are essential for the next evolution in successful management complications and co-morbidities of treatment experienced individuals. Unfortunately, there’s additional burden of rising addiction, accompanying crime, incarceration, and new HIV infections in populations experiencing the worst explosion of drug use since the crack epidemic affecting West Virginia, New Hampshire, and parts of Long Island:  the newest chapter of AIDS in America.

If the first six months of the Trump Administration teaches us anything, it’s that we must fight harder supporting new therapies to change the course of an epidemic transforming right now as much by advances in AIDS research as by the loss of social safeguards for at-risk populations. The danger of referring to the AIDS crisis as chronic and manageable, a pontification invoked too often by key opinion leaders, doesn’t take into account how we’ve assumed that The Ryan White CARE Act, ONAP and PACHA, PEPFAR, HOPWA, The Global Fund and Medicaid can’t be wiped out at the whim of an Administration unconcerned about the lifelines of the vulnerable.

While Trump slashes healthcare, the Administration wraps their small hands around the concept that this Congress needs to get on board with support for the lab-to-drug commercialization of best-in-class HIV therapeutics that are a part of the U.S. Public Investments for Innovative HIV Therapeutics Act of 2017 and the Human Microbiome Innovations Act of 2017 for Public Private Partnerships. These acts are gathering supporters to be submitted in 2018.

New therapeutic approaches in the pipeline addressing HIV’s effect on the microbiome with data on Visbiome, new inhibitory targets like ABX464 in phase 2, targeting HIV’s biogenesis and Sangamo BioScience’s phase 2 investigation of the leading gene therapy, along with the cornucopia of vaccines in various stages of development, all offer the means to ensure that the next decade of this plague is focused on ending AIDS.

Four decades into the AIDS crisis, knowing that cheerleaders don’t score touchdowns, we must preserve programs providing for housing, food, medicine, transportation and electricity through an electoral process that is substantially more inclusive then what we have today. The AIDS crisis grew out of our nation’s imposition of poverty, addiction and alienation. Like the revitalization of the Bronx, IAS 2017 offers promise, a unique hope for innovation, and if it can ever be found in this White House, compassion.



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