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AIDS was first identified in the United States of America in 1981.  Since then, the epidemic has been steadily growing and by the end of 2004, there were estimated to be just over 1 million people living with HIV and approximately 415,000 people living with AIDS in the USA.  AIDS is also thought to have killed over half a million Americans - nearly ten times the number killed in the Vietnam war - and more become infected every day.

The situation now

The adult HIV prevalence rate in the United States is estimated to be around 0.6%.1 This is however only an average figure, and while the virus affects every level of American society, certain social groups within the country's diverse population are more severely affected than others.

The number of HIV+ people living in the USA varies between 900,000 and 1.2 million according to different estimates - UNAIDS currently estimates it to be 950,000. Around 30% of those living with HIV are unaware of their infection - and may unknowingly infect more people as a result.2

It is estimated that 40,000 new HIV infections occur in the US each year,3 and although this is less than the 1980s peak of 150,000 new infections per year, the figure hasn't declined for the past decade. Of these 40,000 annual infections, about 70% are amongst males and about 30% females.

The graph below shows the way in which annual AIDS diagnoses, after falling with the introduction of antiretroviral therapy, have remained fairly constant since 1999, even rising a little. At the same time, deaths of people with AIDS have also remained stable with 15,798 occurring in 2004, the most recent year for which data are available.4

 

Tracking the development of the epidemic in the USA is made more difficult because HIV data collection has, in the past, been patchy and incomplete, with HIV infections not recorded in all states. Even today, the annual CDC (Centers for Disease Control and Prevention) surveillance report only includes HIV diagnosis data from 35 of the 50 US states.  This is because the other states don't have a long enough history of reporting HIV diagnoses via the code-based (as opposed to name-based) system preferred by the CDC.  Diagnoses of AIDS have however always been recorded, so when looking back at previous years, it is usually AIDS cases that are discussed.

It is important to remember that AIDS cases are not the same as HIV infections, because an AIDS diagnosis may occur many years after the initial HIV infection took place. Since about 1996, when combination antiretroviral drug treatment became more common in America, AIDS diagnoses have been an even less reliable way to judge HIV infections. This is because the treatment enables people with HIV for much longer before developing AIDS.

Issues - an unequal epidemic

Social divisions - Sexuality

In the early years of the epidemic, it seemed that HIV was something that predominantly affected gay men. Since then, however, epidemiological patterns have gradually shifted. The majority of people currently living with HIV in the USA are still men who have sex with men, but in 2004, heterosexual transmission accounted for 35% of all newly-diagnosed AIDS cases - up from 3% in 1985.5

Men who have sex with men (MSM) are nonetheless still at a high risk of HIV infection. In 2004 they accounted for more than half of new HIV diagnoses. Particularly at risk are younger MSM and those from racial minorities. Perhaps because their age means that they didn't see friends die in the early years of the epidemic, younger gay men are becoming increasingly complacent about practising safer sex, and they remain at considerably higher risk of encountering a sexual partner who is HIV+ than members of any other group in America.

Social divisions - Injecting Drug Users (IDUs)

HIV can be easily transmitted by sharing infected injecting equipment, so IDUs are another group who are disproportionately affected by HIV in the USA. In 2004, some 34% of women and 21% of men who were diagnosed with HIV were injecting drug users who were assumed to have been infected as a result of their drug use.6

Social divisions - Race

AIDS has also had a serious impact upon racial and ethnic minorities, particularly in recent years. The demography of the epidemic has changed considerably over the last decade, and African Americans in particular are now very disproportionately affected.

Racial minority groups today represent almost three quarters of new AIDS cases. In 2004, African Americans accounted for 43% of all AIDS cases reported during the year, even though they make up just 12% of the population. Among African American women, the figures are even more alarming - 67% of American women diagnosed with AIDS in 2004 were black.7

 

AIDS diagnoses in African Americans, 2004

Racial origin does not make anyone automatically more or less susceptible to HIV infection, so there must be other reasons for this imbalance. Poverty may be one factor which explains the increased HIV prevalence amongst African American populations. Studies have found an association between higher AIDS incidence and lower income.10 It is estimated that a quarter of African Americans live below the poverty-line, a condition which is associated with an increased vulnerability to HIV infection,11 as people on inadequate incomes are more likely to experience discrimination, illiteracy, addiction and sexual exploitation.

High levels of HIV within the population have also been attributed to the practice of being on the 'down low', whereby black men will have sex with other men without necessarily identifying as gay (which can be highly stigmatising in African American society).  Sex between men carries a higher risk of HIV transmission than heterosexual intercourse, and many men on the down low will also have wives or girlfriends who know nothing of their partners' relationships with other men, and are consequently at high risk of infection themselves.

A recent study by researchers at U.C. Berkeley has also suggested that the high numbers of black African American men in incarceration may also have played a role in the spread of HIV. Approximately one in twelve black men are currently in prison (as opposed to one in 100 white men), and at present rates, a third of the black men born today will spend some time in jail. As injecting drug use, unprotected sex between men and male rape make HIV transmission within prisons far more likely, the researchers concluded that the rise in jail-time and the rise in HIV could be linked. Indeed, on further investigation, they discovered that the increase in AIDS among black Americans closely corresponds to the rise in incarceration rates of black men over the past two decades.12 

Finally, once a person is infected with HIV, race plays a factor in determining the type of services they will be able to access. African Americans are considerably more likely to be medically underserved than white Americans.13

Social divisions - Gender

AIDS in the USA began as something that mainly affected gay men. Over the years however, the epidemic has gradually moved towards a gender-balance, as increasing numbers of women have become infected with HIV (something we can infer from rising female AIDS diagnoses). In 2004, women accounted for 27% of all AIDS cases, up from 8% in 1985.

Heterosexual intercourse accounts for most HIV diagnoses amongst women - 70% in 2004 - and there are strong indications that the main risk factor for many women acquiring HIV heterosexually is the risky behaviour of their male partners (of which they are often ignorant). Recent research in a low-income area of New York City, for example, has shown that women were more than twice as likely to be infected by a husband or steady boyfriend than by a casual sex partner.14

Social divisions - Geography

HIV has become a problem in every state in America, but is more an issue for some than others. Some 72% of all AIDS cases to date have been reported in just ten states, and most are found in urban areas.15 This is not exclusively the case, however - AIDS is also a serious problem in rural areas in the South. The map below reveals the unequal geographical distribution.

AVERT.org has a number of pages that present and discuss more detailed HIV & AIDS statistics for the USA.

Issues - discrimination

Discrimination in the USA

HIV-related discrimination is something that happens all over the world, and the USA is no exception. Since AIDS was first identified, many affected Americans have experienced stigma, stereotyping and discrimination. In the early days of the epidemic, this discrimination occurred largely because of the general human tendency to fear what is not understood - many people lacked an understanding of what caused AIDS and how people could become infected.

In 1983, some police officers in San Francisco took to wearing special masks and gloves for use when dealing with a 'suspected AIDS patient', concerned that they could bring the virus home and give their whole family AIDS. At the same time landlords started evicting tenants who had AIDS, and in 1985 Ryan White, a 13-year old schoolboy who had become infected via a blood transfusion, was banned from going to school due to fears that other children 'might pick up AIDS'.

A Florida family called the Rays had three haemophiliac sons who contracted HIV from infected blood products. In 1986, the family were told that their sons were not to attend the local school. They moved to Alabama, where the same thing happened. The family began to be threatened, and eventually the their small single-storey house was doused with gasoline and torched.

Such violence was clearly the result of an extreme and unacceptable level of discrimination. Thankfully the United States now has legislation which makes it illegal to discriminate against someone on the basis of their HIV status, and as early as 1986 the government made clear to employers that they would be prosecuted if they discriminated against HIV+ people. In spite of this, discrimination still occurs today, and can have traumatic consequences for HIV+ people.

Reasons for discrimination

Discrimination is often a result of ignorance - in the early years the general public didn't understand AIDS, didn't know how it was transmitted, and didn't know they weren't at risk from everyday contact with affected people. Authority figures, who were seen as setting an example of how to behave, were unfortunately just as ignorant, and when the public saw police and school officials acting in a way that suggested HIV+ people were dangerous, alarm increased. Given that discrimination is often a direct result of ignorance, this suggests that AIDS education was (and maybe still is) either not working or not present at all.

The USA started early in educating its public about AIDS. The first national AIDS awareness campaign came in 1986, and since then there have been a number campaigns to educate the general public and specific risk groups. Clearly, however, such campaigns have been less than effective, as discrimination continues. Issues surrounding AIDS education in America are examined later in this page.

Another reason for the stigma experienced by HIV+ people in the USA is the existing prejudices against the most-affected groups.  Long before AIDS was an issue, gay people, injecting drug users and sex workers all experienced considerable hostility in society.  AIDS, of course, simply provided another excuse for this prejudice. It seems that a large proportion of the American public still associate HIV with injecting drug users and gay men, and see it as 'dirty' or as something which HIV+ people 'brought on themselves'.

To some extent, this is exacerbated by the media who talk about the 'innocent victims' of the AIDS epidemic: babies infected at birth, or people infected by blood transfusions.  This concept of 'innocent victims' implies a concept of 'guilty victims' - people who were infected via risky sexual behaviour, or injecting drugs. Of course, no-one deserves to die for taking drugs or having sex, but the terminology suggests otherwise. In turn, this increases the stigma directed towards many HIV+ people, who are seen as being to blame for their infection.

Apart from the distress it causes to those who experience it, stigmatisation of HIV+ people can have several other negative consequences.

Results of discrimination

In an environment where people who are HIV+ are discriminated against, anyone who has a positive test result will be very reluctant to 'come out' about their status.  The more people who are open about their HIV status, the more the general public will be aware that there is an ongoing problem, that people do continue to become infected, and that they need to protect themselves. They will also be able to see that HIV+ people are not exclusively gay men or drug users, which will itself help to fight prejudice. Furthermore, if there are already plenty of people who are 'out' about their HIV status, this makes it easier for someone new to 'come out'.

Another negative effect of social discrimination is an increase in people's reluctance to learn their HIV status. People generally don't want to join a group which is stigmatised. Of all HIV infections diagnosed in 2002, 38% progressed to AIDS within 12 months after HIV infection was diagnosed.16 This high percentage suggests that many HIV+ Americans had been infected for a number of years before they were tested - during which time they may have infected other people. Reluctance to learn one's status and thus join a stigmatized group (as well as general fear about having such a serious illness) might help to explain this gap between infection and testing.

Solutions to discrimination

In the early days of the AIDS epidemic in the USA, very few well-known people admitted to having AIDS. Since then, a number of celebrities have decided to be open about their HIV status, something which helped to show the public that the disease is something that can happen to anyone. This has helped to reduce the discrimination felt by HIV+ people across America to a certain degree, but few straight people have 'come out' as having HIV, and there remain relatively few HIV+ 'role models'.

Another way to combat discrimination is to teach people how they can and cannot become infected with HIV - so they understand there is no need to fear those living with the virus. For discrimination to be dissipated however, an effective AIDS education program is required.

Issues - Education and Prevention

Why does the USA need AIDS education?

There are two main reasons that AIDS education is needed.  The first is to reduce stigma and discrimination experienced by HIV+ people. The second is to prevent new infections from occurring.

The ongoing discrimination that occurs across America and the regular number of new infections each year suggest that AIDS education in the US is either insufficient or is not getting through to the groups who need it. There is clearly more that needs to be done. A number of studies indicate as such - for example a 2004 survey found that whilst 99% of Americans knew that having unprotected intercourse and sharing an intravenous needle might transmit HIV, 38% thought that it could be transmitted by kissing, 25% by sharing a drinking glass, and 18% thought that they could be infected by touching a toilet seat.17

Adequate AIDS education can help to prevent new infections from occurring. Teaching people who are not infected with HIV what activities may put them at risk will empower them to protect themselves. Education can also prevent new infections by teaching HIV+ people how they can lead sex lives without passing the virus on to anyone else. The same survey quoted above also found that 21% of Americans were unaware that there was not an AIDS vaccine available - an belief which could have alarming effects on their sexual behaviour.

AIDS education up until now

Although AIDS education is vitally important in saving lives, religious and moral values have greatly influenced the content of what is taught. In 1981 Congress passed the Family Life Act which funded educational programs to promote 'self-discipline' and emphasized sexual abstinence until marriage as the best form of protection from unwanted pregnancy and sexually transmitted diseases.  Whilst this is undoubtedly true, abstinence is not the only way of remaining safe, and is not always a realistic prospect when addressing hormonally-charged young people.

In 1987, President Reagan advocated a modest federal role in AIDS education, "as long as they teach that one of the answers to it is abstinence - if you say it's not how you do it, but that you don't do it". Ever since, the classroom has been opened up to the religious right who have used sexual health education to spread an ideological message - that of sexual abstinence until marriage.

Federal government involvement has come, in part, via the CDC, which has included specific funding for HIV education in its budget since 1988. The CDC, however, has not been immune from 'family values' biasing of 'facts'. In October 2002, a fact sheet on the CDC website that included information on proper condom use, condom effectiveness, and studies showing that condom education does not promote sexual activity, was replaced by a document that highlights condom failure rates and the effectiveness of abstinence.18 USAID similarly altered its website in early 2003.19

In 1996, Congress made federal funding available for a five-year period to teach abstinence-only education in schools. By 2002, some $500 million had already been spent to fund abstinence-only sex education - about $100 million a year since 1996.20 The federal government spent approximately $170 million on abstinence-only education programs in 2005, more than twice the amount spent in 2001.21

AIDS education in American schools

AIDS education in American schools today falls into one of two categories - either Abstinence-only or Abstinence plus (also known as Comprehensive). These are really types of sex education, rather than AIDS education specifically - AIDS education in American schools usually comes as a part of a sex education program, if it occurs at all. Sex education has for some time been led by the 'family values' movement, which dictates what can and what can't be taught. AIDS education, by association, has also fallen victim to faith-based fact-filtering.

Abstinence-only education teaches students that they must say no to sexual activity until they are married. This approach does not teach students anything about how to protect themselves from STDs and HIV, or how pregnancy occurs and how to prevent it, and teaches about homosexuality and masturbation only as far as to say they are wrong. Those who favour this method of education claim that teaching young people about sex will make them want to try it - thus increasing their risk of contracting HIV, amongst other things.

Abstinence plus or Comprehensive sex education teaches about sexual abstinence until marriage, and teaches that it is one way of protecting yourself from HIV transmission, STDs and unwanted pregnancy. It also teaches that there are other ways of preventing these things, such as condom use. People who favour this approach take the perspective that young people should be taught to remain sexually abstinent until marriage, but that there will always be some who won't - and that they must be provided with the information to enable them to protect themselves.

There has been debate for many years over which form of sex education is most effective in terms of preventing underage sex, unwanted pregnancy and STD and HIV transmission.  But a recent study22 in President Bush's home state of Texas found that students who have abstinence-only education are just as likely to have sex as their comprehensively-educated peers.

AIDS education and adults

Of the annual 40,000 new HIV infections in the USA, it has been estimated that around half occur in people aged under 25 years old.23 This means that whilst young people might be an easier target for AIDS education, they are certainly not the only age-group at risk of infection.

Federal AIDS education in America, however, focuses almost exclusively on young people, where it exists at all.  Adults are assumed by the government to already know about HIV transmission risks, and how to avoid them. Some federal money is spent on providing abstinence-only AIDS education to young unmarried adults, but in recent years there has been virtually no adult HIV education strategy, despite the obvious evidence that adults continue to become infected. What has been done has occurred at a state level, and adults receive their information primarily from either the media or from the church, which can sometimes emphasise ideology over scientific fact.

AIDS education and HIV+ people

HIV+ people are sometimes overlooked by AIDS education planners, but they can benefit greatly from effective education strategies. AIDS education with HIV+ people aims to:

  • help them to cope with the knowledge that they are HIV+
  • inform them about the nature of HIV and AIDS
  • enable them to have a safe and active sex life, if they wish to
  • ensure that their infection isn't passed on by any other means
  • enable them to lead full and healthy lives
  • empower them to confront discrimination where it occurs.

The USA has recently increased its focus on positive people as a target for HIV prevention strategies, and is currently trying to encourage as many people as possible to be tested for HIV. The idea to find people already living with HIV and help them to avoid infecting others. AVERT.org has a seperate page about this strategy and other issues related to HIV testing in the USA, as well as a page discussing the CDC's Advancing HIV Prevention initiative and its impact on America's HIV prevention efforts.

Mother-to-child transmission

This is one area in which the US has responded very well to the HIV epidemic. The CDC reports that through 2004 there have been a cumulative 8,779 cases of AIDS in children under 13 years that occurred because of HIV infection during pregnancy, birth or breastfeeding. However, annual numbers have fallen dramatically in recent years, and in 2004 only 47 cases of AIDS were reported in children infected by their mothers. The chance that HIV infection is transmitted from a mother who is HIV+ to her child during pregnancy can be reduced to below 2 percent if the correct antiretroviral medication is administered. This, of course, can only happen if the mother knows she is infected.

The CDC recommends an 'opt out' approach to the testing of pregnant women. This means that an HIV test is offered to a woman among the standard prenatal tests, but she has a right to refuse it if she wishes.24 If she does refuse, however, she might be considered to be putting the health of her unborn baby at risk, so the majority of women agree to take the test. Thanks to this prenatal screening programme, mother-to-child transmission of HIV in America has almost been eliminated.

What else is needed to prevent HIV transmission?

Education is a major component of AIDS prevention, but there are other things which must be done if HIV transmission is to be prevented. The first step in enabling people to protect themselves from HIV infection is giving them the information they need to be aware of the risks, and to know how to prevent transmission from occurring. This is only the first step, however - they then need the resources to put this information to practical use. In the same way that there is no point in telling a motorcyclist to wear a crash helmet if they can't then buy one in a shop, there is no point in teaching people how to prevent HIV transmission if they are not given the tools they need to make use of this knowledge.

Condoms

Studies indicate that simply planning to abstain from sex until marriage doesn't necessarily help to reduce the likelihood of STD infection or pregnancy. This is because many people planning on abstaining until marriage lack the knowledge needed to protect themselves if an unexpected sexual encounter does take place.25

The United States has been criticised for substituting 'abstinence until marriage' programs for science-based HIV prevention strategies that include information about correct and consistent condom use. The U.S. Global AIDS Coordinator Randall Tobias has responded by saying that the US HIV prevention message could be characterised as 'ABC', which stands for Abstain, Be faithful, use Condoms, in that order.26 However, he has also commented that "statistics show that condoms really have not been very effective".27

There has been growing concern that America's policies have been swayed more by faith than by fact - many religious groups, such as the Catholic Church, are anti-condoms, despite the millions of lives these cheap, easily distributed items save. Condom use has, however, increased significantly amongst young people over the last decade.28, 29, 30 Condoms in America are available through a number of sources, such as drug stores and family planning clinics.

Some schools make condoms freely available too, and it has been found that this does not increase sexual activity. However, when schools don't offer such programs, it can be difficult for young people to access condoms - a 1996 survey found that condoms were sold from behind the counter in 83% of all convenience stores, and that young females asking for help in locating or purchasing condoms encountered resistance or condemnation from clerks on 27% of occasions.31 Recently, some stores have even taken to locking condoms in glass cases to prevent theft, meaning an assistant has to be called to access them.

It can be even more difficult for young people to access reliable information about condoms. Some have even been taught untruths - for example that HIV is small enough to 'pass through' the pores in latex - in an effort to get them to abstain from sex altogether.

Needles

HIV transmission among injecting drug users (IDUs) has always been a serious problem in America because of the risks posed by sharing injecting equipment. A study in 1988 found that one in four persons with AIDS in the United States had used illicit drugs intravenously32 and, while this may not have led to their infection, it could certainly have led to that of someone else. More recently, 21.5% of adult HIV diagnoses in 2003 and 26% of cumulative infections through 2004 were in people who had probably been infected by using needles or by being the partner of an IDU.33

According to a 1996 study,34 an estimated 2.4 million Americans have used heroin at some time in their lives and nearly 216,000 of them reported using it within the month preceding the survey. Injecting is the most commonly-favoured method of taking the drug, but it is not only 'street' users of heroin who are at risk. The drug has spread into mainstream culture, and other drugs - such as crystal methamphetamine, favoured by the gay community, and steroids, used by body-builders - also carry the risks of injecting without the stigma of heroin use. The prevalence of drug use in America shows clearly that the potential for HIV transmission amongst American IDUs is very high.

Working specifically with IDUs can help to reduce their risk of HIV. If IDUs are provided with information and clean injecting 'works' (syringes and needles) then they can be empowered to take action to prevent HIV infection. IDU-related HIV transmission can be greatly reduced by the provision of clean needles, and the safe removal of used ones - a system known as 'needle exchange'.

Needle exchange schemes specifically address the high risk behaviour of IDUs - sharing works - rather than the root cause of their behaviour - addiction. This strategy is therefore referred to as 'harm reduction', since it does not attempt to prevent or stop their drug use, merely reduce the harm it causes them. Because it does not try to break the incredibly powerful dependence on drugs that most addicts have, this strategy is usually far more successful at preventing HIV transmission than relying solely on 'rehabilitation' schemes. 

IDUs are often very aware of the risks of sharing injecting equipment, and do not do so through choice, but through a lack of alternatives. When they are able to access clean equipment, they do so. Needle exchange schemes have been shown by a number of studies to significantly reduce HIV transmission amongst IDUs, but they are often unpopular - even criminalised - in much of America.

What is more, many states have 'drug paraphernalia' laws that make it a crime to possess or distribute needles or syringes, and five U.S. states impose a total ban on sales of syringes in pharmacies without a prescription. Because they are so difficult to acquire, and in order to reduce the chances of prosecution, IDUs are forced to either share syringes or stop taking their drugs. The power of heroin addiction means that few consider the latter. Even where over-the-counter sales of syringes are permitted by law, pharmacists are often reluctant to sell to IDUs.

One argument against the provision of needle-exchange facilities comes from the discriminatory view of IDUs as 'guilty victims' - which forgets that IDUs endanger not only themselves, but their sexual and injecting partners and their families. Another argument - which has been proved wrong - is that needle exchanges actually encourage the use of illegal drugs. Needle exchange schemes in America have been opened and closed again as the political climate has shifted. One significant development came in September 2004 when Arnold Schwarzenegger, Governor of California, signed legislation permitting the sale of sterile syringes without a prescription - something not previously possible in California.

Nevertheless, in many other parts of the US, American legislators prefer the belief that needle exchanges cause increased drug use to the scientific fact that they do not. Furthermore, the federal government is using its economic power to try to export this view to the rest of the world - recently America tried unsuccessfully to pressure the United Nations Office on Drugs and Crime to remove all support for harm reduction programs.35

Issues - Treatment

Life for a person who is HIV+ may be less harsh in the USA than in many other countries, but even in the richest nation on earth, it is not always easy. Aside from having to face discrimination - both socially and in the employment market - there are issues surrounding access to treatment.

Many US citizens will be aware of the shortage in Africa of life-saving AIDS drugs, which is leading to the unnecessary deaths of millions. They are also likely to be aware of the US government's plan to spend US$15 billion fighting AIDS in the developing world - much of which will be spend on the provision of these drugs.

They might be more surprised to learn that it isn't only in the poorest parts of Africa that people die for lack of drugs - that it happens in the USA, too - and that it isn't rare.

How is AIDS treatment funded in the USA?

On 8th April 1990 in the United States, a young haemophiliac named Ryan White died. He had become infected with HIV through the use of contaminated blood products and had become well known a few years earlier as a result of his fight to be allowed to attend public school. A few months after his death the Ryan White Comprehensive AIDS Resources Emergency (CARE) Act was passed by Congress. The aim of this act was to provide grants to improve the quality and availability of care for HIV+ people.

The federal budget request to Congress for fiscal year (FY) 2007, submitted in February 2006, included an estimated $22.8 billion for HIV and AIDS. Federal funding for AIDS programs falls into five basic categories: care, financial and housing assistance, prevention, research, and global spending. Of these five budgets, domestic AIDS care spending is by far the largest, with $13.2 billion requested for FY 2007 - a 7% increase on 2006, and 58% of the total budget request. The majority of care funding goes out through the federal Medicare and Medicaid programs for people who do not have adequate private health insurance. The remainder is then principally spent on Ryan White CARE Act programs.

Medicaid is a medical assistance funding program which is paid for by federal and state governments. It provides coverage for medical, dental, optical, mental, hospital, and long-term care costs for eligible people. It also covers prescription medication. Eligibility criteria vary slightly from state-to-state, but generally eligibility is based on one of the following: having children and a limited income, receiving or being eligible for Social Security benefits, being a pregnant woman and having an income below a set amount, or having family assets below $2,000. Medicaid is supposed to be accessible only to people who have exhausted all of their alternative financial resources.

Medicare is a medical insurance program that provides health insurance to people who are 65 years old or over, or people with certain disabilities. Medicare Part A pays for necessary medical care given at specific, certified hospitals, clinics or hospices. Part A is free to those who are eligible, and does not cover prescription medication. Medicare Part B helps to pay for doctors, outpatient hospital care, ambulance costs, and other tests and services. If a person qualifies, this costs $66 a month, which can be taken out of social security. Part B pays for 80% of most of the services covered, unless the person is treated by a doctor or institution that doesn't accept Medicare, in which case the person must pay the full cost of treatment. In order to qualify for Medicare, someone must be over 65 and have had at least 10 years of Medicare-covered work, must qualify for social security retirement or disability benefits, or be a kidney transplant patient.

AIDS medication can be very expensive, and there are many cases of people who have AIDS, lack adequate private health insurance, and do not qualify for either Medicare or Medicaid, but still have expensive treatment needs which their income and assets cannot cover. Without the correct drugs, these people will die, so in the USA there are a number of other sources of help for people in need of AIDS treatment, the largest of which is the AIDS Drug Assistance Program covered by the Ryan White CARE Act.

The AIDS Drug Assistance Program (ADAP) is intended to help HIV+ people purchase prescribed AIDS medicines when they don't have private health insurance, don't qualify for Medicaid, and are unable to afford the cost of the drugs. Rather than one ADAP, there are actually 57, run separately by each state or US Territory and drawing their funding mostly from Federal government at a level which is not necessarily related to the level of need in that particular state. State contributions, where they exist, are usually higher in those states which have high prevalence levels and vocal AIDS advocacy groups.

In June 2005, ADAPs were supporting approximately 134,000 people with HIV in the USA, either by directly paying for drugs, or by financing their private health insurance plans.   ADAP clients represent around 25% of those thought to be living
with HIV/AIDS and receiving care in the U.S. each year.36 Although they help a large number of HIV+ people, ADAPs have been critically underfunded for years, meaning many people with HIV are now on waiting lists for HIV drugs.  As a result, something is now happening in the USA that many people believe doesn't happen anywhere outside the third world - people are dying for want of AIDS medication.

The total number of Americans living with HIV and AIDS is growing because more people are becoming infected and because treatment lengthens the life-span of an infected person. The pool of people dependant on ADAPs is therefore increasing, and is unlikely to get any smaller in the immediate future. Furthermore, the financial pressure on ADAPs continues to grow as the cost of prescription drugs rise meaning that people suddenly discover they can no longer afford the drugs (particular if they have to change to a new medication) and are forced to become ADAP clients.37

The federal contribution towards ADAPs increased by 10% in FY2005 to $1.3 billion, and was boosted by an extra $20 million from President Bush as part of the President's ADAP Initiative (PAI) in 2004. But the problem is still extensive.

A person who has AIDS, if denied ARV drugs, is likely to become ill and die within months. Anyone who is on an ADAP waiting list is someone who needs drugs and is unable to get them. If the person is lucky, they will get to the front of the queue before their health has been significantly harmed. If they are less lucky, they will get to the top of the waiting list and receive medicine only after experiencing significant health problems. And if they are very unlucky, they will die before they ever get to the top of the list.

Information about ADAPs waiting lists collected by the Kaiser Family Foundation, which is accepted by Congress as being accurate, shows that lengths of waiting lists can fluctuate massively. For example there were 1,108 people on lists in 7 states in July 2002, and 813 in 9 states in November 2004.38 Between these dates, numbers waiting peaked at 1,629 and a total of 18 different states had waiting lists at some point.39  Since then, fluctuations have been smaller but there has been very little overall change, despite the introduction of the President's ADAP initiative. In February 2006, 791 people in 9 states were on ADAP waiting lists.40

Dr. Faisal Khan, director of West Virginia's HIV/AIDS/STD program, when commenting on his state's ADAP waiting list said,

"People are now starting to die while they're on the waiting list. It is a crisis that will continue."41

It is very hard to find an exact number of people who have died whilst on ADAP waiting lists, but the figures are likely to be significant.  There are also no data on the number of deaths amongst people who failed to get on to the ADAP waiting lists, because tightening eligibility criteria meant that they had just a few dollars too much in their pay cheque to qualify for help.

Conclusion

In his State of the Union address in February 2005, President Bush called for the Ryan White Act to be 'reauthorized' (funded for a further 5 years) saying, "we must focus our efforts on fellow citizens with the highest rates of new cases, African American men and women".42 As might have been expected, the first half of the address concentrated on America's economic issues, and the last focused on her security. Between the discussion of these two very important concerns came the brief mention of 'HIV/AIDS'.

Plans are now underway to fully reauthorize The Ryan White Act, but meanwhile cases of HIV and AIDS amongst African Americans, and most other sectors of society, continue to rise, and many are forced to live without treatment.

AIDS is an economic issue as well as a humanitarian one - the cost of AIDS to America's economy is substantial, and might well be reduced by an increased investment in HIV prevention.

AIDS is also a security issue. On World AIDS Day 2004, Ambassador Randall L. Tobias, the United States Global AIDS Coordinator, discussed the White House view on AIDS and homeland security, saying,

"Our long-term strategy for protecting our nation against the threat of terrorism must rest on [promoting] freedom, and hope around the world... The President has made clear that in many of those places, bringing hope simply must include aggressively confronting HIV/AIDS. So we must confront global AIDS because it is the right thing to do - and because it is the wise thing to do."

This viewpoint is to be credited for the $15 billion President's Emergency Plan for HIV/AIDS Relief (PEPFAR), which is providing life-saving AIDS drugs to hundreds of thousands (one day perhaps millions) of HIV+ people in the world's poorest countries. Randall Tobias is right - not only is PEPFAR a humanitarian act of generosity, it is also the wise thing to do. However, although there may be no security issue involved, the US government must not forget that it is equally important to get AIDS drugs to people who need them in America - AIDS has to date killed far more US citizens than terrorism.

The situation, while serious, is far from irresolvable.  American legislators must approach HIV as a health problem, which should be addressed from a scientific perspective, and not an ideological one. It is easy to see how the two became confused - HIV is usually sexually transmitted, and because it involves sexual behaviour, it was seen as a moral issue. However HIV is ultimately a public health problem, however it is transmitted, and scientific fact must be allowed to guide the choice of prevention strategies.

The USA has done some excellent work in some areas of prevention (such as reducing the numbers of babies born with HIV) but much more needs to be done.

All people in the US - including young people - need to be able to access condoms easily and cheaply, without fear of having their morals judged. Injecting drug users also need access to clean injecting equipment - drug addicts have always existed, but if their drug problems can't be resolved they must be enabled to protect themselves and their families from HIV infection.

AIDS education in the USA must also be improved. Ideology and religious faith have been allowed to dictate prevention methods, even when clear evidence indicates that other methods may be preferable. While abstinence is a highly effective HIV prevention method, it is not suitable for everyone, and it is unrealistic to pretend otherwise. Those in power need to ask themselves if their faith really asks them to value the teaching of ignorance over the saving of lives. Better HIV prevention is needed across the USA - not only for young people in schools, but for adults and for HIV+ people.

In the past few years, America has had a great many other matters to deal with, and it seems that AIDS is not as much of a priority as perhaps it should be. ADAP waiting lists show that there is simply not enough money being spent to help American people, and that people are dying because of this. Better care must be provided and more money must be made available - no one should have to die whilst on a waiting list, particularly not in the richest country in the world.

When it comes to helping the poorest countries, the USA has set an example for the rest of the world by creating PEPFAR. Now America must also set an example at home by protecting its own citizens from the deadly grip of HIV/AIDS.

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Copyright 2001, The Urban Eye