William Smith is Vice President for Public Policy at the Sexuality Information and Education Council of the United States.
The US Conference on AIDS (USCA) wrapped up this week on the sun-drenched Southern Florida coast with nary a mention in the press or elsewhere. This is a far cry from the extensive coverage of the "Bill and Bill" show at the international meeting in Toronto in August. There, news coverage documented the re-emergence of prevention and the global push-back against U.S. dogmatism on key issues like abstinence-until-marriage programs, the lack of support for condoms and the prostitution pledge. In Florida, the conversation could not have been more different.
HIV/AIDS looks different in the U.S. so the conversation should be different than in the global context. Yet, other factors were also at play. Part of the divergence can be explained by timing. It may be telling secrets outside of school, but at present, domestic HIV/AIDS advocacy is both justifiably preoccupied and unfortunately, very nearly a house divided against itself.
Last week, the re-authorization of the Ryan White CARE Act, the very backbone of our country's HIV/AIDS care and treatment services, was moving through the House of Representatives. The bill has fueled passions by reallocating money away from areas like New York and California to southern states, many of which argue that they have been woefully under funded for too long and face increasing caseloads as the domestic epidemic changes. That, in and of itself, would be enough to put prevention and everything else on the backburner. And it now looks like this may be a prolonged condition if the CARE Act is extended for just a single year, likely renewing the family struggle in the first session of the new Congress.
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Another explanation for the difference between Toronto and USCA can be viewed through the relation of our national meeting to our own government. USCA is and has been a conduit for the federal government to engage the many staff members of community based AIDS service organizations and advocacy agencies. After all, this year, records show more than 3,000 people were registered for USCA. It's a great audience if you can get it and the federal government gets it by footing much of the bill.
This year the feds were strategic in setting the agenda. On the conference's first day, the CDC released long anticipated new guidelines around HIV testing. Of particular interest, was the decision to recommend testing without providing counseling as part of the upfront process. When HIV was viewed as-and often meant-a death sentence, the counseling was done to prepare the person for the weight of such news. More recently and in practice, counseling evolved into prevention education and instruction on how to reduce exposure to risk.
When someone seeks testing, it is likely because they have developed some physical symptoms that are of concern, have participated in behaviors that may have put them at risk, or know they were exposed to HIV. Whatever the case, why would we do away with an opportunity to do provide prevention education?
It is true that broader testing for HIV has been inhibited by many barriers. Unfortunately, instead of formally recognizing the pre-test counseling session as a prevention education session, the federal government has convinced many long-time leaders in HIV/AIDS, whom I respect immensely, that pre-test counseling is one of those barriers. The result: a scale-up for testing means a scale-down for prevention education. At USCA, this was barely discussed as many admirers of the new guidance, and government officials themselves, applauded the new effort and made the hard sell that it was a long-time in coming. I, and many others, remain unpersuaded and thus we have the second issue currently dividing our forces-one against the other.
For those who do evidence-based prevention and those who advocate for it, the situation just got worse. With an Administration that doesn't believe in risk reduction, but touts risk elimination, the new guidelines make good sense and the timing was Machiavellian. It was yet another opportunity to pull back "condom promotion" while at the same time, funnel more money to groups to promote abstinence-only-until-marriage as a means of disease prevention and as "the expected standard of human sexual behavior."
The next USCA is a year out and though our epidemic is different, domestic HIV/AIDS advocates need to come together and engage in the global discussion where prevention has again come to the forefront. After all, our own country, while the source of much goodness, is also the wellspring of much of the mischief on global HIV prevention, including the mischief in our own midst. Here. There. It makes no difference. We owe it to ourselves, but also to those relying on us in lands where 1 in 3 people have HIV.