So, how is it cities the size of San Francisco and New York are able to virtually wipe out new HIV cases, but Atlanta isn’t?
I raised this question last week as I left off sharing with you a conversation I had with Dr. Melanie Thompson about President Donald Trump’s announcement at this year’s State of the Union address to end the HIV epidemic in just 10 years.
Thompson, you may or may not recall, has spent the past 30 years trying to help defeat America’s AIDS epidemic, caring for people living with HIV (which causes AIDS), trying to prevent its spread, researching new drugs for HIV treatment and prevention, and working at the national and local level to influence policy and create plans to end the HIV epidemic.
Like a lot of people working on the frontlines of the epidemic, her optimism about Trump’s announcement was tempered with caution.
Cautious because she knows it will take a lot of work and steady commitment to get the job done. Optimistic because, when she looks at cities like San Francisco and New York, she sees what’s possible.
San Francisco has about the same number of people living with HIV as Fulton County alone, yet in five years its new HIV diagnoses have decreased by more than half to 221 while Fulton County had nearly 700, essentially unchanged over five years. New York’s cases have decreased 36 percent over five years.
What’s the difference? Not only have both cities invested in overall public health, state and local governments have invested money and expertise in the fight against HIV. Public health leadership in these cities has been very effective in building innovative programs like providing free PrEP at clinics, offering same-day HIV treatment and opening sexual health clinics to fight sexually transmitted infections.
The story is quite different here in Georgia.
For one thing, Thompson said, robust public health leadership on HIV has been lacking at the state and county levels for decades.
And for another, “this is the South, where poverty, income inequality and inadequate public health systems overlap with racism, homophobia, transphobia, and stigma against people living with HIV,” she said. “Stigma is literally killing people here.”
Thompson said that while Ryan White clinics, both nationally and locally, have been highly effective in treating people living with HIV, local clinics are underfunded and understaffed, and substance use and mental health services are insufficient. Because Georgia lacks Medicaid expansion, the Ryan White program provides the only safety net for uninsured people living with HIV. Ryan White not only provides medical care, case management and mental health services, but also HIV drugs at no cost. It also helps patients purchase health insurance, which is often less expensive than providing drugs.
Even though the 20-county Atlanta Eligible Metropolitan Area received over $26 million in 2018, money has increased slowly while the number of people living with HIV continues to increase more rapidly.
Grady’s Ponce Clinic alone now cares for over 6,200 people living with HIV, a 33 percent increase over a decade, but without a proportionate increase in funding. Every single year, the number of patients needing care in metro Atlanta has increased faster than funding, so clinics have been asked to do more with less.
While clinics struggle to care for all the people who are currently in care, there is simply not enough workforce capacity and funding to provide care; 50 percent of people diagnosed with HIV in Fulton County are no longer receiving care, Thompson said.
“Without more funding, we will definitely see a worsening of the epidemic, and it could be dramatic. It’s a time bomb. We have to help people stay in care so they stay on medicine to keep the virus undetectable,” Thompson said. “This keeps people healthy, but also addresses the public health issue of HIV transmission. In 2019, the people who are the most in need are people who have the most complex lives. They don’t have housing, transportation to get to clinics, and they often have other issues with substance use and mental health that have not been addressed. And they often have no other access to health care.”
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Here’s yet another issue that needs addressing: There is no existing funding stream for PrEP, pre-exposure prophylaxis, to help with HIV prevention.
“Unlike other states that are making progress, Georgia has not invested a single dime in PrEP,” Thompson said. “PrEP can be up to 99 percent effective in preventing HIV when a single pill is taken once daily with good adherence. But the people who most need PrEP are not getting it in Georgia, where racial disparities are stark. Among black gay and bisexual men who could benefit, only 12 percent are on PrEP. We don’t even have data for at-risk women and transgender persons. We desperately need Medicaid expansion in Georgia to fully expand PrEP access.”
We got a bit of good news last week on this front.
A bill introduced in the state Legislature would give Gov. Brian Kemp authority to pursue two different kinds of waivers so the state can tweak how it administers federal health care programs.
One waiver would focus specifically on Medicaid. The other would seek to reduce insurance costs for consumers.
Meanwhile, Thompson said PrEP has fallen between the cracks of funding silos from CDC and the Health Resources and Services Administration. She’s hoping we will see something in this new federal initiative that will remedy that.
Either way, we won’t likely hear more about this until early March when the White House budget is released.
“This is a 10-year plan,” Thompson said. “We need to see increased funding in the billions every year to get close to ending the epidemic, but I fear that is unlikely.”
Here at home, she believes the new federal initiative will require a comprehensive and innovative approach at the county level to be successful. Thompson hopes to see Fulton County take the lead in convening other metro Atlanta counties and partnering with cities, especially the city of Atlanta, to revise and adopt the Strategy to End AIDS created in 2017 by the Fulton County HIV/AIDS Task Force, the predecessor to the new Fulton County HIV Advisory Committee.
She said: “It’s time to do something different if we want different outcomes.”