In December 2013, San Francisco became the first jurisdiction in the United States to launch a process to end AIDS as an Epidemic. Six months later, New York became the first state to commit to that goal. In the months and years that have followed, ten other states, including Washington, Oregon, Arizona, Colorado, Minnesota, Illinois, Massachusetts, Connecticut and Texas, as well as the District of Columbia, have been developing and implementing plans to end AIDS as an epidemic. Another six states are at the beginning stages. And some twenty cities and counties have joined San Francisco, developing and implementing their own plans.
The beauty of these efforts is that they have captured the imagination of stakeholders who have focused their attention on key interventions, and harnessed new resources. In these jurisdictions, we are seeing advances in HIV diagnosis, linkage to care, viral suppression and scale up of Pre-exposure Prophylaxis, all dramatically outstripping what is happening in the rest of the nation.
In 2017, San Francisco became the first jurisdiction to achieve one measure of ending the epidemic by reducing the rate of new infections below the all-cause rate of death of people with HIV.
Another terrific example is the work of AIDS Free Pittsburgh, a community-government partnership in Allegheny County, Pennsylvania. Due to their efforts, from 2015 to 2017, new HIV cases decreased by 30% and new AIDS cases decreased by 56%.
The District of Columbia is reporting remarkable progress, including a 31% decline in new diagnoses since 2013, and a viral suppression rate of 65% among its residents living with HIV, which is stopping disease progression and preventing transmission of the virus. This compares with a 50% rate of viral suppression nationally.
In New York State, the effort is led by a coalition that includes the New York State AIDS Institute, the New York City Department of Health, and community activists and service providers. Because of the coalition’s focused effort, 93% of all New Yorkers living with HIV now know their status.
New York State reached a record low in new diagnoses in 2017, only 2,700 cases for the entire State, in a state that once had as many as 15,000 new diagnoses every year!
Remarkably, New York declines are among all but one of the populations at risk. In fact, diagnoses among women, including all races and ethnicities, declined 11% in 2017. The only group that didn’t see a measurable decline was Latino gay and bisexual men, who actually saw an increase in the City.
Importantly, in 2017, more than 87% of all New Yorkers receiving care, were virally suppressed. Among all New Yorkers living with HIV, 72% were virally suppressed.
These examples show what states and local jurisdictions can do to end the epidemic without specific support by the Federal government. That is why the ACT NOW: END AIDS Coalition believes that, if the Federal government was to harness all of its resources toward Ending the Epidemic, we could accelerate this effort and End the Epidemic in every single jurisdiction across the nation by 2025.
As proud as I am of what New York and other jurisdictions have accomplished, and as much as I believe we can replicate these efforts nationally, I still must express my single biggest concern. We have and understand the biomedical tools to end the epidemic: Universal testing, universal treatment to sustained viral suppression, and scale-up of PrEP and PeP to at least 50% of people at high risk. Do these three things consistently among all populations, and the virus will be contained and eventually die out.
But, if we do a deep dive, what we see is that, even in the most successful jurisdictions, there are disparities in almost every metric, from PrEP uptake, to new incidence, to linkage to care, to rates of viral suppression, to mortality, that show that some groups are not benefiting as much as others.
I believe we will continue to see this phenomenon until we recognize that the root causes behind the spread of this virus are racism and misogyny. Without addressing these root causes, our efforts are doomed. In fact, I would posit that even if we find a vaccine and a cure, if we don’t address the root causes, we will just be setting ourselves up for the next virus or other natural phenomenon that comes along ready to take advantage of our own inhumanity.
Like you, I have watched in horror as Donald Trump has unleashed daily appeals to nativism, white supremacy, and misogyny across this land. In a nation that has never truly reckoned with the genocide and racism that are in coded into its foundational DNA, it is no surprise that these appeals are what many want to hear, giving rise to an overt national cult of Christian White Male Supremacy. And whether in its overt form or in day to day institutional racism and misogyny, this, I am convinced, is the biggest threat to our ability to end this epidemic.
By the way, you will notice, I didn’t mention homophobia or transphobia. That’s on purpose. You see, both of these are derivative. They are rooted in misogyny, which systematically devalues women as somehow less than men. And that is exactly what Trump is doing every time he speaks degradingly about a woman and when he condemns the #MeToo movement as a threat to women’s husbands and sons, as if women’s rights were secondary.
What is transgressive about being gay is our desire to have sex with another man, in other words, wanting to be like a woman. What is transgressive about being lesbian is not needing a man for sexual fulfillment. What is transgressive about being a transgender man is that he is seen as a “woman” trying to pass as a man, and most transgressive of all, a transgender woman, a “man” desiring to be less than what he is, to be a woman. All four of these challenge the underpinnings of male supremacy.
Reflecting on the need to address root causes, and appreciating that as a white man, I don’t experience racism or misogyny in the way that people of color and women do, I made two pilgrimages this last August. First, I went to Montgomery, Alabama, to visit the Legacy Museum and National Lynching Memorial. The museum begins with an exploration of the internal slave trade that ripped apart husbands and wives, and tore parents from their children as 3.5 million slaves were sold down river to work a booming cotton economy that spread from the Carolinas all the way across Texas. It then details how people ostensibly freed by the Civil War were re-enslaved through Jim Crow laws, enforced by nearly a century of lynching. It then demonstrates how this was replaced with mass incarceration, something that Richard Nixon accelerated through his “war on drugs,” a deliberately racist political strategy designed to give Republicans permanent control of the South. One walks away from Legacy with a clear understanding that structural racism is a driving force no less deliberate or less pernicious in our own day.
My second pilgrimage was to the Rio Grande Valley in South Texas, where I spent two days meeting with undocumented immigrants, just absorbing stories…of women working in abusive domestic labor, fearing that speaking out would result in deportation. Of patients reluctant to come to the clinic out of fear that a traffic stop might lead to separation from their children. Of gay men and transgender women engaging in survival sex without recourse for violence or abuse. Of a pregnant woman who is afraid that if she takes Ryan White-funded ARV’s, it will lead her Mexican husband to be classified as a public charge.
These two pilgrimages led me to revisit the research on racism and misogyny as AIDS epidemic pathways. Now we know the consequences: Black women are 16 times more likely to become infected with HIV than white women. Latinas are 8 times as likely as non-Latina whites.
One in two Black gay and bisexual men is likely to become HIV positive. A white gay or bisexual man has less than one fifth the same risk. Transgender women are 49 times more likely to acquire HIV than anyone else, and that rate is dramatically worse for trans women of color.
Rates of new infections among Latino gay and bisexual men are increasing in jurisdictions that have high rates of Latino immigrants, where a majority of new infections are among those who are foreign-born, even while they are going down or at least stabilizing in every other group.
As for trans men, Native Americans, and Asian and Pacific Islanders, we don’t really know what is going on because they are usually classified as “other”.
Let’s start with segregation. It is no accident that our communities are just as segregated today as they were when discrimination in housing and public accommodation was legal. Housing segregation was official government policy from the time of the Civil War through the 1960’s. This includes patterns of federal and state investment of tax dollars in housing, as well as mortgage policies. Redlining hasn’t just been the policy of bad banks. It has been encouraged by federal and state governments which both have oversight and which backstop mortgages. Even now, ostensibly race-neutral policies effectively serve to benefit white communities, while fueling disinvestment from communities of color, furthering gentrification.
Of course, segregated neighborhoods drive poor school options, poor food and health care options, and poor employment opportunities, all of which deepen both poverty and social inequality. Neighborhood inequality not only drives crime, but it also invites racist policing strategies.
Income inequality stresses family and social networks, as does mass incarceration, thus the increased rates of violence and trauma. Segregation, social inequality and a scarcity of available male partners make the sexual networks available to lower income women of color much smaller and more fraught with risk. At the same time, poverty makes sex more likely to be transactional, increasing that risk.
For Black and Latino men, as well as women, social inequality often propels illegal drug activity, which carries its own set of risks, particularly in light of racist practices in both drug treatment and the courts.
The same stressors impact on young Black and Latino gay and bisexual men. But those stressors are turbocharged when you add the homophobia. In fact, studies show that where sexual orientation is protected, HIV transmission goes down among these men even with the other stressors of social inequality still in place.
Add to that a person who doesn’t have legal recognition, whether it is a transgender person, who the Trump administration is literally trying to erase, or a gay, bisexual or transgender undocumented immigrant who is demonized every day in the media.
You and I know that biomedical interventions won’t work unless we are doing something about these drivers. Yes, I am talking about addressing the social determinants of HIV. Of course, safe secure housing, vocational opportunity, peer support, trauma informed care, and behavioral health services must be a part of the mix. But I am telling you something more.
We who represent the communities impacted by the AIDS epidemic need to make fighting these root causes central to our efforts. There are concrete ways to do so that will require moving beyond a narrow focus on HIV. Let’s start with Medicaid expansion if you live in a non-expansion state and universal health care coverage everywhere. Not only would universal health care dramatically improve our ability to end the epidemic, but it would create tens of thousands of jobs, shore up our health care systems, and generate more than enough economic activity to cover its cost -- including providing health care to immigrants, no matter what their legal status.
But don’t stop there. Join with those who are fighting to protect women’s reproductive health and rights. Fight for humane immigration policies that acknowledge the humanity of people crossing our borders and the desperate circumstances that are compelling them to come here. Fight to end the war on drugs and mass incarceration. I could go on, but I think you get my drift. We need to think big and be bold.
Among other things, let’s stop with this idea that we are going to change individual behaviors. People are going to have sex, and, for most people, sex is not going to involve latex. People are going to use drugs and alcohol as well. Our fear tactics aren’t going to change this, and offering moral judgements just drives people away. If we want to end AIDS as an Epidemic, we need to change the systems, communities and culture that put people at risk and prevent people from accessing the prevention, treatment and care that they need.
I actually have tremendous hope for our nation. My hope has been strengthened by what I have observed over the last couple of years as people have been galvanized, not just by the vision of ending the epidemic, by a vision of making our country a place where justice and equality truly can prevail. On a national level, I have thrilled to see members of the Positive Women’s Network engage in civil disobedience, tell US Senators about their experiences of sexual abuse, and then go knocking on doors to turn out the vote. On a local level, during my visit to south Texas, folk at the Valley AIDS Council proudly told me of organizing the first Gay Pride event in the Valley in 2013, when 500 people came out. This year, more than 9,000 people attended the event. One woman described to me finding her husband sitting in the car in tears at the McAllen Convention Center as he watched macho Texas farmers driving up in their pickups to drop of their LGBT sons and daughters dressed in all their queer regalia.
In Mississippi, this fall, I was privileged to watch as women living with HIV practiced using their own stories to confront elected officials and then pledged to publicly disclose their HIV status combat stigma and bigotry. And, my God, we have seen so much fierce transgender advocacy from North Carolina to Texas to Alaska, that I know we are on the winning side of history. From this November’s election results, we know the political tide can be turned. That is because of people like you, who have done the hard work to fight against the impossible and make change happen. That is why I am confident that we can, not only end the epidemic, but also topple its root causes all across this land.
Thank you.
