Morbidity and mortality rates among IDUs remain disproportionately high. People who inject drugs bear the highest burden of hepatitis C virus (HCV) infection and are at increased risk for hepatitis A and B, despite the fact that vaccination against these infections is cost-effective and feasible within public health settings. Recently, alarming epidemiologic reports indicate a rise in HCV infections among young IDUs throughout the country.  Effective prevention interventions do exist, although these interventions are not widely available and additional prevention strategies are needed. 

In addition to becoming infected with HIV and viral hepatitis, people who inject drugs are fatally overdosing at elevated rates, despite available prevention tools. Access to substance use treatment is limited and overdose prevention efforts rarely have a “home” in state drug and alcohol, injury prevention or public health agencies. These concerning trends are clearly evident throughout our health care system, and yet the system often remains inaccessible and at times hostile to IDUs. 

Recognizing the progress we have made in reducing new HIV infections among the IDU population, we acknowledge that our nation’s efforts are not sufficient to meet the comprehensive health needs of this population. To change the course it will require an honest and critical examination of our efforts among all stakeholders.  NASTAD and its members commit to explicitly identify and implement effective public health programs for IDUs.

Expanded federal investment in disease and overdose prevention, care and treatment programs is paramount. NASTAD and its members will continue to advocate for increased and targeted resources. 

Approved by NASTAD’s Executive Committee on August 5, 2011

“Having a coordinated national plan is an important step in responding to these epidemics, but state and local health departments and community based organizations need funding to provide basic services,” said NASTAD Executive Director Julie Scofield. Each state receives an annual average award of $90,000 to address adult viral hepatitis prevention. This barely supports one full time position in each jurisdiction and does not allow for any adult viral hepatitis prevention or care services. “The Administration and Congress must act with a greater sense of urgency around viral hepatitis and adequately fund state and local public health programs addressing viral hepatitis in the U.S.,” Scofield continued.

NASTAD is concerned that the Administration and Congress have not adequately prioritized viral hepatitis. The Centers for Disease Control and Prevention’s (CDC) Adult Viral Hepatitis Prevention Coordinator program, the public health professionals responsible for the implementation of this plan across the nation, needs adequate funding to respond to the viral hepatitis epidemics. This Action Plan will be difficult to implement unless investments are made to actively integrate hepatitis services into the existing public health infrastructure.  This should begin with funding to implement direct services such as hepatitis B and C testing, hepatitis A and B vaccination of adults, education and a national chronic hepatitis surveillance system. 

State and local health departments are important implementing partners of this plan, and their expertise should be sought throughout the implementation process. “Just as the HIV/AIDS community has been a valued partner in the implementation of the National HIV/AIDS Strategy, the viral hepatitis community should be included in the implementation of this Action Plan,” commented Scofield. In addition, the federal government cannot successfully implement this Action Plan if health departments are not funded to the fullest extent in every state, regardless of disease burden. It is estimated that over five million people are infected with viral hepatitis in the U.S. and 65-75 percent are unaware of their infection.  The costs of inaction are too high not to be a priority, especially given this new federal roadmap and the tools to effectively prevent and manage viral hepatitis (hepatitis B vaccine and effective hepatitis B treatments that reduce disease progression and new treatments that increase hepatitis C cure rates up to 75 percent).

Toward that end, NASTAD calls on HHS and CDC leadership to strengthen the Adult Viral Hepatitis Prevention Coordinator program in all jurisdictions and to allocate increased resources to prevention services.  These include testing to identify the 65-75 percent who are living unaware of their infection, education to increase public and provider awareness, and surveillance to increase knowledge of disease burden and to improve targeted interventions. 

NASTAD applauds the Administration and Congress for increasing the budget of the Division of Viral Hepatitis (DVH) in recent years and calls on Congress to provide at least an increase to the President’s FY2012 request of $5.2 million for DVH.   DVH, however, has developed an estimated need of approximately $300 million to expand testing, education and chronic surveillance.  In addition to funding for DVH, NASTAD requests that the HHS Office of the Assistant Secretary for Health be provided resources to implement the Action Plan and that CDC identify funding to continue the At-Risk Adult Hepatitis B Vaccine Initiative.

 The Annual Report of NASTAD’s National ADAP Monitoring Project is based on a comprehensive survey of all ADAPs.  This 16^th release of the Annual Report updates prior findings with data from ADAP’s fiscal year 2010 as well as provides a detailed snapshot of data from the month of June 2010.  Modules of the Annual Report reflect the latest available data and discusses recent policy and programmatic changes affecting ADAPs.  

To provide interested stakeholders with more timely information, NASTAD released the 2011 National ADAP Monitoring Project Annual Report in several modules.  Detailed information related to ADAP budgets, client enrollment and utilization, client demographics, program eligibility, and program management and administration are included in Module One.  Module Two includes detailed information on prescription distribution and payment methods, expenditures and prescriptions filled, insurance coordination, ADAP coordination with Medicare Part D, ADAP coordination with Pre-existing Condition Insurance Plans (PCIPs), and updated client enrollment and utilization.  A final, supplemental module highlights hepatitis treatments.  These modules will be combined into a final, comprehensive report.

Summary slide sets for each module are also available at www.NASTAD.org.

Given the alarming infection rates among LGM, the report gives voice to LGM whose perspectives are often neglected in policy decision-making processes. The study represents LGM voices from diverse socio-economic backgrounds across the U.S. and gives voice to those who, as state health officials and CBOs, are responsible for providing HIV prevention and care and treatment services to LGM. Pursuant to the recommendations made in the National HIV/AIDS Strategy (NHAS) released in July 2010, data presented in this report are intended to contribute to the four primary goals of the NHAS:  reducing HIV incidence; increasing access to care and optimizing health outcomes; reducing HIV-related health disparities; and achieving a more coordinated national response.

The NHAS emphasizes that “not every person or group has an equal chance of becoming infected with HIV.” Specifically, it notes that Latino gay and bisexual men “represent the greatest proportion of HIV cases among Latinos.” In 2006, Latino men who have sex with men (MSM) represented 72 percent of new infections among all Latino men and nearly 19 percent among all MSM. Among all LGM and other MSM in 2006, the largest number of new infections (43 percent) occurred in the youngest age group (13–29 years).  At 35 percent, LGM and other MSM aged 30-39 years were also heavily impacted with a substantial number of new HIV infections.  These data indicate the depth of the HIV crisis among LGM and the consequences associated with paltry efforts to prevent HIV transmission.

NASTAD and the National Coalition of STD Directors (NCSD) released a Statement of Urgency in June 2010 expressing concern about the stronghold that HIV and STD infections continue to have on gay and bisexual men.  Consistent with the goals of the NHAS, as well as NASTAD and NCSD’s Statement of Urgency, this report seeks to generate key themes to assist and inform effective federal, state and local public health responses to HIV/STDs among LGM. Moreover, the data collected for this project will increase understanding of the facilitators, barriers and gaps in the provision of HIV prevention and care and treatment services targeting LGM for HDs, CBOs, federal partners and other relevant stakeholders. 

A Través de Nuestros Ojos (Through Our Eyes): Promoting Health and Social Equity to Address HIV/AIDS among Latino Gay Men is also available in Spanish.

 As a member of the Positive Justice Project, a coordinated national effort to address “HIV criminalization” statutes – laws that create HIV-specific crimes or which increase penalties for persons who are HIV positive and convicted of criminal offenses –

NASTAD supports efforts to examine and support level-headed, proven public health approaches that end punitive laws that single out HIV over other STDs and that impose penalties for alleged nondisclosure, exposure and transmission that are severely disproportionate to any actual resulting harm.  Steps identified to reach this goal in the Federal Implementation Plan include step 3.3, Promote public health approaches to HIV prevention and care which states that “state legislatures should consider reviewing HIV-specific criminal statutes to ensure that they are consistent with current knowledge of HIV transmission and support public health approaches to screening for, preventing and treating HIV.” In addition, step 3.4, Strengthen enforcement of civil rights laws requires an examination and report by the Department of Justice on HIV-specific sentencing laws and implications for people living with HIV.

HIV criminalization has often resulted in egregious human rights violations, including harsh sentencing for behaviors that pose little to no risk of HIV transmission.  Thirty-four states (34) and two (2) U.S. territories explicitly criminalize HIV exposure through sex, shared needles or, in some states, exposure to “bodily fluids” that can include saliva.  Examples include: 

• A man with HIV in Arkansas was sentenced to 12 years (and must register as a sex offender after release) when he failed to disclose his status with his girlfriend  and another woman – both women tested negative;
• A man with HIV in Iowa, who had an undetectable viral load, was sentenced to 25 years after a one-time sexual encounter during which he used a condom;
• A woman with HIV in Georgia, who was sentenced to eight years imprisonment for failing to disclose her viral status, despite it having been published on the front page of the local newspaper and two witnesses who testified her sexual partner was aware of her HIV positive status.

In none of the cases cited was HIV transmitted.  In fact, most prosecutions are not for transmission, but for the failure to disclose one’s HIV status prior to intimate contact, which in most cases comes down to competing stories about verbal consent that are nearly impossible to prove.

HIV criminalization undercuts our most basic HIV prevention and sexual health messages, and breeds ignorance, fear and discrimination against people living with HIV.  NASTAD members commit to examining existing public health policies related to HIV criminalization that may exacerbate stigma and discrimination and lessen the likelihood that individuals will learn their HIV status.  NASTAD members will also continue to emphasize the importance of providing comprehensive prevention and care services for HIV positive individuals to help reduce the risk of transmission to others.  In conjunction with new and existing partners, our members also pledge to:

•  Support the maintenance of confidentiality of HIV test and medical records in order to encourage and support individuals to be tested, learn their status and enter services if positive;
• Identify and share best practices related to successes in repeal of policies and/or laws and statutes in jurisdictions that are not grounded in public health science;
• Promote public education and understanding of the stigmatizing impact and negative public health consequences of criminalization statutes and prosecutions;
• Provide unequivocal public health leadership on the relative risks of transmission and the dangers of a punitive response to HIV exposure on the epidemic.

NASTAD will continue to advocate at the national level to raise awareness of this urgent issue.  Realizing the vision of the NHAS is predicated on a strong foundation of public health science and practice void of stigma and discrimination.  Instead of applying criminal law to HIV transmission, state and local governments should expand programs to reduce HIV transmission while protecting the human rights of people living with HIV. 

Approved by NASTAD’s Executive Committee: February 2011

TABLE OF CONTENTS:

• Testing and Linkages to Care
• Expanding the Nation’s Approach: Testing and Linkages to Care Webinar
• NASTAD Expanded HIV Testing Report
• CDC’s Approach To Testing and Linkages to Care
• Overview of HRSA/HAB Linkages to Care Activities
• Member Perspectives: Examples of Health Department Approaches from Florida, Mississippi and Texas
• NASTAD 2010 Surveys on Testing and Linkages to Care

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Today, we commemorate the 5th annual National Women and Girls HIV/AIDS Awareness Day.  Yesterday, I had the opportunity to participate in a briefing held by the National Alliance for State and Territorial AIDS Directors (NASTAD) and the HHS Office on Women’s Health with important leaders in Congress.  The event highlighted how the domestic epidemic is affecting women and how much we need to maintain our commitment to addressing this public health issue.

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“These rates, when coupled with existing data indicating that gay and bisexual men make up the majority of new HIV and syphilis infections, are further evidence that prevention for gay and bisexual men of all races must be our highest priority at all levels,” said Julie M. Scofield, Executive Director of the National Alliance of State and Territorial AIDS Directors (NASTAD). “It is time to value the lives of gay men in our communities. They are fathers, brothers, sons, uncles, colleagues and friends, and it is time to fight for their lives,” continued Scofield.

Despite the high rates revealed in the data released today, federal support for HIV and STD prevention has faltered. Over the last decade, federal funding for domestic HIV prevention to health departments has been cut by $23 million and STD prevention efforts, when adjusted for inflation, have 22 percent less funding compared to seven years ago.  “This new data is a clarion call to deal with the persistent neglect of the health of gay and bisexual men across the country,” said William Smith, Executive Director of the National Coalition of STD Directors (NCSD). “Thankfully, the President has recognized the situation and called for increased resources for HIV and STD prevention efforts for MSM. Now it is Congress’ turn and they need to expand upon the President’s request.”

According to the U.S. Department of Health and Human Services, men as a whole are less likely to use the health care system than women and often seek care when they are experiencing critical health problems. In gay communities, men who do not access health care may not know they are infected with HIV or an STD, thus compromising their own health status. The persistence of stigma and homophobia compounds the situation still further.  In this time of economic decline, health departments and their communities are bending under the weight of these public health crises. NASTAD and NCSD call on policy makers across the U.S. to provide leadership to stop the unnecessary spread of HIV and STDs by ensuring all gay men have access to preventive services, know their status and, when positive, are linked to quality care and treatment.

Founded in 1992, NASTAD is a nonprofit national association of state and territorial health department HIV/AIDS program directors who have programmatic responsibility for administering HIV/AIDS and viral hepatitis health care, prevention, education, and supportive services programs funded by state and federal governments. For more information, visit www.NASTAD.org.

Founded in 1996, NCSD is a nonprofit national association of state, territorial and local health department STD program directors who have programmatic responsibility for administering STD prevention and control programs funded by state and federal governments. For more information, visit www.NCSDDC.org.

READ CDC’S press release.

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