U.S. & U.K political climate impacting HIV prevention

BY MELVIN HAMPTON, M.Div. & PERRY N. HALKITIS, Ph.D.  |  A diverse group of students from New York University, my teaching assistant, Melvin Hampton and I, had the opportunity to travel to London in order to participate in our class, “HIV Prevention and Counseling.” We have offered this class for seven years — and in January, we traveled with 19 graduate students from various programs across New York University (including mental health counseling, higher education, music therapy and public health).

The purpose of the class is to explore the differences that exist between the United Kingdom’s (U.K.) efforts to negotiate the HIV epidemic as compared to the efforts that have emerged in the U.S. over the past 30 years. At the heart of the matter are the differences that emerged in a country with a national health system (such as the U.K.) as compared to one without (such as in the U.S.).

In July 1948, the United Kingdom undertook an important step in providing basic human rights to its citizens by implementing comprehensive health care in the form of the National Health Services (NHS). Every citizen of the U.K. is able to access comprehensive medical care without cost. An important aspect of this system was its response to the emergence of HIV as a major health and social concern in the U.K. — from the early 80s up to the present.

It is this difference in relation to HIV prevention and treatment that we seek to explore every year when we teach the class. As part of the course, we invite speakers from the NHS and local community-based organizations to talk to our students. These presentations are complemented by lectures and discussions regarding the history, epidemiology and biology of HIV — as well as presentations on HIV treatment and behavioral theories that have defined HIV prevention for the past 30 years.

This class offers a great opportunity to branch out into other experiences in relation to HIV prevention and counseling work. Previous students have gone on to develop relevant HIV prevention programs for their local communities and community agencies. It is this chance to help foster future efforts in relation to HIV prevention and working with HIV-positive communities and individuals that has primarily motivated me to keep teaching this class.

Over the years, it has become clear that the United Kingdom’s response to HIV prevention and treatment has been, in many ways, superior to the United States’ response. In the late 1980s, during the height of AIDS hysteria in the U.S. — in which key government officials were working to impose clearly homophobic legislation in the U.S. — the U.K. was adopting more liberal approaches to HIV prevention, including harm-reduction models of prevention with injection drug users and gay men (two of the groups hit the hardest by HIV in the early part of the epidemic). While the U.S. struggled to provide basic medical care to its citizens living with HIV, the U.K. folded comprehensive HIV treatment into their medical system, assuring that every HIV-positive member of their society received the care they needed.

Another key difference can be seen in the work of such agencies as Gay Men’s Health Crisis (GMHC) in the U.S. and the Terrence-Higgins Trust (THT) in the U.K. Both community-based agencies were started in their respective country’s epicenters of the HIV epidemic in relation to the high numbers of HIV-related deaths among gay and bisexual men. However, whereas GMHC (similar to a lot of great agencies in the U.S.) was limited in their efforts by conservative governmental politics, THT was supported in their efforts to bring about comprehensive HIV prevention strategies by the British government. This resulted in agencies in the U.S. having to adopt narrow and often ineffective strategies for improving their communities (since much of these agencies’ funding came from a conservative government that refused to give money to more innovative and less stigmatizing approaches to HIV prevention). Given these limiting political realities, the efforts of leading community-based agencies in the U.S., such as GMHC, are even more impressive. In comparison, THT has made significant steps toward reducing the incidence of HIV among persons in the U.K. by reducing the stigma and social pressure that so often accompany being a member of a minority community, such as being a gay or bisexual man in a predominantly heterosexual society, versus by merely telling its community members to “wear a condom every time.” From graphically detailed safer sex guides and HIV testing in key social venues to lobbying for same-sex civil partnerships (which include full citizenship rights for bi-national couples), THT has been supported by the British government in their holistic approaches to prevention.

That said, our respect and admiration for the British response to HIV came to a screeching halt this year when we returned to a very different London than in years past. In 2010, the British government underwent a dramatic shift, implementing a markedly more conservative government, similar to the U.S. context under presidents Ronald Reagan and both George Bush Sr. and George Bush Jr. With this shift we found that not only had funding for HIV prevention work been cut, but also the ways in which HIV prevention and treatment work was being implemented had begun to change. As each speaker came to our class, a clear theme of regression began to emerge. Where once these same speakers had talked about social and contextual influences of risky sex and substance use, they now spoke of campaigns based on overly simplistic notions of individual responsibility without context or social influence. We also heard about cuts to NHS funding and a shifting of responsibilities from medical providers who have spent years learning about and treating person with HIV to clinicians who are our equivalent of general practitioners/ family clinicians, untrained in the complexities of HIV medical care. Although much debate appears to be emerging in relation to these shifts in service providers and prevention strategies, things have changed and are continuing to change.

So the question emerges, “What does that have to do with us, here in the U.S.?” Well, a lot. It was not long ago that our own government refused to support HIV prevention and safer sex campaigns that were not based on abstinence-only models of prevention. For decades, racial, ethnic and sexual minorities have been marginalized in larger discourses about program funding and access to appropriate and comprehensive medical care. And although under the current presidential administration we have seen for the first time ever a National HIV/AIDS Strategy for the U.S. (whitehouse.gov/sites/default/files/uploads/NHAS.pdf), the reality is that this first step is one that other countries have already made.

As HIV behavioral researchers, the fact that the CDC and other government agencies have begun to have public discussions about the contextual factors that influence HIV risk, beyond simple individual responsibility, is both refreshing and reassuring as we move into the third decade of the epidemic. As we adopt more holistic understandings of what is needed in order to reduce the large disparities in HIV incidence and treatment in the U.S., our historical allies seem to be shifting away from these discussions, after having already come so far. The insightful and inspired work of the National HIV/AIDS Strategy (whitehouse.gov/administration/eop/onap/nhas/) puts us in a noteworthy position to reduce the 60,000 new HIV infections our nation currently experiences on a yearly basis.

However, our enthusiasm has been tempered given the recent shift in our own government from a more liberal congress to a markedly more conservative one — with Republicans currently holding the majority in the House of Representatives and having an increased presence in the Senate. Under the 111th Congress of the United States, important steps were taken for HIV prevention, as well as in relation to reducing larger social inequalities that continue to exist for communities that are so often pushed to the sides in our society. Although not as swift as some would have liked, progress was being made, including the repeals of our antiquated HIV immigration law and the military’s, “Don’t Ask, Don’t Tell” policy.

So what will happen now? Is the pendulum swinging back? Is the situation in the U.K. a foreshadowing of the U.S. going back to where we used to be? Will we choose to learn from our past and from the concerning patterns of those who are so politically and historically connected to us? Will we continue to see great strides made in the fight against HIV in the U.S., as well as in the fight to bring about more compassionate and fair social conditions for those of us who have spent our lives living in the margins? Our hope is that the current shifts that are occurring in the U.K. will not last and that the U.S. will learn to meet its full potential to eliminate a social ill that is so intimately connected to issues of race, sexual orientation, socio-economic status and stigma. To not acknowledge these connections would be impossible. We are hopeful and yet wary. What will the future hold?

Perry N. Halkitis, Ph.D., is Professor of Applied Psychology and Public Health and Director of the Center for Health, Identity, Behavior & Prevention Studies (CHIBPS); Melvin Hampton, M.Div., is a researcher at CHIBPS and a doctoral student in Counseling Psychology at the Steinhardt School, New York University.