What will federal AIDS efforts look like in a Bush administration? The President-elect was virtually silent on HIV/AIDS issues as Governor of Texas. His written responses on the subject during the campaign were supportive but generic in content. The overwhelming majority of people working in the AIDS "industry" have a liberal/democratic political bent and fear the worst from the conservative.
The AIDS Policy & Law newsletter speculated in late November that Bush would eliminate the Office of National AIDS Policy, often referred to as the "AIDS czar," and the Presidential Advisory Council on HIV/AIDS ( PACHA ) . That prompted calls to several of the leaders in the field, who offered their predictions and recommendations for the new administration.
"The Bush family takes loyalty to a whole new level," said Steve Gunderson in explaining how to deal with the new regime. The former congressman from Wisconsin was among those openly gay Republicans who met with Bush in Austin last April. He has maintained contact with the campaign and transition efforts.
"Bush does not like to be shot at," said Gary Rose, a New York lobbyist/ activist who spends much time in Washington. "Publicly embarrassing Clinton often was the only way to get anything done. But I think that with Bush it is going to be finding the politically smart way to get in, make your case as well as possible, build support on both sides of he aisle, and then maybe you will get your stuff done. In terms of AIDS funding, that is going to work okay."
The appointment of Wisconsin Gov. Tommy Thompson to be Secretary of Health and Human Services ( HHS ) did much to allay fears in the area of AIDS. Thompson has been very supportive on issues of AIDS care, but less so in the area of prevention, said Christopher LaBonte, health policy analyst with the Human Rights Campaign ( HRC ) .
Most AIDS advocates believe that prevention activities have been under-funded for the last several years. Political restrictions and mandates for abstinence-only programs limit the effective use of funds that are available. That seems unlikely to change. The solution will be to better use a mix of state, local, and private funding for some of those activities.
"I don't think that we have much to worry about in terms of legislation," said Anne Donnelly, director of public policy with Project Inform.
Gunderson thinks that the Republican administration will do more "indirectly through nonprofits and community-based organizations." That is the approach Thompson took in Wisconsin. There also may be more flexibility for states to try their own initiatives with federal money.
LEADERSHIP
One big question is leadership. "We have an epidemic that can still threaten our society," says Cornelius Baker, executive director of the Whitman-Walker Clinic in Washington, D.C. "Part of the challenge for the United States is not only how we deal with the epidemic in our own country, but what role do we play in alleviating this around the world."
"The presidency is not about being an administrator, the presidency is about setting a direction and priorities for the nation," says Baker. Research priorities remain the same, a cure and a preventative vaccine. "If we can't implement it with 90 percent of those affected by HIV, then it is not a viable medical solution."
He sees the domestic agenda as focusing on "how to sustain an infrastructure for people in care while further reducing new infections." One component of that may be to encourage states to expand Medicaid coverage to the disabled, including PWAs, something that Thompson pushed in Wisconsin.
"We've done the easy part," says Terje Anderson, executive director of the National Association of People With AIDS ( NAPWA ) . An estimated 300,000 to 500,000 Americans are HIV positive but do not know it. The hard work that remains is to bring those people into a system of healthcare so that they learn their HIV status and have access to appropriate care.
The epidemic is expanding most rapidly in communities of color. Anderson believes, "The leadership of the African American and Latino communities are not going to allow that to fester." Their reticence to push Clinton will evaporate with a Republican in the White House, "They won't be afraid to label it a civil-rights issue and fight it on that basis."
Internationally, sub-Saharan Africa is destabilizing socially and economically, while Asia and Eastern Europe are traveling down that same path, says Baker. He points to the American Revolution as an example of how "a couple of hundred thousand people in what was then a backwater of the world" ultimately had "a profound effect" on history. He believes "the President has to be engaged in more than just an ad hoc way."
"When the invasion of Kosovo need to happen, Congress voted $21 billion overnight, without question. We anted up," says Anderson. Today, when an epidemic is only a plane flight away and can be introduced to this country just as quickly, "we are arguing over $300 million a year for AIDS. We can do more and we should be doing more."
AIDS CZAR
"I think it would be a mistake to abolish the Office of National AIDS Policy because is provides useful staff for an important national problem," says Jim Driscoll, HIV lobbyist for Log Cabin Republicans. There also are purely political reasons to maintain the office. He says, "You need someone there to handle the press and take the brunt of the criticism," shielding the White House at least to some degree.
"By getting rid of it, you run the risk of making it look like you don't care about the issue," says Anderson. The administration needs to figure out avenues for input from the community and from experts. It needs a place where the disparate threads from agencies within HHS, the Departments of Housing and Justice, and the international sphere are pulled together and integrated into a cohesive policy.
The important question for Anderson is the resources behind it. The office "is not viable with three staff people and no resources, no authority," which is what Sandy Thurman had to work with for most of her tenure. He thinks that a staff of 10-12 would be sufficient. It should remain within the White House organizational chart rather than HHS because of growing activity on the international side.
Baker and Gunderson are among the names most prominently churning through the rumor mill for the position of czar. We have "a moral obligation in the fight against AIDS," said Gunderson. "If the President came and asked me to serve, it would not be an option."
His personal and professional relationship with Secretary Thompson, dating from 1974, would only enhance his clout in the position. But that personnel decision likely is months away, perhaps not until early summer.
ADVISORY COUNCIL
"It was ridiculously large, it was unwieldy. It was like, okay, how many people can we say served with the President, it will make them feel good." This evaluation came from Ben Schatz, someone in a unique position to know. He was a member of the Presidential Advisory Council on HIV/AIDS and former executive director of the Gay and Lesbian Medical Association. A change in careers gives him ample freedom to speak his mind.
Schatz says that PACHA "managed to be enough of a pain in the ass that we pushed [ the Clinton administration ] to do what they might not have done otherwise simply because it was not politically convenient or because there were other focuses." But he also acknowledges, "A council like this in never going to get an administration to do things that it fundamentally opposes."
He sees Bush's record on AIDS as creating "more of a need" to maintain such a body. Its size and frequency of meeting was "a waste of money and a waste of time," both could be reduced substantially, says Schatz.
Log Cabin's Driscoll concurs. He says that eliminating the body "would provide an excuse, and a fairly valid one, for attacking the Bush administration." But the 35-member body "could be cut down in size a great deal."
NAPWA's Anderson continues to sit on PACHA. While he applauds the "diversity of representation" on the body, "it was always frustrating to me how few of the Council members had ever had any role in administering, planning, or running in any form, any of these [ HIV/AIDS ] programs."
He would like to see the Council retained, perhaps with a smaller membership, and definitely with more attention paid to having specific expertise among the members. He also would like to see the White House say, "Okay, we are really wrestling with this issue, you guys take six months and chew it over and come back with something." The Clinton administration did not do that. Anderson believes "that is an important piece of how [ an advisory council ] is taken seriously within an administration."
Baker puts the question of an AIDS Council in rather stark term: "Do we need a Presidential Council on Physical Fitness but not one on AIDS?" His answer is that "AIDS is something that requires presidential leadership."
