Politics Before Science?

There was a time when the nation's top AIDS advisory panel operated outside the political climate that pervades Washington, D.C.'even under conservative presidential administrations'and took surprisingly independent and science-based positions. For example, during the waning months of the Reagan administration, James Watkins, who chaired the President's Commission on the HIV Epidemic, became an unlikely hero by leading his conservative panel in support of antibias laws to protect HIV-positive people, on-demand treatment for drug addicts, and the speeding of AIDS-related research. 'Semen, blood, and ignorance surround this epidemic, and we were in that last category,' Watkins said at a 1988 press conference. Later, President George H.W. Bush turned to June Osborn, MD, the former dean of the School of Public Health at the University of Michigan, to head the National AIDS Commission. And the members of Bill Clinton's panel'the Presidential Advisory Council on HIV and AIDS'were mostly prominent figures with a long history of working on AIDS policy. But the independent, science-based focus of the national AIDS panel has withered under the George W. Bush administration. Instead, conservative ideology has emerged as the defining characteristic of the council. Toning Things Down Bush first considered scuttling the 35-member PACHA soon after his inauguration, but then he instead engaged in a yearlong process of replacing most of Clinton's appointees and installing a new, right-wing executive director who favors abstinence over condoms to prevent HIV infections. Bush's reorganized panel held just two meetings in 2002 and issued only five recommendations to the White House'down dramatically from the 597 recommendations offered by the 10-member Watkins panel in its year of existence. The current council supported allocating more funds for local and international treatment access and backed the development of an unspecified HIV-prevention program. None of the recommendations were enacted. 'Nothing happened as a result of PACHA's work. It was the same normal course of Washington-based business,' says A. Cornelius Baker, who heads Washington's Whitman-Walker Clinic, a health and service facility for lesbians and gay men. The council is now cochaired by Tom Coburn, an obstetrician and former Republican congressman from Oklahoma who gained a national reputation for his opposition to safer sex as a way to prevent HIV infections. The other cochair is Louis Sullivan, the secretary of Health and Human Services during the first Bush administration. Sullivan usually takes more-moderate positions, including supporting needle-exchange programs to provide injection-drug users with clean syringes. The advisory council also was guided for more than a year by executive director Patricia Ware, who has a long record as a sexual-abstinence activist. Minds Set The council as a whole, though, is even more philosophically polarized than its leaders. 'About a third of the council is abstinence-only advocates and have raised doubts about effectiveness of condoms. This is a threat because we know that using condoms can reduce chances of getting HIV,' says Caya Lewis, one of the few Clinton holdovers on the panel. But the encouragement of condom use has been supplanted by more 'family values''oriented prevention approaches. At the council's second 2002 meeting, Ware gave a surprise speech on the need for promoting marriage and two-parent families'particularly among African-Americans. Brent Minor, a gay member of the council says he 'responded to Ware's speech by asking, 'What do you tell an 18-year-old gay kid?' If Ware's there to promote abstinence, I'm there to say, 'What happens when you can't?''' Complaints also have been raised about the way Ware seemingly pitted African-Americans against gays, advocating for increased funding for HIV programs for blacks at the expense of those serving gay men, whom she blames for the epidemic. 'Ware does go down the road of blaming white gay men and dividing African-Americans, but this is a broader issue,' says Baker. Unfortunately, the council's divisions are likely to continue. With the new year came seven new Republican appointees, furthering a shift to the right [see accompanying article]. The appointees leave the council with only four gay members, few panelists with national HIV experience, and such disparate points of view that policy development is in disarray, says Lewis. On a Road to Nowhere? 'The conversation on the council is much different from what it was on the [Clinton] council because all our divisions keep us from discussing substantive issues,' Lewis continues. 'Prevention has not been addressed. I think there needs to be people talking about women and HIV, but the fact of the matter is that most people with HIV are gay men. We're seeing rates in young gay men rise and need to address that. But [PACHA's leaders] have crafted the agenda and invited speakers to the meetings who share their viewpoints. These are not exactly the most objective viewpoints, and it gives new members a false impression on what the science is.' So the presidential advisory council is likely to continue to fiddle with ideological positions, while out in the real world HIV pays little attention. Nor does anyone else, it seems. 'PACHA is not influencing the media or public discussion,' Baker says. 'It's important to have this vehicle, but the current structure is not the right way to be effective. PACHA should be like the Watkins commission, a smaller group with more direct charge and engagement with the president.' The Watkins and Osborn commissions, despite their shortcomings and failures, were successful in focusing public attention on the need for an effective AIDS agenda within a conservative White House. But the current panel seems assembled more as a politically expedient way to please contentious constituencies than to seriously addressing the Watkins-dubbed issues of 'semen, blood, and ignorance' that continue to characterize the epidemic. Gilden has written about AIDS policy and HIV medical research for the past 13 years.