Through the Eyes & Ears of a PWA: Dr. Thomas J. Coates Resonates Prevention Justice

This past Thursday Dec 18, 2008, having taken pleasure in a deliciously prepared Thai Cuisine lunch sponsored by The Univ of Penn, CFAR CAB, as a welcoming salutation to our distinguished guest speaker Dr. Thomas J. Coates, UCLA AIDS Institute at the David Geffen School of Medicine,  I couldn’t imagine anywhere else I’d rather be. That is to say except to join the migration to Penn’s BRB Auditorium along with both Drs. John and Loretta Jemmott, some Penn Staff & Researchers and members of the CFAR CAB. Here we were to be served the academic portion and the main course of Dr Coates expertise, through his lecture entitled” HIV Prevention What’s Next Globally”.

Through a conversation with Michael Blank, Ph.D., Co-Director Penn Behavioral & Social Sciences Core and Tiffany Brown, Penn CFAR CAB Coordinator, I learned it took every bit of “two years” to coordinate Dr. Coate’s appearance. As Vice-Chair of Penn’s CFAR CAB and a person who is living with AIDS, I would like to extend my heartfelt thanks to Penn’s competent Staff for facilitating Dr. Coates’ appearance and affirm that Dr Coates’ appearance was well worth the 2 year wait. It was an enriching experience. 

Our luncheon was thoughtfully planned to be small and intimate, which allowed for some informal conversation. Up until now, of course all of my encounters with Dr. Coates had been external and superficial. I knew of him and his work through teleconferences, list serves, medical journals, internet, magazines, web cams, closed circuit TV and satellite presentations at various conferences. I took pleasure in meeting Dr Coates face to face and I got the distinct impression that he liked me too, but I’ll leave him to blog about that. I found Dr. Coates to be good-natured, up-beat and charming. I knew I would learn many things today in the course of conversation over lunch and by way of his lecture, and unexpectedly one of the first things I learned was The David Geffen School @ UCLA (where Dr Coates joined the Division of Infectious Diseases in 2003) is “the only school in the world named after a Gay Man.” Mmm, I thought. Interesting.

Having covered an array of topics over lunch we began our migration toward the auditorium, but not before Dr Coates turned our focus to prevention research around substance abuse as a driver for HIV infection. Then he raised his concern that there is lack of prevention research around Alcohol Abuse and its relationship to HIV infection... And again I thought, “Very impressive” especially since we know alcohol use is associated with high-risk sexual behaviors and injection drug use, two major modes of HIV transmission. 

It was intriguing to hear Dr Coates talk about the challenges facing many of the newer Principal Investigators as they apply for grants in accordance with new NIH criteria. He spoke about the need for mentorship of the newer Pi’s and how in many cases he has been able to provide that sort of support for them. There was some conversation around Researcher initiated and Community Initiated NIH grants, such as the (R-021) grant which our CFAR CAB has recently applied for to conduct our Stigma Study.

Although Dr Coates’ emphasis of expertise “these days” are centered on the global epidemic, we did get a minute to check in on both our involvements with (2) Domestic HPTN Studies targeting MSM and Women at Risk, HPTN 061 and 064 respectively. Incidentally several of CFAR CAB members including the CAB Chair Rick Britt, have direct community involvement with both HPTN 061 & 064 at the Protocol level by way of CHAMP (Community HIV AIDS Mobilization Project)'s Prevention Research Advocacy Working Group.

The auditorium was nearly filled to capacity as Dr Coates began his lecture entitled “What’s next in HIV Prevention Globally.” A suitable topic as researchers scale up their efforts to identify effective interventions and models to expand our HIV Prevention Tool Boxes. His presentation began by acknowledging the milestones and success of 20th century research and how vaccines have became available for many diseases which used to result in deaths: Diphtheria, Small Pox, Tetanus, Yellow Fever, Polio, Measles, Hepatitis and Malaria (outside of Africa).

Dr. Coates reviewed the “10 Best things we know about HIV Prevention”

• Prevention is possible
• We have knowledge of what does work
• Male & Female Condoms
• HIV testing of individual, couples & families
• Behavioral options
• MTCT works
• Needle exchange works
• Male Circumcision works
• Tx for Positives works
• PREP studies are in the works and looks promising

The Meat & Potatoes so to speak of Dr Coates’ lecture centered on the CHALLENGE & RESOLUTION that affective HIV Prevention will be bought about through “radical behavior modification (Highly Active Combination HIV Prevention) and not simply subtle or restrained change. And that model would have to include:

• Political support and institutional participation
• Planning, surveillance, lab support
• Access to VCT (voluntary counseling & testing) , PMTCT (preventing mother-to-child transmission), Male Circumcision and Treatment
• Community Buy-in and Mobilization
• Inspiration Leadership & Community –grown Strategies
• Behavior options, that include delay of sex and decrease in partners
• Support for HIV+ People
• Access to technological advances as they are proven to be efficacious.

The Dec 2008 issue of the Bay Area Reporter mentioned Dr. Tom Coates literally gushes with enthusiasm for PrEP. "I really believe it will work. If it is as effective as we think it is going to be, it should revolutionize the way that HIV prevention dollars are spent." That reported enthusiasm was very apparent in the room as Dr Coates led a discussion on the latest progress surrounding PrEP, the latest biomedical approach to HIV prevention. PrEP (pre-exposure prophylaxis) refers to the use of antiretroviral drugs by HIV negative individuals to prevent infection. I sensed his concern over the amount of time (years) it takes to deliver prevention strategies like PrEP to those populations that need it the most. Referring to the effectiveness of antiretroviral drugs in preventing HIV infection in the area of mother-to-child transmission Dr Coates pointed out, how long it took to get this intervention out to the populations. “If PrEP is found to be effective we have to get it out to the populations in a timelier fashion.”

Dr Coates went on to say he was “Proud of the US investment in PEPFAR” (the president’s emergency plan for AIDS relief). And I tell you, my “Spidey Senses” started tingling. As AIDS Activists we maintain pressure on the US Government to improve both their domestic and global AIDS policies. There is no doubt that PEPFAR has been extremely beneficial, the fact still remains that PEPFAR is still underfunded by the US and loaded with “gag rules. But as I continued to listen my faith was almost immediately restored when Dr Coates cited a report released earlier this year published by the Institute of Medicine that contained recommendations that the new administration double or triple their contribution to the Global Fund. Currently the US misses its own target of 0.54 of our national gross income. There is simply a bald assertion that the United States is a strong and consistent supporter of the goals of the Millennium Declaration of the United Nations. The truth is with a current contribution of only 0.16 of its GNI the U.S. government has been one of the laggards when it comes to aligning aid with country priorities, and untying gag rules. As such the US is letting down the most vulnerable people in the world.

As a leader on HIV/AIDS-related policy Dr. Coates agrees that it's time to End the Epidemic at Home and reminds us to keep pushing for a National AIDS Strategy, similar to PEPFAR with the resources measurable outcomes and accountability to make it effective.

I am pleased to announce that the Obama Transition Team is currently in the process of setting up both conference calls and face to face meetings with representatives of several National AIDS Movement Groups. Leaders within these groups who are HIV+ will have crucial roles in these upcoming meetings. These meetings are a direct response to our voices being heard, calling for our next presidential administration to begin to develop a National AIDS Strategy within its “1^st One Hundred Days”. Nov 20, 2008 over 1200 People with AIDS and their supporters Rallied in our nation’s capitol. They staged a mock inauguration representing their Hope that President –Elect Obama will be the President who would change the way the US fights AIDS.

Just hearing Dr Coates lecture resonate the values of the present AIDS movement gave me a sense of well being. That the labor of the pioneers of the AIDS movement had not been in vain. Their voices had indeed been heard. Our voices are indeed being heard, and our allies in science and research like Dr Thomas Coates are conduits that echo our values to decision makers and world leaders.

Reflecting on our shared values, my thoughts drifted back to some of conversations we had over lunch. Dr Coates spoke about the US economic recession which triggered the AIDS/Prison Activist in me, to point out (the obvious, or maybe the not too obvious) that while numerous community and social services find themselves on the chopping block across the country, the prison budgets are still on the increasing.

Even here in Philadelphia, Mayor Michael Nutter has announced the closing of area libraries, fire stations and recreation centers as a way of balancing the city’s budget. The fact is the Prison budget here in the city of Philadelphia has seen a steady increase over the last 10 years; from 100 Million in FY97 to 220 Million in FY07. What’s important to identify here and what may not be so (obvious) are the intersections of HIV and mass incarceration. HIV continues to be fueled by the mass incarceration of poor people and people of color. This past summer at the USCA, CHAMP launched “Project Unshackle”, a national effort to link movements around HIV and Incarceration. We are vigorously advocating for scaling up research around how community infrastructure is harmed by imprisonment and to examine the far-reaching effects that imprisonment and HIV have within our communities. It doesn’t take a scientist to see the correlations, between HIV & incarceration...... but it certainly felt good to have a scientist like Dr. Coates contemplate and agree that this is an area of research that ought to be funded and made a priority and that can be added to our expanding tool box of Highly Active Combination HIV Prevention.

Lastly, and of enormous importance was some stimulating conversation around Single Payer Health Care and ETHA (Early Treatment for HIV Act). AIDS Activists have insisted that ETHA be reenacted by the new administration as a major component to the National AIDS Strategy. That once a person tests positive for HIV they become immediately eligible for Medicaid and not have to wait until they get really sick or near death to qualify. Interesting enough Dr Coates and Michael Blank both favored ETHA being built around the Medicare v/s the standard Medicaid Model. Dr. Coates reasoned that Medicare (for all people diagnosed with HIV) would offer an all inclusive entitlement. Whereas Medicaid is governed by and varies from different state to state. In addition Medicaid is not accepted in many places b/c the payout is far too low. For instance he said,” In Texas Medicaid will only pay for 3 drugs. So if you are a person with HIV and Diabetes, what do you do?”

As I anticipated, I learned many things today in the company of Dr. Thomas J Coates. And the food was good too. But the real treat for me came in the form of seeing the warmth emanate of his smile and getting a glimpse at the depth and profound passion Dr Coates has for his work. And I think he liked me too. But I’ll let him blog about that.

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