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Particularly crucial was the issue of definition: an official AIDS diagnosis was needed to qualify for most federal assistance programmes, yet the existing clinical definition omitted important manifestations characteristic of groups other than gay men. Expanding the definition was nonetheless politically difficult, because the change would increase diagnoses by up to per cent, thereby driving up federal expenditures. In advocates won out, and the CDC adopted a new definition of AIDS that included invasive cervical cancer, recurrent pulmonary tuberculosis and other conditions specific to women or injecting drug users.

PEPFAR poured millions of dollars into delivering medication to parts of the world where it would not otherwise have been accessible. Domestically, meanwhile, a profound shift was underway.

In response, academics mobilised through national organisations such as the Union of Concerned Scientists and Research! America to protect scientific autonomy and the peer-review process. Alongside the movement to better align HIV prevention with conservative values came other shifts in prevention, many of them geared toward routinising testing and the identification of HIV-positive individuals. With SAFE, the CDC moved away from the longstanding strategy of balancing general AIDS awareness programmes with ones targeted to high-risk groups; the CDC now focused on raising the number of HIV-positive people who knew their status, understood it, and received treatment for it, making them less likely to transmit the virus to others.

In the agency dropped longstanding requirements that every HIV test be accompanied by written consent and pre-test counselling. It also recommended that adults and adolescents in all health care settings be tested for HIV at least once and that those engaging in risk behaviours be tested annually.

Even though CDC leaders had determined that routine testing would benefit both those with HIV by setting them on a road to effective treatment and those without HIV by clarifying the HIV status of partners or potential partners , Left-leaning activists worried about the potential for coercive testing of marginalised people and the stigma that those who tested positive might face. Despite opposition, the routine testing policies of the George W.

Political struggles over Medicare resulted in repeated, temporary losses of prescription drug access for patients. Financial constraints on Medicaid, which covered many more HIV-positive people than Medicare, forced patients to forgo certain medications. Although delayed by Hurricane Katrina and war in Iraq, the reauthorisation process was long and, once again, contentious.

With regard to the first, the final legislation increased proportional allocations to rural and Southern states, while still limiting to 5 per cent the amount that early epidemic centres could lose. The abstinence-based policies of the s were largely dismantled. Several judicial decisions weakened the federal policy, and the Supreme Court overturned the entire law in These years also witnessed the next chapter in needle-exchange controversies. Seizing a rare moment when Democrats controlled Congress and Republicans were occupied by other issues, the Obama Administration quietly lifted the federal funding ban at the end of The Obama administration also moved in new directions.

An Implementation Plan was released alongside the Strategy , and each relevant federal agency devised an operational plan to facilitate implementation. ONAP itself spearheaded efforts to increase coordination, for instance, through the introduction of common requirements for grantee reporting. The CARE Act reauthorisation helped preserve treatment services for those without quality health insurance.

Analysts estimate that up to 70 per cent of people with HIV who were uninsured before the ACA now qualify for Medicaid, and many of the remaining 30 per cent are gaining access to private insurance. First, the law could help decrease the stigma associated with HIV by allowing most HIV-positive people to access medical treatment through traditional health care structures; and, indeed, HIV-related stigma may be ebbing, as evidenced by the recent re-examination of issues ranging from blood donation by gay men to treatment of HIV-positive inmates in prison.

In the Strategy was revised to reflect substantial advancements in AIDS science and to note progress on goals made to date. While the long-term legacy of the Strategy cannot yet be determined, it is clear that the Obama years witnessed decreasing infection rates. Under Democratic administrations, central concerns of the political Left come to the fore: providing for the disadvantaged, expanding the health care social safety net and combatting the discrimination and stigmatisation of marginalised groups. Under Republican administrations, the epidemic is viewed through central concerns of the political Right: trimming government-funded social programmes, emphasising personal responsibility and protecting citizens and society from the negative impacts of behaviours coded as immoral.

Public health experts often view Democratic presidential administrations and Congresses as easier contexts in which to advance their preferred policy choices, particularly since Conservative leaders are more likely to accord the same weight to ideological discourses about sexuality and drug use as to scientific consensus in their policy making.

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So, for instance, most prevention experts strongly advocate the comprehensive approaches to sex education that research finds most effective, and such programmes generally thrived during the Clinton and Obama administrations. Under Republican administrations, prevention efforts have focused on abstinence, and grant guidelines have had a chilling effect on programmes promoting more frank and holistic approaches. Similarly, socially-conservative legislators have been steadfast in their opposition to needle exchange, which they see as conveying permission to engage in immoral behaviour.

Thus, despite strong scientific consensus that needle exchange programmes reduce HIV transmission without increasing drug use, a ban on federal funding for needle exchange was enacted during the Reagan years and affirmed during the conflict-ridden Clinton administration. This is not to say that members of the political Left never elevate their own concerns over the science-based recommendations of public health experts. Leaders on the political Right were less concerned about stigmatisation and more concerned with insulating the broader American public from a disease affecting primarily marginalised groups.

Thus, routine testing was a relatively easy policy to implement during the Republican-led George W. Bush years. With no cure yet in hand, however, significant challenges remain, including, first and foremost, in the arena of treatment financing. However, the election of Republican President Donald Trump and a Republican-dominated Congress in complicates that forecast, raising the real possibility that the ACA will be dismantled, de-funded or radically revised.

How can both medical resources and financial burdens be distributed equitably? Beyond the treatment arena, we should expect that prevention programmes will remain particularly susceptible to political attack, since they necessarily involve politicised choices about which populations to target and how to communicate on sensitive topics.

This resource was produced by the Kaiser Family Foundation, and terminated in September Kaiser Family Foundation is committed to, and a respected source of, non-partisan health-news. POZ stories were used to supplement the Kaiser source starting from the point when Kaiser stopped producing a daily report focused solely on HIV. News data were analysed by summarising the main content of each individual news story; cataloguing and sorting stories by year and theme using extensive Excel spreadsheets; and analysing patterns across themes and across time.

Legislative histories were gathered from the Congressional Universe database. Interviews averaged about 90 minutes; most were conducted in person, the remainder by phone. Interviews followed a semi-structured format, in which informants reflected in their own words on their policy making work and the larger contexts of national policy debates and decisions.

Most informants spoke confidentially and are thus cited using unique identification numbers; others waived confidentiality and chose instead to be identified by name. Interview data were analysed using the inductive methods of thematic coding and constant comparison, with the aid of NVivo software for qualitative data.

Barney G. Glaser and Anselm L. These include agency reports, hearing and debate transcripts, congressional and parliamentary testimony, executive orders, issue briefs, advocacy guides and meeting notes. Many of the documents are publicly available; the remainder were provided by study informants.

The term HIV came into use after the viral origin of the disease was discovered. Mirko D. Other sources argue for slightly different benchmark dates for first recognition of the problem.

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Sandra Panem, ed. The high level of mortality was due to a standard two-year waiting period between diagnosis of a recognised disability and eligibility for benefits under Medicaid. See Julia A. Ericksen and Sally A. For the rising levels of demand on health services, see Victoria A. Virginia Berridge, ed. Tasleem J. Barbara A. Officially, the provisions of the Helms Amendment applied only to federally-funded materials and activities. Peter Lewis Allen, ed. In both cases, funding for needle exchange programmes could have been filtered through state or regional public health departments.

For discussion of the role of scientific expertise in American versus European policy making more generally, see Sheila Jasanoff, ed. Victor F. Bradley M. Mathers et al. Brier, Infectious Ideas: U. Recommendations and Reports 41, no.

Lee and Carroll L. Robin Weiss and Leslie M. Samuel A. Bozzette et al. Fleishman et al. The aerosolised pentamidine treatments that emerged in the late s helped stave off deadly pneumonias in AIDS patients, and research seemed to show that AZT might delay the onset of full-blown AIDS and death. Confidential Informant 6, Interview with Author, The formulation of a method to cover all members of a particular group was particularly striking in the pre-ACA era.

Robin A.

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Cohen et al. ADA protections with respect to HIV were significantly strengthened in subsequent years; the ADA now protects persons at all stages of HIV disease, as well as people suspected of being infected or at risk of being infected, from discrimination. Stine, eds. Peter S. Arno et al. Kahn et al. Morin and Edwin D. In the absence of a comprehensive, federal solution, advocates pursued a piecemeal strategy, seeking federal waivers to allow states to cover people with HIV in their Medicaid programmes.

Some scholars argued that this strategy would ultimately prove more productive than efforts at federal reform.

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However, waivers were only granted where states could prove their expanded programmes would be federally cost-neutral, and, prior to the ACA see below , only Mississippi, Maine, Massachusetts and Washington, DC had active expansion programmes. Mayer and H.