The State of Prevention


Barack Obama stood, jacket off and sleeves rolled, shouting into his mic and straining to be heard over the roaring crowd that turned up to welcome him back to Kenya. It was August 26, 2006, and the world was already watching.

The young senator was just a few months away from launching his improbable bid to become the 44th president of the United States, and he needed to demonstrate his ability to walk on the global stage. So he’d chosen a swing through Africa as his first major diplomatic foray, with a grand return to his father’s homeland as the highlight. The trip would be roundly praised. He’d be warm, but also challenging. He’d make a bold statement against corrupt government in African nations. And he’d offer his family as a deeply personal example of leadership in the fight against HIV.

“One of the reasons that we’re here today,” Obama began, having quieted the crowd gathered around him in front of a tiny mobile clinic, “is because HIV and AIDS have ravaged the community.” His visit to Kenya had just begun and he’d decided to use this welcoming moment, in which thousands thronged the streets, to send a pointed message about ending AIDS. He told the crowd that he and his wife, Michelle, were about to take HIV tests—and if they could do it, so could everyone else present. “I am so happy now because I know the status of my wife and I,” Obama declared after the test. “We are both negative, and I can take control of my family and all tasks that lie ahead of me.”

Just over two years later, those tasks are greater and graver than anyone ever imagined. President Obama now faces crises ranging from a global economic collapse to a rapidly destabilizing environment. But the challenge he chose to highlight that Saturday afternoon in Kenya has also grown more urgent, including right here in the United States.

Over the past eight years, America has rested on the AIDS treatment successes of the previous decade, turning its focus solely abroad while assuming a domestic victory it has not yet won. The result, as the Black AIDS Institute outlined in our 2008 report, Left Behind: Black America—A Neglected Priority in the Global Epidemic, is a black epidemic that looks more and more similar to those in places like Kenya. From rural Alabama to densely packed Oakland, California, the black American epidemic’s breadth and complexity mirrors that of poor communities throughout sub-Saharan Africa.

During his presidential campaign, Obama signaled that he understands the tangled up crises that have produced the epidemic in black neighborhoods, and he vowed not to shrink from that reality if elected. “When we are impoverished,” he said during a primary debate at Howard University, “when people don’t have jobs, they are more likely to be afflicted not just with AIDS, but with substance abuse problems, with guns in the streets. So it’s important for us to look at the whole body here.”

His campaign platform included a plan he argued would do just that. Complex, big picture analysis like the one Obama offered at Howard too often becomes an excuse for inaction in the face of tough problems; it’s a trap that many people in all walks of life have fallen into when confronted by HIV. But Obama’s potential is to spring policymakers from this trap and end Washington’s three-decade-old vacillation between ignoring the problem and groping for a quick fix to it.

From Bad to Worse

The year 2008 was chocked full of bad news, far too much of it as predictable and preventable as it was devastating. AIDS was no different.

For many Americans, the news got lost amid the uproar over soaring gas prices and plummeting 401Ks. But the summer of 2008 marked a similarly grave turn for the health of black neighborhoods: The U.S. Centers for Disease Control and Prevention, or CDC, announced that the American AIDS epidemic is at least 40 percent larger than previously believed.

Nearly a decade ago, the CDC began developing a new system for monitoring the American AIDS epidemic. For years, HIV tests could determine only whether the virus was in a person’s blood, not how long it had been there. That meant researchers couldn’t differentiate a new infection—say, one that’s six months old—from an old infection—one that’s six years old. And as a result, they couldn’t detect with precision how fast or slow the virus was spreading, only how fast or slow health workers were diagnosing its spread.