years ago hundreds of organizations signed a Call to Action demanding a more
accountable, coordinated, and outcomes-oriented approach to tackling AIDS in
America. It called for setting clear
targets for progress, increasing collaboration, and focusing on hardest hit
we saw five years ago was a patchwork effort: people and organizations doing
great work in countless ways, but ultimately not focused collectively on
getting the job done. Today, a lot has
changed for the good—in science, policy, and in evidence of success. On the second anniversary of this country’s
first comprehensive National HIV/AIDS Strategy, it’s worth thinking about what
has gone right, and where we go next.
Strategy changed—and in a way, restarted—the conversation on HIV in the United
States. Five years ago the domestic
epidemic seemed invisible, and President Obama should be applauded for making
it a priority in policy and funding.
With the Strategy came a whole string of reforms—some of them
demonstrating real political courage, like greater emphasis on serving people
at the center of the epidemic, including gay men and African American and
Latino men and women; rechanneling money to more closely follow the epidemic;
calling on states to undo senseless criminalization laws; and redirecting
prevention money to have tangible impact on overall HIV infection rates.
was written in 2010, the Strategy anticipated crucial developments of the next
two years. The HPTN 052 study
established conclusively that HIV treatment is also HIV prevention. The Affordable Care Act promises health
coverage for millions.
course, it hasn’t all gone as planned.
There have been some advances in interagency coordination, streamlining
funds and reducing reporting burdens, but there also have been numerous
hold-ups in these areas. The 12 Cities
Project is a worthy effort to improve the response in urban epicenters, but it
has faced its own challenges with bureaucracy, paperwork, and
underfunding. Evidence took a back seat
to ideology when Congress prohibited federal funding for syringe exchange
original principles of the National HIV/AIDS Strategy movement remain critically
important, but the context has changed significantly. Today it’s less about calling for improved
federal coordination, and more about challenging every level of government to
build an effective response that we now know is possible. In places like San Francisco and Massachusetts
we have started to glimpse success in reducing HIV incidence. A recent analysis by David Holtgrave of Johns
Hopkins University shows that the Strategy goals are attainable with expanded
delivery of multiple evidence-based interventions.
Massachusetts, Medicaid was expanded to cover people living with HIV in 2001, and
in 2006 the state enacted health reform legislation achieving over 98% health
insurance coverage of its residents by 2010.
HIV infection rates have fallen sharply—by 45% between 2000 and
2009. The state is fortunate to have
many accessible community health centers, providers who are comfortable
delivering quality HIV care to people most likely to be affected, and support
services like housing, nutrition, and transportation. Evidence-based harm reduction programs such
as syringe exchange are in place. In
many areas of the state, it’s OK to be gay.
All this means that people have a reason to get an HIV test; if they are
positive they know they can get care and be treated respectfully.
Francisco has similar advantages, including broad health coverage. There the public health department ramped up
testing and earlier initiation of HIV treatment and the percentage of gay men
who didn’t know their HIV status fell from 20% in 2004 to 6% in 2011. Prevention dollars were concentrated in areas
where they would have the greatest impact.
As more people became aware of their HIV infection and brought their HIV
viral load down, HIV incidence decreased and stabilized at a lower level.
the National HIV/AIDS Strategy goals is going to require more examples like
these, though of course each setting will be different. There is no substitute for local and state
leadership. It is at the local level
where decisions can be made to scale up HIV testing and treatment access,
create comfortable health care environments, and match resources with the
realities of the epidemic. State
participation in expanded Medicaid is a top priority. Advocates will also need to press states to
increase investment in HIV services, and insist that public health departments
focus resources on interventions that can have the greatest benefit for the most
acutely affected populations.
federal government has to set the incentives to drive local success. That means increasing funding for AIDS
programming and implementing health reform so that it serves people with
chronic health conditions including HIV.
Federal agencies also have to be clear about the markers for success. In an era in which we understand the
connection between treatment and prevention, viral load should be a key measure
in evaluating patient health, provider quality, and community outcomes. If the federal government clearly emphasizes a
few measures such as testing rates, linkage to and retention in care, and viral
load, it can focus efforts at the state and local level.
addition, the federal government needs to partner with others to launch a
full-scale media effort aimed at fighting HIV-related stigma, and using the
voices of people affected by HIV to encourage HIV testing and treatment. As Jared Baeten from the University of
Washington said recently, “It should be a badge of honor to know your HIV
status and be on treatment if you have HIV, and on remaining HIV-free if you do
years after the movement for a National HIV/AIDS Strategy started, we can be
far more specific about what is needed. And
we can be confident that we can make great progress against the epidemic at
Chris Collins is Vice
President and Director of Public Policy at amfAR, The Foundation for AIDS
Research. E-mail: email@example.com
This op-ed originally appeared on The Huffington Post.