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Advocates Take Aim at 'Targets' of the Updated U.S. HIV/AIDS Strategy

October 29, 2015

As the first comprehensive federal plan to address the United States' HIV/AIDS epidemic, the 2010 National HIV/AIDS Strategy (NHAS) met with a great deal of support from advocates and members of the HIV/AIDS community. Five years later, reaction to the Obama Administration's mid-decade Strategy update is decidedly more mixed. Among other things, advocates are voicing concerns that the update doesn't specify how it would prove ambitious goals (called "targets" in the plan) were reached.

While not a carbon copy of its predecessor, "The National HIV/AIDS Strategy: Updated to 2020" doesn't overturn the initial Strategy. Instead, it incorporates small tweaks and additions based on scientific advances and lessons learned since 2010

One prominent addition is the update's emphasis on pre-exposure prophylaxis (PrEP), a scientific breakthrough in the last five years that has become an important new HIV-prevention tool. The updated Strategy also places greater emphasis on the need to make HIV care accessible, affordable and broadly defined throughout the entire continuum of care, with a specific focus on testing and linkage to care and achieving universal viral suppression among people in the U.S. living with HIV.

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Kenyon Farrow, the U.S. and global health policy director for Treatment Action Group (TAG), was unimpressed by the ambition of the strategy's updated targets and questioned how progress towards achieving those targets would be measured.

"Some of the basic targets are questionable and in some cases insufficient," Farrow said in a recent interview with TheBody.com. He also cast doubt on the utility of much of the data being gathered to measure progress towards meeting the Strategy's goals. Farrow pointed out the use of HIV diagnoses rather than incidence as one example of the problems plaguing the NHAS update.

"[O]nly focusing on diagnoses ... could result in a situation where you could increase diagnoses and it could mean either that you're doing a good job or a bad job and you wouldn't know," Farrow said.

Farrow also expressed concern that the Strategy update failed to address key questions around funding and the stark differences in state implementation detailed in a recent report. "There are some decent proposals in the Strategy update, but it doesn't do a very good job of addressing the question of how we are going to fund all of this work, especially in areas where the Affordable Care Act isn't implemented and Medicaid expansion isn't there," Farrow said. He believes it's imperative that any comprehensive strategy update should focus in greater depth on successful programs at the state and local level so that we can "learn from the models and practices of states and cities that are getting it right."

He noted that he was looking forward to seeing the Federal Action Plan to implement the Strategy, which is due to be released by December 1st.

The updated NHAS identifies portions of the U.S. population that are disproportionately affected by the virus so that resources can be more effectively allocated to those with the greatest need. The update identifies men who have sex with men (MSM), blacks, Latinos and Latinas, people who inject drugs, youth age 13-24, people living in the Southern U.S. and transgender women as communities that deserve additional attention and funding, while further highlighting black gay and bisexual men, young black gay and bisexual men, and black transgender women as those subgroups most at risk.

The National Center for Transgender Equality, while welcoming the inclusion of trans people in the strategy, also took issue with the update's targets -- in this case, the lack of a specific target for transgender people.

"We are disappointed that the Strategy does not include concrete indicators for addressing HIV among trans people,instead promising to develop those indicators by 2020. More data on trans people and HIV is certainly needed-a problem that itself has not seen adequate action from the federal government. We strongly urge the Administration and all levels of government to prioritize setting and achieving concrete goals to prevent and treat HIV among trans people, with an emphasis on trans women and people of color," they said in a statement.

The first Strategy was roundly criticized by women with HIV and allies for giving scant attention to gender issues. While the update mentions women much more frequently, Barb Cardell, a steering committee member for the Positive Women's Network USA (PWN-USA), was disappointed by the lack of emphasis on specific issues facing women, particularly women of color. "Attention has not been paid in the update to the challenges women of color face to accessing care, to dealing with intimate partner violence and to issues of cultural sensitivity," Cardell told TheBody.com. "We have to address the HIV/AIDS epidemic in a way that recognizes the special needs of all groups, and that includes women," she said.

According to Megan McLemore of Human Rights Watch, the update also "severely shortchanges two key groups: sex workers and transgender women, both of whom are heavily burdened by HIV and the criminal justice system."

In addition, Cardell took umbrage with the update's failure to mention sexual and reproductive health and its seeming emphasis on biomedical approaches over solutions focused on social justice and stigma.

"There is a lot of systemic abuse that happens in doctors offices," she noted. "Spoken or unspoken, the message from many medical providers is that 'Poz women shouldn't be having sex,' and that is frankly unacceptable. There is often no counseling around viral suppression or safety in relationships and the complexity of HIV-positive sexuality is not reflected in the training."

"For roughly two decades, since the first Pediatric AIDS Clinical Trials, women have been able to safely have children through the use of antiretroviral medications and women are still being told by their physicians that they're selfish for having children," Cardell said. "That is absurd. All people living with HIV -- women, gay men, transgender individuals -- are complex and they need a strategy that reflects that fact."

Drew Gibson is a social worker and freelance writer based out of Cincinnati, Ohio. He does his best to split his time and efforts between his work as a case manager for people living with HIV/AIDS in Northern Kentucky and the maintenance of his blog, "Virally Suppressed ," which covers a multitude of issues related to inequity and social justice. You can follow him on Twitter at @SuppressThis.


Copyright © 2015 Remedy Health Media, LLC. All rights reserved.


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