A Call to Action: The U.S. Is Past Due for a National AIDS Strategy

HIV/AIDS remains one of the most significant public health problems in the United States. More than one million people are now living with the disease. HIV infection rates have not fallen in over a decade, and those rates may be up to 50% higher than previously thought.¹ Half of those living with HIV/AIDS are not receiving lifesaving healthcare. One quarter of Americans who have HIV do not even know it. This epidemic requires a strategic plan of action that promotes coordination across agencies, accountability, evidence-based policy, and a focus on improved outcomes.

Numerous governmental and private studies have pointed to the need for better planning of national policy and programming. In 2004, the Institute of Medicine determined that current federal financing of AIDS-related health care "does not allow for comprehensive and sustained access to quality HIV care" nationwide.² A 2003 study found that failure to meet the government's then goal of reducing HIV infections by half would lead to $18 billion in excess expenses through 2010.³ A 2005 Rand Corporation study determined that if CDC's HIV prevention funds were allocated based on cost-effectiveness research, total annual HIV infections could be reduced by half.⁴

A national plan can rectify disparities by ensuring prevention, treatment, care, and support reach the communities most affected and at risk. For example, half of new infections are among African Americans, who compose only 13% of the population, and half are among gay and bisexual men. African Americans are not only at disproportionate risk of infection but also suffer poorer treatment outcomes. Between 2000 and 2004, deaths among whites living with HIV declined 19 percent compared with only seven percent for blacks.⁵

The international community, including UNAIDS, has encouraged and supported governments to create national AIDS strategies based on evidence and best practices, human rights frameworks and community input. Other countries, including Brazil and Thailand, have had measured success in addressing AIDS with comprehensive strategies. Through a coordinated response, Thailand reduced its number of new HIV infections from 143,000 in 1991 to 19,000 in 2003.⁶ Brazil has also shown success in the fight, by increasing condom use, targeting disproportionately affected communities, and increasing access to ARVs.⁷

The U.S. government appears to agree that a central strategy is important and makes a country operational plan a condition of foreign aid. Under the President's Emergency Plan for AIDS Relief (PEPFAR), the 15 focus countries, including violence rattled Haiti and Uganda, cannot receive funding without a country operational plan, a roadmap for effective delivery of services and steadily improved results. A similar approach to the domestic epidemic, however, has not followed.

Several hundred organizations have declared their support for a National AIDS Strategy, and individuals and organizations can add support at www.NationalAIDSstrategy.org. Collectively, these advocates state that a successful plan will require clear objectives, goal-oriented strategies, and mechanisms for monitoring and evaluation. They recommend the following priorities:

• Improve prevention and treatment outcomes through reliance on evidence-based programming;
• Set ambitious and credible prevention and treatment targets and require annual reporting on progress towards goals;
• Identify clear priorities for action across federal agencies and assign responsibilities and timelines for follow-through;
• Include, as a primary focus, the prevention and treatment needs of African Americans, other communities of color, gay men of all races, and other groups at elevated risk;
• Address social factors that increase vulnerability to infection;
• Promote a strengthened HIV prevention and treatment research effort; and
• Involve many sectors in developing the national strategy: government, business, community, civil rights organizations, faith based groups, researchers, and people living with HIV/AIDS.

Moving forward, Senator Obama, if elected, has pledged to implement a national HIV/AIDS strategy within the first year of his presidency.⁸ Senator McCain, at the time this article went to press, had not committed to such an idea. On June 17, 2008 the U.S. House of Representatives Financial Services Appropriations Subcommittee approved a bill that includes $1.4 million to the White House Office of National AIDS Policy for the development of a National AIDS Strategy. Public health experts, service providers, and advocates nationwide applauded this official first step toward a plan. At the time this article was printed, the Senate was expected to take similar action in July.

Brian Bonci is a J. K. Watson Fellow in the public policy department at GayMen's Health Crisis.

References

1. "Estimate of AIDS Cases In U.S. Rises: New Test Places the Rate Of Infection 50 Percent Higher." The Washington Post, December 1, 2007.
2. Institute of Medicine, Public Financing and Delivery of HIV/AIDS Care: Securing the Legacy of Ryan White (Washington, DC: 2004): 9.
3. Holtgrave, D, Pinkerton, S, Economic Implications of Failure to Reduce Incidence HIV Infections by 50% by 2005 in the United States, JAIDS, 33:171-174.
4. Cohen, D., et al., "Cost-effective Allocation of Government Funds to Prevent HIV Infection," Health Affairs, vol. 24, no. 4 (July/August 2005).
5. Collins, Chris. "The U.S. Needs a National AIDS Strategy." Black AIDS Institute. 23 Oct. 2006. www.blackaids.org.
6. Kanabus, Annabel & Jenni Fredriksson "HIV & AIDS in Thailand." Avert. www.avert.org/aidsthai.htm.
7. Pembrey, Graham. "HIV & AIDS in Brazil." Avert. www.avert.org/aids-brazil.htm.
8. Senator Obama's pledge is available at: www.barackobama.com/pdf/AIDSFactSheet.pdf.

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