During the 2008 campaign, a coalition of AIDS service organizations and advocates called upon all candidates for the Presidency to develop a National HIV/AIDS Strategy to address serious gaps in progress against HIV/AIDS. As a candidate, the future President Obama pledged that his administration would develop a Strategy and, since his election, the White House has actively solicited advice from people living with HIV and community groups on what should be contained in the Strategy. Project Inform has served as a member of the Steering Committee of the Coalition for a National AIDS Strategy and has provided significant advice as to what we believe this much needed document should contain.
In December 2009, Project Inform and the Community HIV/AIDS Mobilization Project co-hosted a meeting of leading HIV experts who recommended that the Strategy include an initiative called Testing & Linkage to Care Plus (TLC+). TLC+ proposes that by greatly increasing HIV testing nationally and quickly linking newly diagnosed HIV-positive people to primary medical care, social services, prevention counseling, plus treatment, the U.S. could greatly increase the percentage of HIV-positive people adhering to care and treatment, improve their heath outcomes, prevent new infections, and reduce health disparities suffered by women and people of color.
On July 13, President Barack Obama released the National HIV/AIDS Strategy and warmly welcomed HIV advocates to a White House reception to mark this important development in the epidemic. Project Inform was honored to be in attendance at that historic event. The Strategy was prepared in close coordination between the President's Office of National AIDS Policy (ONAP) and an Inter-Agency Work Group made up representatives of all Federal agencies involved in the nation's response to HIV/AIDS. It was reviewed before being released by the President's Advisory Committee on HIV/AIDS (PACHA), which includes people living with HIV and representatives of AIDS service organizations.
The Strategy is almost entirely what Project Inform hoped for. It sets assertive but achievable goals for improving the health of HIV-positive people and reducing new infections. It is deliberately and thoughtfully focused on a limited set of goals and activities that are most likely to have significant impact on the epidemic. ONAP, the Inter-Agency Work Group and PACHA deserve enormous credit both for the plan itself and the inclusive process used to develop it. Project Inform's summary of the Strategy can be seen here. President Obama's remarks about its release are available at AIDS.gov.
First and foremost, the Strategy takes a well-reasoned and thoughtful public health approach previously missing in the epidemic. HIV treatment has historically been focused on improving the health of the individual, as well it should be. However, just as TLC+ does, the Strategy is focused on making certain that more HIV-positive people know their status and are linked quickly to care and social services that will prepare them to take HIV medications early in infection and remain adherent to treatment. It asserts that doing so will help to meet the important goals of increasing the percentage of HIV-positive individuals engaged in care and treatment that prolongs and improves quality of life, as well as reducing new HIV infections. The Strategy also makes clear that effective HIV prevention requires combining different proven methods, including promotion of condoms, availability of sterile syringes for injection drug users and supporting HIV-positive people to avoid transmitting the virus to others.
With regard to prevention, the Strategy courageously promotes two additional actions. First, it asserts that the focus of prevention programs and funding should be on those geographic areas and risk groups that are actually suffering the greatest burden of new infections. Those include urban areas and gay and bisexual men, particularly gay and bisexual men of color, transgenders and injections drug users. It notes that most, though certainly not all, HIV cases among people of color occur in gay and bisexual men. Second, the Strategy supports the development of prevention interventions that are likely to have community-wide impact, not just individual impact.
While both the HIV care and prevention provisions of the Strategy have a decidedly medical focus, the document correctly asserts that successfully engaging HIV-positive people in care and treatment, as well as preventing HIV, requires an increased focus on the enormous needs of people living with and at high risk for HIV for basic social services including housing, mental health and substance abuse treatment. It also asserts the importance of reducing stigma and discrimination against people with and at risk for HIV -- including among medical providers -- in order to increase chances that individuals will obtain HIV testing, medical care and treatment.
Importantly, the Strategy contains a discussion about the need for much greater coordination of the work of Federal agencies involved in the nation's response to HIV/AIDS, and for improved coordination and streamlining of programs among Federal, State and local government agencies. The President has directed the Office of the Assistant Secretary of Health & Human Services (HHS) to coordinate the efforts not just of the many agencies involved in HIV/AIDS within HHS, but of all Federal agencies.
The document does not discuss financing of new directions in the fight against HIV at great length, a point that many HIV advocates have noted with concern. It correctly argues for the more effective use of existing funding, particularly for HIV prevention programs. It notes that recently adopted national health care reform will provide the means by which most HIV-positive Americans will be able to access primary medical care and treatment. And it asserts that the Ryan White Program, which currently provides over $2 billion in Federal funding for care, treatment and social services programs for people with HIV, needs to extended and reconfigured to support this new direction in the fight against HIV/AIDS. It does not, however, commit to whether all of those $2 billion should be preserved.
Project Inform agrees with all of these points regarding financing of HIV/AIDS services. But we believe that all of the $2 billion appropriated to the Ryan White Program -- and perhaps more -- will need to be appropriated to fill in for gaps in health care reform and assure the level of social services and linkage of HIV-positive people to care and treatment that are called for in the Strategy. We also believe that HIV research, particularly cure-related research at the National Institutes of Health, and HIV prevention programs of the Centers for Disease Control & Prevention (CDC), will need funding increases in coming years. And we are alarmed that the Obama administration and the Congress are currently placing insufficient funding into the AIDS Drug Assistance Program (ADAP) as a bridge to health care reform, which is to be fully implemented in 2014.
An otherwise visionary and thorough document, the Strategy's main weakness appears to be in the area of expanded HIV testing. This is particularly disappointing in that the fundamental goal of increasing participation in care and treatment is predicated on greater awareness of HIV status. The CDC has previously been cited as making some progress on its goal of assuring that all Americans aged 13 to 64 know their HIV status, but inadequate progress. And while the Strategy does encourage greater cooperation from major national medical groups in assuring that medical providers routinely offer testing to their patients, it does little else to make clear how the nation will increase the percentage of HIV-positive Americans who know their serostatus. Project Inform will press to assure that the detailed implementation plan that is to follow the release of the Strategy by December 13, 2010 corrects this problem.
This is an extremely encouraging and opportune time in the domestic fight against HIV and AIDS. The National HIV/AIDS Strategy sets the proper course for improving the health of HIV-positive individuals, reducing new HIV infections, and reducing great disparities in the HIV health now experienced by women and people of color. National health care reform will greatly help us to assure access to care and treatment for most, though not all people living with HIV. The current arsenal of HIV medications, while not perfect, is capable of greatly prolonging the length and quality of life of HIV-positive people when taken early in infection and preventing new infections. It is vital that the nation seize on this set of advances and fund them adequately in order to achieve the vision of President Obama's Strategy: that "The U.S. will become a place where new HIV infections are rare and when they do occur, every person, regardless of age, gender, race/ethnicity, sexual orientation, gender identity or socio-economic circumstance, will have unfettered access to high quality, life-extending care, free from stigma and discrimination."
Project Inform is proud to have played a part in the development of the Strategy and will remain heavily engaged both in informing the details of its implementation and monitoring its results. We will regularly update our constituents about progress in this regard.