Obama Releases Updated National HIV/AIDS Strategy to Combat U.S. Epidemic
On July 30th, President Obama signed an executive order to release the "National HIV/AIDS Strategy: Updated to 2020." The document, which supplants the first National HIV/AIDS Strategy (NHAS) released in 2010, details the guiding principles behind the United States' response to its own HIV epidemic over the next five years.
The two documents are more similar than dissimilar, with the updated NHAS reflecting strides made in the fight against HIV during the last five years. The four main goals of the original NHAS are still intact: to reduce new infection, to increase access to care for people living with HIV (PLWHIV), to reduce HIV-related health disparities and inequities, and to achieve a more coordinated national response.
In a press release issued the same day as the updated Strategy, Gay Men's Health Crisis (GMHC) CEO Kelsey Louie praised the new Strategy. He said, "GMHC is proud to have worked closely with the White House to help provide key feedback and data from our work."
"We look forward to continuing our important work with President Obama and his team to help make the goals in this strategy a reality," Louie added.
Mark Harrington, executive director of national AIDS policy and research think tank Treatment Action Group (TAG), had a different view.
In a statement to TheBody.com, Harrington said, "There is very little 'new' in the [updated NHAS], aside from fancy new graphics and peppy, upbeat references to great new scientific results which have been released since the original [NHAS], such as HPTN-052, iPrex, PROUD, iPERGAY and others."
Recently, TAG released their own national strategy for HIV prevention, entitled "Toward Comprehensive HIV Prevention Service Delivery in the United States: An Action Plan," which proposed an HIV prevention continuum to mirror the HIV care continuum for PLWHIV.
The HIV Care Continuum
The HIV care continuum -- which offers a snapshot of what percentage of people reach significant steps on the path to knowing their status, finding care and treatment, and reaching viral suppression -- is the foundation for many of the NHAS's objectives. The updated NHAS will focus on making people aware of their status through HIV testing, and promoting linkage to care and support services for PLWHIV to help them achieve viral load suppression.
While more people than ever know their HIV status, an estimated one in eight PLWHIV do not know their status. Moreover, currently nearly a quarter of people diagnosed with HIV receive a concurrent AIDS diagnosis, meaning that they likely had been living with HIV for a long time when they were diagnosed.
According to the U.S. HIV care continuum, as recently as 2012 only 39% of PLWHIV were engaged in care, despite 82% of people being linked to care after diagnosis.
The final step of the care continuum, viral load suppression, has received greater emphasis in the fight against HIV since the results of the PARTNER study showed zero HIV infections among serodiscordant (mixed-status) couples who engaged in condomless sex.
New Prevention Approaches
For those who wish to prevent HIV acquisition, the plan also emphasizes "full" access to pre-exposure prophylaxis (PrEP) services, which would entail not only access to pills but also to related monitoring services such as testing for HIV and sexually transmitted infections (STIs). Truvada (tenofovir/FTC) was approved for use as PrEP by the U.S. Food and Drug Administration in July 2012, two years after the release of the initial NHAS.
The updated Strategy integrates other major policy and scientific advances that have come since the original Strategy was released.
The original NHAS was released just months after the approval of the Affordable Care Act (ACA) and years before it was fully implemented. Now, after the full roll-out of the ACA, more Americans have access to health coverage, including preventive services such as HIV testing.
In terms of prevention, the updated Strategy will emphasize "High Impact Prevention," an approach adopted by the Centers for Disease Control and Prevention (CDC) in 2010 that emphasizes combination strategies and targeting of resources.
In the past five years, research funded by the National Institutes of Health (NIH), especially the Strategic Timing of Antiretroviral Treatment (START) study, has provided undeniable evidence that HIV treatment keeps PLWHIV healthy and stops the spread of the virus. Consequently, the updated NHAS emphasizes the importance of HIV treatment, and the continuation of the Ryan White HIV/AIDS Program and the AIDS Drug Assistance Program (ADAP), which expand treatment access.
Progress on the NHAS will be measured through a series of outcomes the President hopes to reach by 2020. The NHAS aims to see 90% of people know their status, to reduce the number of new diagnoses by 25% and to increase the number of people linked to and retained in care. The NHAS seeks to reduce homelessness among PLWHIV to no more than 5%. A 2007 study from the National Coalition for the Homeless showed that almost 50% of PLWHIV felt they were at risk for homelessness.
Populations and Regions
The 2015 NHAS identifies several key populations and geographic areas that required specific attention in order to address the U.S. HIV epidemic. These groups include: gay and bisexual men (especially black gay and bisexual men), black men and women, Latinos and Latinas, injections drug users, people between the ages of 13 and 24, people who live in the U.S. South and transgender women, especially transgender women of color.
In 2010, groups of women living with HIV and their allies were critical of the first NHAS for lacking clear strategies for women. Organizations that collaborated on a gendered analysis of the original NHAS gave the plan a grade of C+ on women's issues.
In a statement on the updated plan, Naina Khanna, executive director of Positive Women's Network - USA (PWN-USA), applauded it for addressing several gender-based gaps that the group and allies had pointed out in their 2010 critique.
However, PWN-USA also noted that the updated NHAS fails to address health disparities and specific barriers to access for black women living with HIV, including transgender women. PWN-USA also bemoaned the updated Strategy's lack of focus on sexual and reproductive rights of PLWHIV, which they maintain is routinely violated and ignored.
The 30 for 30 Campaign, a coalition of HIV and reproductive health organizations advocating for the health of HIV-positive women, also commended the updated Strategy, while calling for a greater emphasis on sexual and reproductive health and noting the omission of the needs of sex workers.
To read the National HIV/AIDS Strategy in full, head over to AIDS.gov.