Because the National HIV/AIDS Strategy (NHAS) is a priority endeavor for the U.S. government, when the President released his Fiscal Year 2012 (FY12) budget proposal in February of this year, he proposed a special fund to support the implementation of the Strategy. If approved, the FY12 Budget Proposal authorizes the Secretary of the Department of Health and Human Services (HHS) to transfer one percent of the department's domestic HIV/AIDS spending to promote new, collaborative efforts in support of the goals of the NHAS. If approved in the Congressional appropriations process, this would establish a fund of approximately $60 million dollars that would be administered by the Assistant Secretary for Health whose office would work closely with HHS operating divisions, staff offices, and community partners to determine the most strategic ways to use these resources to move us closer toward achieving the goals of the NHAS.
Re-Purposed, Not New Resources
We need to be clear, up-front, that we aren't talking about new dollars, but "re-purposed" or "re-directed" dollars. Also, it is important to keep in mind that at this point in time, the "Implementation Fund" has been proposed but not yet approved. Congress and other key stakeholders will definitely want to weigh-in with their thoughts about this proposal and priorities for addressing the HIV/AIDS epidemic in the United States.
Consultation on Possible Uses of NHAS Implementation Fund
To begin the process of seeking input, on June 21, 2011, HHS convened some 40 stakeholders (PDF 64KB) from inside and outside of government to discuss principles and priorities that should be considered in the event that these resources become available in FY12. Mr. Jeffrey Crowley, Director of the White House's Office of National AIDS Policy (ONAP), noted at the start of the meeting that the idea for an NHAS Implementation Fund grew out of requests from the community to ensure that resources are available to implement the Strategy.
Principles for Use of the Strategy Implementation Fund
The stakeholders who gathered last week shared many perspectives on how these re-purposed resources could best be utilized, should they become available. Among the principles they proposed were:
- All uses of the funds must have a clear link to NHAS goals -- the outputs and outcomes of all activities must contribute to and be measured against NHAS goals.
- Be strategic. Uses of these funds should be truly transformative and support "game changing" activities, not merely fill gaps.
- Use these resources as a catalyst for systems change that can be sustained, not to do something that agencies should be doing with existing resources.
- Do a few big things. As one consultant observed, "do three things, not 15." Focus on big impacts, rather than supporting many small efforts.
- Require participation/collaboration of two or more HHS agencies and/or address issues and areas that are not clearly within the domain of a single agency.
- Ensure accountability for use of funds -- within HHS as well as at grantee levels. Be transparent and communicate clearly about how the funds are used.
- Build HHS capacity for NHAS implementation.
- Use these resources to leverage other resources.
- Don't establish a new program or activity silo.
- Don't concentrate these resources exclusively in high-incidence areas; it is important to recognize the geographic diversity of the U.S. epidemic.
Perhaps one of the keenest principles proposed and echoed by several participants was the following: Invest this 1% to make the remaining 99% of the Department's HIV resources work even better.
In addition to overarching principles about how the funds could best be utilized, the participants suggested a variety of possible activities that might be supported with such funds. Among those were:
- Pilot the development of state HIV/AIDS plans and offer technical assistance for modeling and priority setting in high, moderate, and low HIV incidence states.
- Develop a national dashboard of metrics to better inform program planning, including: surveillance data available in real time; estimates of the numbers of individuals, by state, with undetected infection; estimates of the number of persons, by state, who are in need of ARV treatment; and estimates of the number of persons who have been diagnosed with HIV, by state, but have fallen out of care.
- Incentivize the uptake of a core set of common HIV/AIDS metrics to be used across all HHS-supported programs so as to reduce grantee reporting burden and better monitor progress toward the NHAS goals.
- Provide technical assistance to HIV care organizations to assist them in the transition to full implementation of health care reform.
- Increase the capacity of providers to deliver high-quality, culturally competent, HIV/AIDS care, particularly to the populations most impacted, and those that are underserved.
- Support states in efforts to harmonize various data systems.
- Improve linkages to and retention in care by: improving health literacy and supporting the use of navigators; using information technology to promote continuous, high-quality clinical and preventive care; and supporting research and evaluation activities to better understand -- and develop solutions for -- persons who have been diagnosed with HIV but are not in care.
- Emphasize efforts to increase HIV testing from several fronts. For individuals, promote HIV testing among vulnerable populations and encourage efforts to provide HIV testing as part of a bundle of other health care services in heavily impacted communities. For providers and health systems, improve adoption of routine HIV testing and pursue systemic efforts, such as electronic medical record (EMR) prompts and quality performance measurement and feedback, that will encourage routine HIV testing in a variety of public and private health care settings.
- Support the development and study of community health equity zones in a number of locations that bring together government and private partners to pursue aggressive improvements in HIV-related health outcomes in a specific community or even a specific population within a community. Activities would include identifying and implementing the optimal combination of interventions, getting funding streams -- including those beyond public health -- to work together more efficiently, and engaging more deeply traditional/indigenous community organizations in HIV education, prevention, testing and care.
- Use these funds to support critical operational research, that is, learn more about the "real-world" effectiveness of prevention interventions that have shown efficacy in research settings.
- Use these funds to "re-build" and "re-focus" HIV/AIDS surveillance to provide "real-time" data that takes advantage of the burgeoning implementation of electronic medical records and other health information technology.
While certainly not unanimous, the breadth and variety of thoughtful suggestions shared during the consultation have given us a great deal to consider if these re-purposed funds should become available. What are your thoughts on how the Strategy Implementation Funds could best be utilized, should they become available? What principles should govern their use? What types of activities should be supported? Share your suggestions in the Comments section here.
Ronald Valdiserri, M.D., M.P.H., is the Deputy Assistant Secretary for Health, Infectious Diseases, U.S. Department of Health and Human Services.