The Five Pillars: A Plan to End the AIDS Epidemic in New York State
Less than two years after AIDS was first identified, New York State took the lead in the fight against the epidemic when Governor Mario Cuomo signed Executive Order 15 on May 16, 1983, establishing an Interagency Task Force on AIDS. Within two months, the NYS DOH AIDS Institute was created and given "the central responsibility for ... coordinating the state's policies with respect to AIDS." Thirty years later, his son, Governor Andrew Cuomo, has the chance to once again take the lead -- this time to actually end the epidemic in New York State.
In May 2013, Treatment Action Group and Housing Works convened a meeting on how to revitalize the HIV response in NYS. The meeting, held with the support of Columbia University, brought together advocates, health and social service providers, researchers, and government representatives to discuss ending the AIDS epidemic in New York State. Since then, there have been several community meetings to define what it means to end the epidemic, organized by the AIDS Institute, ACRIA, and advocates from across the state. Five pillars have been identified (treatmentactiongroup.org/policy/NYS-end-aids):
1. Adopt 21st century surveillance strategies: Know who is living with HIV and where HIV is being transmitted, and intervene quickly to stop chains of transmission. The State should invest in fourth-generation antigen/antibody test machines. They can detect recent HIV infections (just before and right after seroconversion), which is important for detecting early HIV infection and preventing transmission.
Screening for HIV is now recommended for all persons 13-64 in the U.S. About half of Americans (and more among high-risk groups such as young men who have sex with men) have never been tested for HIV, and nearly 200,000 people with HIV in the U.S. are unaware they are infected. This number must be lowered if we are ever to reverse the course of the epidemic.
2. Reduce new infections through evidence-based prevention: Routine, voluntary HIV testing is a gateway to prevention for those who test negative. Treatment for people with HIV lowers viral load and reduces the chance of transmission. Both groups benefit from interventions to address behavioral risk factors. HIV prevention services should include:
- High-quality HIV and sexual health education at all levels
- Post-exposure prophylaxis (PEP) in pharmacies and clinics available within two hours of exposure
- Pre-exposure prophylaxis (PrEP) for those who need it
- Treatment for substance use, mental health, and violence for those at risk
- Housing, needle exchange, and other harm reduction services
3. Maximize the number of people with HIV able to suppress their viral load: U.S. guidelines recommend HIV treatment for everyone with HIV, regardless of CD4 count. While NYS is doing better than the nation with respect to the HIV treatment cascade (see article in this issue), in 2011, only 55% of New Yorkers with HIV received any HIV care during the year, and only 39% had an undetectable viral load.
New York State's Medicaid reform, plus the advent of the Affordable Care Act including Medicaid expansion, offer the opportunity to fill some of these gaps, and must use the expertise of HIV care providers. This can lead to near-universal health care access and earlier treatment, which has been shown in Massachusetts to generate billions of dollars in savings while reducing HIV transmission and deaths.
Using the State's market power to negotiate better drug prices with industry is essential. Generic HIV meds enabled PEPFAR to treat 3 to 4 times as many people in 2012 as were treated in 2009 while maintaining a flat budget. The savings from earlier testing and treatment, better prevention, and switching to generics can be used to pay for increased health coverage and needed support services.
4. Support health, prevention, and retention in care for all New Yorkers with HIV: For HIV-positive New Yorkers, retention in care requires addressing a cluster of issues. Homelessness, hunger, and other needs are powerful barriers to prevention and care. Eliminating new infections and retaining all New Yorkers with HIV in care will require continued reliance on the Ryan White CARE Act and HOPWA, as well as treatment for other health conditions such as diabetes, drug use, mental health, trauma, and viral hepatitis.
Housing and food security are essential components of an effective HIV response. Clean needles, harm reduction, and opiate substitution therapy are essential as well. Other approaches also play a role, such as the decriminalization of non-violent drug use, consensual sex work, and carrying condoms, while reducing the burden of incarceration for young men.
5. Commit political leaders and all communities to the plan: Community activism and service provision have been essential to the HIV response from the beginning. We will not end AIDS without a combined commitment by government at all levels, including NYCs newly-elected Mayor de Blasio. Community organizations, the private and non-profit sectors, and service providers must work together until there are no more infections and no more deaths.
By investing now in these strategies for better surveillance, prevention, treatment, support services, and community ownership, NYS can lead the way to ending the AIDS epidemic and set an example for other states, and countries, to follow. The time to end the epidemic is NOW and we urge Governor Cuomo to lead the fight!