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The National HIV/AIDS Strategy at Two: The Beginnings of Reform, and a Glimpse of Success

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Five years ago, hundreds of organizations signed a call to action demanding a more accountable, coordinated, and outcomes-oriented approach to tackling AIDS in America. It called for setting clear targets for progress, increasing collaboration, and focusing on hardest hit populations.

What we saw five years ago was a patchwork effort: people and organizations doing great work in countless ways, but ultimately not focused collectively on getting the job done. Today, a lot has changed for the good -- in science, policy, and in evidence of success. On the second anniversary of this country's first comprehensive National HIV/AIDS Strategy, it's worth thinking about what has gone right, and where we go next.

The strategy changed -- and in a way, restarted -- the conversation on HIV in the United States. Five years ago, the domestic epidemic seemed invisible, and President Obama should be applauded for making it a priority in policy and funding. With the strategy came a whole string of reforms -- some of them demonstrating real political courage, like greater emphasis on serving people at the center of the epidemic, including gay men and African American and Latino men and women; rechanneling money to more closely follow the epidemic; calling on states to undo senseless criminalization laws; and redirecting prevention money to have tangible impact on overall HIV infection rates.

As it was written in 2010, the strategy anticipated crucial developments of the next two years. The HPTN 052 study established conclusively that HIV treatment is also HIV prevention. The Affordable Care Act promises health coverage for millions.

Of course, it hasn't all gone as planned. There have been some advances in interagency coordination, streamlining funds and reducing reporting burdens, but there also have been numerous hold-ups in these areas. The 12 Cities Project is a worthy effort to improve the response in urban epicenters, but it has faced its own challenges with bureaucracy, paperwork, and underfunding. Evidence took a back seat to ideology when Congress prohibited federal funding for syringe exchange programs.

The original principles of the National HIV/AIDS Strategy movement remain critically important, but the context has changed significantly. Today it's less about calling for improved federal coordination, and more about challenging every level of government to build an effective response that we now know is possible. In places like San Francisco and Massachusetts we have started to glimpse success in reducing HIV incidence. A recent analysis by David Holtgrave of Johns Hopkins University shows that the strategy goals are attainable with expanded delivery of multiple evidence-based interventions.

In Massachusetts, Medicaid was expanded to cover people living with HIV in 2001, and in 2006 the state enacted health reform legislation, achieving over 98 percent health insurance coverage of its residents by 2010. HIV infection rates have fallen sharply -- by 45 percent between 2000 and 2009. The state is fortunate to have many accessible community health centers, providers who are comfortable delivering quality HIV care to people most likely to be affected, and support services like housing, nutrition, and transportation. Evidence-based harm reduction programs such as syringe exchange are in place. In many areas of the state, it's OK to be gay. All this means that people have a reason to get an HIV test; if they are positive, they know they can get care and be treated respectfully.

San Francisco has similar advantages, including broad health coverage. There, the public health department ramped up testing and earlier initiation of HIV treatment and the percentage of HIV-positive gay men who do not know their HIV status has fallen significantly. Prevention dollars were concentrated in areas where they would have the greatest impact. As more people became aware of their HIV infection and brought their HIV viral load down, HIV incidence decreased and stabilized at a lower level.

Achieving the National HIV/AIDS Strategy goals is going to require more examples like these, though of course each setting will be different. There is no substitute for local and state leadership. It is at the local level where decisions can be made to scale up HIV testing and treatment access, create comfortable health care environments, and match resources with the realities of the epidemic. State participation in expanded Medicaid is a top priority. Advocates will also need to press states to increase investment in HIV services, and insist that public health departments focus resources on interventions that can have the greatest benefit for the most acutely affected populations.

The federal government has to set the incentives to drive local success. That means increasing funding for AIDS programming and implementing health reform so that it serves people with chronic health conditions including HIV. Federal agencies also have to be clear about the markers for success. In an era in which we understand the connection between treatment and prevention, viral load should be a key measure in evaluating patient health, provider quality, and community outcomes. If the federal government clearly emphasizes a few measures such as testing rates, linkage to and retention in care, and viral load, it can focus efforts at the state and local level.

In addition, the federal government needs to partner with others to launch a full-scale media effort aimed at fighting HIV-related stigma, and using the voices of people affected by HIV to encourage HIV testing and treatment. As Jared Baeten from the University of Washington said recently, "It should be a badge of honor to know your HIV status and be on treatment if you have HIV, and on remaining HIV-free if you do not."

Five years after the movement for a National HIV/AIDS Strategy started, we can be far more specific about what is needed. And we can be confident that we can make great progress against the epidemic at home.

Chris Collins is Vice President and Director of Public Policy at amfAR, The Foundation for AIDS Research. His email is chris.collins@amfar.org

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