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The Challenge and Opportunity of a National AIDS Strategy

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The clear-sighted federal response to the H1N1 flu outbreak is testament to the value of careful planning and coordinated government action in the midst of a public health threat. It also shines a harsh light on our failure to develop a similar, comprehensive strategy to address one of our country's most significant and enduring public health challenges: the HIV/AIDS epidemic. Twenty-eight years into the epidemic, the United States still does not have a National HIV/AIDS Strategy to guide use of AIDS-related dollars or hold government agencies and others accountable for steadily improved outcomes.

New estimates about the HIV infection rate in America are a wake-up call for everyone concerned about AIDS in our country. Last summer the CDC announced that HIV incidence is 40% higher than previously estimated, with a new infection every nine and a half minutes. There are now more than 1.1 million Americans living with HIV, and about half of them are not receiving care. Additionally, profound racial disparities continue to characterize AIDS in our country.

We cannot continue to address a serious national epidemic with a largely uncoordinated, patchwork response that has been flat funded for years and is too often hindered by policies not based on evidence of what works. That is why President Barack Obama's commitment to develop and begin to implement a National HIV/AIDS Strategy within his first year in office has received such broad support in the AIDS and health communities. The president has said his Strategy will focus on three primary goals: lowering HIV incidence; increasing access to care; and reducing health disparities in the epidemic.

This kind of National HIV/AIDS Strategy could lead to dramatic progress against AIDS, but only if it emphasizes bottom-line outcomes and the need for a more strategic, accountable, and coordinated federal response -- not simply more resources and programs. Like the broader effort for health reform, a National HIV/AIDS Strategy is going to require fresh thinking instead of just more of the same.

For the president's first goal, lowering HIV incidence, a National HIV/AIDS Strategy is an opportunity to advance evidence-based policies, such as federal support for syringe exchange, as well as increased resources for HIV prevention. But the Strategy is also a chance to step back and take a hard look at our prevention efforts. We need to ensure federal resources are used to bring the best HIV prevention interventions to scale. Prevention programs must be targeted in a way that matches the dynamics of local epidemics, and planned and delivered with the goal of demonstrating population-level impact on incidence.

It is also time to think about new approaches to prevention, like greater emphasis on interventions that address structural and network-level factors in risk, and greatly enhanced HIV and STI diagnosis, prevention, and treatment campaigns in the highest incidence areas. Better information will also drive a more strategic prevention response. For example, the CDC could provide annual surveillance reports that include estimates of where the next 10,000 infections will occur. And in planning HIV prevention for young people, we should spend much more time testing and implementing programs that work for young gay men and men who have sex with men (MSM) of all colors, as they are among the youth populations at the highest risk of infection. Lastly, it is important to begin planning now for strategic delivery of prevention technologies of the future, including, possibly, pre-exposure prophylaxis (PrEP), which might protect HIV-negative people from HIV infection.

For the president's second goal, increased access to lifesaving AIDS treatment, the National HIV/AIDS Strategy is an opportunity to press for a better resourced Ryan White CARE program, expanded Medicaid eligibility for people with HIV, and greater access to HIV testing. But the Strategy is also a chance to ask a fundamental question: why are only about half of people living with HIV in care? An effective National HIV/AIDS Strategy would seek answers and then map out specific steps to reach more people with the treatment they need. This might include better coordination of the multiple systems that provide HIV-related health care, improving linkages between testing and treatment, and enhancing research and data collection on care utilization and access barriers.

For the president's third goal, reducing disparities in the epidemic, a National HIV/AIDS Strategy is an opportunity to build on the important Minority AIDS Initiative that provides needed resources to organizations responding to HIV in communities of color. But the Strategy is also a chance to act much more broadly by establishing a truly comprehensive and coordinated program that engages all relevant federal agencies to address enormous racial disparities in HIV infection and treatment outcomes.

The HIV/AIDS epidemic in America is far too serious to squander the opportunity that a National HIV/AIDS Strategy presents. The domestic effort on HIV requires expanded resources and immediate action to enact evidence-based policies. Beyond those measures, however, we need a revitalized response to AIDS with specific targets to help lower incidence, increase care access, and reduce disparities, along with annual reporting on progress toward these targets.

Designing the Strategy will not always be easy, as the process will challenge all those engaged to identify what is working and what needs to be improved to accomplish the president's central goals. But the stakes are too high to dodge the difficult questions and the political challenges ahead. With presidential leadership and the collaboration of a broad set of committed stakeholders, the National HIV/AIDS Strategy can help all of us -- government, the private sector, affected communities, and people living with HIV/AIDS -- establish a much more efficient and effective response to AIDS at home.