National Strategy on HIV/AIDS Geared Toward Elimination of HIV

A newly revised national strategy on HIV/AIDS, released by the White House in July, outlines a detailed path toward an ambitious goal—the virtual elimination of HIV/AIDS in the United States.

“The National HIV/AIDS Strategy for the United States: Updated to 2020,” developed by the Presidential Advisory Council on HIV/AIDS (PACHA), opens with the following vision statement: “The United States will become a place where new HIV infections are rare, and when they do occur, every person, regardless of age, gender, race/ethnicity, sexual orientation, gender identity, or socioeconomic circumstance, will have unfettered access to high-quality, life-extending care, free from stigma and discrimination.”

Importantly, the new strategy emphasizes the need for collaborative care across multiple disciplines, including attention to psychosocial factors in the prevention of HIV/AIDS and treatment of people living with HIV. This year, for the first time, a psychiatrist—Jeffrey Akman, M.D., dean of the School of Medicine and Health Sciences at George Washington University—was appointed to PACHA (after being nominated for the position by APA) and served as a vital voice for the role of psychiatry in HIV/AIDS care in the development of the revised strategy (see story above).

The revised strategy includes four broad goals: reducing new HIV infections, increasing access to care and improving health outcomes for people living with HIV, reducing HIV-related health disparities and health inequities, and achieving a more coordinated response to the HIV epidemic.

For the goal of increasing access to care and improving health outcomes, the revised strategy emphasizes that an expansion of the workforce to include the entire continuum of care will be vital.

“Developing models of competent care that treat the whole person, as well as the virus, is crucial,” the strategy states. “People living with HIV—after being diagnosed, entering the health care system, and being prescribed treatment—require supports to remain engaged in care. A culturally competent and skilled workforce is vital to this effort and includes a range of providers. … Key priorities for improving outcomes along the care continuum include expanding the workforce by engaging and training nontraditional providers and expanding proven models of team-based, patient-centered care that facilitate ongoing engagement in care.”

The national strategy is a revision of the document released in 2010. Since that time, the strategy document notes that there have been a number of developments that require a significant “re-thinking” of the approach to HIV/AIDS. These include, notably, the passage of the Affordable Care Act as well as groundbreaking work by the National Institutes of Health (NIH). One of NIH’s initiatives is the HIV Prevention Trials Network study, which Science magazine called the scientific breakthrough of 2011 and which demonstrated that early treatment for HIV reduces the risk of onward transmission by 96 percent while simultaneously improving health outcomes.

Additionally, the period since 2010 has seen the introduction of pre-exposure prophylaxis (PrEP), a biomedical prevention tool that helps people reduce their risk of HIV infection by taking a daily pill. Based on evidence from multiple clinical trials released from 2011 to 2013, the Food and Drug Administration approved PrEP in 2012, and in 2014 the U.S. Public Health Service issued clinical practice guidelines for PrEP.

“These and other accomplishments have resulted in important gains toward targets for increasing the percentage of persons living with HIV who know their status, are linked to care, and have achieved viral suppression, as well as reducing death rates,” according to the strategy. “Despite this progress, the level of infection is stable overall. While declines in diagnoses have occurred for women, persons who inject drugs, and heterosexuals, the epidemic among gay and bisexual men remains severe, with increases in new diagnoses. Achieving the goals of the strategy will require intensified efforts for this population in order to realize the greatest impact.”

Each of the four goals in the national strategy includes specific steps required to reach the goal, measurable indicators of progress, and explicit policy actions that are required at the federal, state, and community levels. For instance, the goal of reducing HIV infections includes the following specific steps:

• Intensify HIV prevention efforts in communities where HIV is most heavily concentrated.

• Expand efforts to prevent HIV infection using evidence-based approaches.

• Educate all Americans with easily accessible, scientifically accurate information about HIV risks, prevention, and transmission.

Indicators of progress for those steps include increasing the percentage of people living with HIV who know their seropositive status to at least 90 percent, reducing the number of new diagnoses by at least 25 percent, and reducing the percentage of young gay and bisexual men who have engaged in HIV-risk behaviors by at least 10 percent.

Each of the steps and indicators is accompanied by specific policy actions. For instance, the step toward intensifying prevention efforts in communities where HIV is most heavily concentrated includes the following policy actions:

• Allocate public funding consistent with the geographic distribution of the epidemic. “Governments at all levels should ensure that HIV prevention funding is allocated to grantees according to the latest epidemiological data so that funds reach areas with the highest burden of disease.”

• Focus on high-risk populations. “Federal agencies should ensure that funding to state and local health departments and community-based organizations is allocated according to the epidemiological profile within the jurisdiction and is directed to high-risk populations accordingly.”

• Maintain HIV prevention efforts in populations at risk but with a low national burden of HIV. “Federal, state, tribal, and local agencies should make the best use of surveillance and other appropriate data, including the HIV care continuum, to characterize the burden of disease and apply high-impact prevention strategies for populations such as Asian Americans, Native Hawaiians and other Pacific Islanders, American Indians, and Alaska Natives.” ■