The strategy is not ours, it’s yours – it’s not the CDC’s, it’s not ours, it’s not California or Alabama’s or Washington DC’s, it’s all of ours. And it’s our responsibility to make sure the nation knows about it.
The Summit was pleased to welcome Douglas Brooks, Director of the Office of National AIDS Strategy, to deliver a special presentation on the updated National HIV/AIDS strategy, released in July 2015.
Brooks began by acknowledging the recent anniversary of the Ryan White Comprehensive AIDS Resource Emergency Act, passed in 1990. The Act allowed for the creation of the Ryan White HIV/AIDS Program, which provides HIV care to people who are uninsured.
Changing focus to the Strategy, Brooks explained that the overall vision articulated in the strategy to 2010 remains the same – the United States will become a place where new infections are rare and, when they do occur, every person will have unfettered access to high-quality, life-extending care, free from stigma and discrimination. Among other things, the updated strategy attempts to harness the benefits of the Affordable Care Act, incorporate new scientific knowledge and build on lessons learned from the 2010 strategy.
Throughout his presentation, Brooks highlighted the need to focus on the right people, places and practices in the updated strategy. He identified the disproportionate burden on men who have sex with men, black and Latino men and black and Latina women, including trans women, as well as the burden felt in major metropolitan areas and in the southern United States, where half of all new HIV diagnoses are found. Brooks also identified the need for widespread testing and linkage to care, early access to treatment, and access to PrEP.
“The nation needs to know that PrEP works,” he said. “We need to not be ashamed of promoting it and not be shaming of people who are trying to access it and save their lives.”
Changes to the Strategy
Brooks explained that the executive summary to the updated Strategy mentions housing, specifically, as an important structural approach to health care and that linkage to supportive services such as housing and employment is essential. He highlighted the fact that access to housing is an important precursor to stable treatment regimens, and that it would be impossible to advocate for treatment without considering whether people living with HIV are stably housed.
The updated Strategy includes a series of 10 indicators, and Brooks noted that indicator seven has been modified. The previous indicator, “Increase the percentage of Ryan White HIV/AIDS Program clients with permanent housing from 82 percent to 86 percent” has been changed to “Reduce the percentage of persons in HIV medical care who are homeless to no more than 5 percent.” The government has also released supplementary documents detailing how the indicators are measured.
The Strategy includes three indicators under development – meaning that targets and quantitative measures for these indicators have yet to be identified, but that they will be tracked in the future. These three indicators concern PrEP uptake, stigma and HIV among trans people. Brooks noted that systems and structures that capture information related to trans people will need to be built before stakeholders can develop helpful ways to respond.
Brooks explained that, as a social worker, he’s pleased that the Strategy focusses on whole person health and the understanding that people interact with systems on a daily basis and have bio-psycho-social needs that must be addressed. He emphasized that implementation of the Strategy needs to be a national – rather than federal – project in which communities work with the next administration to advance their goals.
In an interview with OHTN staff, David Holtgrave, Vice-Chair of the Presidential Advisory Council on HIV/AIDS, sounded a similar note when he expressed confidence that efforts to address the HIV epidemic will survive the 2016 presidential election. “Just because there’s a change in political office, whether it’s a party or a person, we can’t let up on our efforts around HIV and AIDS, and so I think it’s been critical to be able to put [the Strategy] in place,” he said. “I think the best way to prepare for the next election is making sure that there’s a long-term strategy, and our foot is firmly on the throttle moving forward.”
Strengths and Weaknesses of the Updated Strategy
In a panel discussion following Brooks’ address, David Holtgrave shared highlights from the SWOT analysis that he and Robert Greenwald completed in response to the updated strategy. Among the Strategy’s strengths were:
- It strikes a balance between addressing the needs of the general population and communities disproportionately affected by HIV.
- It includes complimentary services to address the social determinants of health.
Potential weaknesses identified through the analysis include the fact that the Strategy is not (and is not intended to be) a budget document, which means that it is unclear how some of its recommendations will be funded.
For example, Holtgrave’s calculations revealed that the annual cost of providing PrEP to everyone eligible would be 6.7 times the entire CDC HIV prevention budget, and he emphasized that funding plans involving private sector partnerships would be important.
Changes to the indicators may also present reporting challenges. Incidence and transmission rates have been replaced by an indicator that tracks new diagnoses. Holtgrave pointed out that, in the short term, new diagnoses should actually rise in areas where people have had less access to testing.
Among the opportunities identified were:
- the chance to reenergize as a nation and focus on addressing the HIV epidemic
- the chance to link a national strategy with local planning efforts to end AIDS.
Potential threats included:
- proposed decreases to HIV funding
- the fact that 19 states had not yet expanded Medicaid
- malaise about HIV.
Holtgrave argued that, at times, the response to HIV is too reactive, with organizations and policy makers responding after the fact rather than taking proactive steps.
Speaking as part of the same panel discussion, Russell Bennet, Executive Director of the National AIDS Housing Coalition, argued that, while the Strategy currently portrays housing as a structural intervention that mediates access to care, housing should also be considered HIV prevention. He added that there was a need for broader affordable housing policy in the United States, and that homelessness is not, by itself, a complete indication of the role that housing plays in health contexts.
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David Holtgrave and Robert Greenwald’s SWOT analysis of the updated National HIV/AIDS Strategy