Position paper
On July 30th, 2015, the White House released the National HIV/AIDS Strategy for the United States: Updated to 2020. It is a follow-up document to the same strategy released in 2010 to reflect progress realized in the past 5 years, as well as discuss new scientific developments in the HIV response. The plan is described to be the result of contributions of those living with HIV, community groups and national organizations, medical providers, researchers, and other individuals working with Federal, State, tribal, and local agencies. The document presents a 5-year strategy with four specific goals: 1) reducing new HIV infections; 2) increasing access to care and improving health outcomes for all people living with HIV; 3) reducing HIV-related disparities and health inequalities; and 4) achieving a more coordinated national response. The National HIV/AIDS Strategy is intended to be a guiding document for the United States in creating a more effective and deliberate HIV and AIDS response.
The updated US Strategy has a number of important strengths:
Addressing Social Determinants:
The document begins by stating a hard but critical truth: HIV does not affect Americans equally but is felt disproportionately among minorities and other socially disadvantaged groups. This is reflected in an impressive change to the indicators from the 2010 strategy. Rather than measuring reductions in the rate of transmission among gay and bisexual men, young Black gay and bisexual men, Black females, and those living in the Southern United States, the updated indicator measures the reduction in HIV disparity amongst these four groups. Compared to the 2010 document, there is also a more aggressive emphasis on the social inequalities that perpetuate the unequal distribution of the epidemic. Throughout the updated Strategy, the social determinants of HIV infection are woven into how they impact one’s access to prevention, treatment, and care. It is extremely important to understand that the scope of HIV reaches far beyond medical issues and into the realms of stigma and discrimination, which cause unequal access to necessary services. Further, no goals can be met without addressing determinants of social inequality such as homelessness, transportation, unemployment, intimate partner violence, poverty, and child-care services. Overall, this document does a very good job defining HIV as the social issue it is.
One of the major components to addressing these inequalities is funding. The Strategy proposes that financing should be proportional to the HIV burden regionally – in so – emphasizes need for concentrated efforts in high burden communities such as in the US South and African American communities. It argues that since the last report the Federal Government of the USA has led by example, and recommends that state governments do the same.
Addressing Holistic Treatment and Retention:
The Strategy describes both a progressive commitment to enact holistic treatment for HIV positive individuals and a commitment to maintaining linkage to and retention in care. This is significant because it shows that HIV cannot be treated in a vacuum; rather, the many other health conditions and socio-environmental factors that often co-occur with HIV must also be addressed. Linkage to and retention of care illustrate the importance of all HIV positive individuals’ seamless incorporation into medical services and ensure that they have the ability to remain engaged. The document also underscores the need for the integration of both normal hospital services and non-medical services, such as social work and care coordination. It stresses this point for groups most vulnerable to HIV, such as African-Americans or gay men who have experienced lower rates of engagement and retention in care due to the effects of traditional and historical forces of poverty, discrimination, and disenfranchisement. This makes it not only difficult to engage in clinical services, but also difficult to maintain stable housing and access to other needed resources, such as proper nutrition. The updated Strategy seeks to rectify this situation by promoting the idea that one cannot engage successfully in HIV care if the basic needs of life are not met.
Addressing Prevention:
The section of the Strategy addressing prevention, under Goal 1.B, is a remarkably comprehensive section. It emphasizes the importance of both biomedical and behavioral interventions, noting that biomedical interventions will not work on their own. In addition to the availability and proper use of methods such as condoms and PrEP or PEP, HIV prevention also requires that people living with the disease know their serostatus, immediately initiate treatment, and remain in care. The Strategy effectively acknowledges this by recommending improved linkage to care and prevention services for those living with HIV and the utilization of behavior-based prevention strategies, along with expanding access to PrEP and PEP and sterile needles and syringes. This push for PrEP is an addition to the Strategy from the 2010 version, reflecting the release of PrEP in the USA as a new tool for prevention beginning in 2014. This push, in combination with an additional indicator for reduced engagement in HIV-risk behaviors among young gay and bisexual men, highlights the updated Strategy’s commitment to a comprehensive approach to HIV prevention.
Addressing Education:
The document recognizes the gap in accurate information that many Americans still have when it comes to HIV. There is an emphasis on the importance of educating all Americans on a common baseline of information, not only about transmission and prevention, but also about the current state of the epidemic in the USA. Importantly, this education effort links back to the goal of decreasing stigma and discrimination based on inaccurate information about HIV transmission, as well as increasing individual knowledge to help prevent further HIV transmission. Another strength regarding education is placing ownership in the hands of civil society and community groups as the drivers for increasing access to accurate information. The initial HIV response in the 1980s was effective due to the prevention messages and campaigns created by civil society groups. This document makes a significant effort to call upon community-based organizations to reinvigorate their leadership in responding to the epidemic.
Implementing Tailored Responses:
The updated Strategy calls for the implementation of tailored HIV responses. This is important for several reasons, but perhaps most importantly, it recognizes that HIV is a fluid, dynamic epidemic that does not affect groups or communities exclusively but, rather, creates intersectionalities amongst them. HIV is a disease that preys upon the most vulnerable of society, but these vulnerabilities do not exist in neat, boldly defined categories.
It is imperative to recognize that identities often overlap: rather than being simply a gay man or a Black woman, one can be both a gay man and an injecting drug user, and one can identify both as Black and transgender. The updated Strategy recognizes this fluidity and overlap of risk factors. It emphasizes the importance of keeping those most vulnerable to HIV in treatment, and guaranteeing their access to prevention via creating response narratives that are meaningful to their experience. It also emphasizes that there are unique biological and structural differences in the way that HIV impacts and is transmitted among women and girls, and that these differences affect prevention, treatment, and care responses. The document aptly highlights the need for tailored responses among a variety of intersecting populations so that the disparities fostering the HIV epidemic are minimized.
Other Positive Advances in the Updated US Strategy:
There are a number of other additions to the updated Strategy that make a significant improvement in comparison to the Strategy document that was issued in 2010. The first is its inclusion of a “progress report” in Appendix 1, which details the state of the epidemic in the USA since the Strategy’s first release. This section highlights where progress has hit, exceeded, and missed national targets as of the writing of the document, pointing out the strengths and weaknesses of the implementation of the 2010 Strategy. By noting the country’s failings and successes, implementation and future evaluation of the results of this updated Strategy can be more efficiently conducted. Another difference in this report is the acknowledgement of the positive impact that the Affordable Care Act has made and will continue to make in improving access to and retention of treatment and care. This is in comparison to the hopeful rhetoric regarding the pending enactment of the ACA that dominated the 2010 Strategy. While the ACA was considered a tool that would potentially improve the lives of people living with or at risk of HIV when the initial Strategy was first issued, the positive impact of ACA in relation to HIV is now confirmed in this updated Strategy, which is no doubt an important sign of success.
A final difference between the original and updated Strategies worth noting is the change of measurement from incidence rate to diagnostic data for the indicator regarding HIV diagnoses. The change was done because incidence estimates provide the number of estimated people who are positive for HIV, whether they have been diagnosed or not. Diagnostic data, however, allows for monitoring the degree of testing services being utilized in comparison to the percentage of individuals being diagnosed as positive. This change in surveillance data shifts the focus to testing rather than abstract incidence, which can increase linkage to treatment and care; what is lacking from this indicator, however, is the engagement of individuals being tested and treated so that their human rights are respected. Monitoring access to testing is an important change, but ensuring empowerment within testing is a crucial next step.
In spite of these advances in the updated US Strategy, significant challenges nonetheless remain and need to be confronted moving forward:
While the updated National HIV/AIDS Strategy expresses an aggressive commitment to addressing the many social and structural forces that perpetuate the AIDS epidemic, it is not without areas that require further investigation and elaboration. In particular, the document is strikingly vague on implementation planning and action steps for moving forward with its recommendations. The updated Strategy is perhaps a reflection and a victim of the lack of a uniform body governing the HIV and AIDS response in the United States. The Strategy itself admits that this lack of uniformity is an issue. The document defers nearly all recommendations to undefined “federal and state” agencies, which it states operate under independent statutory regulations as defined by Congress. While it may be true that the Executive Branch of the US government lacks the ability to mandate the actions of some of these various agencies, as a strategy, more clearly defining specific actions to be implemented by specific organizations or departments would have resulted in a much more pragmatic and robust plan for the nation. Its failure to do this relieves specific agencies of responsibility for implementing the Strategy, and potentially undercuts the effectiveness of the recommendations outlined in the Strategy.
Another key weakness is that the document skirts serious consideration of some politically charged issues. While it acknowledges the importance of recent changes in state laws that have decriminalized spitting and biting in order to reduce stigma, the recommendations moving forward merely hint at the need to dismantle HIV criminalization rather than addressing the issue of criminalization head on. The decriminalization of needle exchanges is one such example. The document recognizes the effectiveness of this harm-reduction method, but does not specifically advocate for states to decriminalize it. Instead, it recommends that state legislatures compare state law to make sure they are “consistent with current scientific knowledge of HIV transmission and support public health approaches to preventing and treating HIV.” This wording assumes that any state legislature will arrive to this logical conclusion to decriminalize needle exchanges and other stigmatizing criminalization of people with HIV. This is a dangerous assumption since the extreme inconsistencies across current state laws on HIV criminalization demonstrate a need for more explicit direction.
A second issue that the document tiptoes around is the barrier of discrimination that the LGBT population faces when accessing healthcare. The discussion around Goal 2.B emphasizes the need for better-prepared healthcare professionals who are trained in appropriate HIV care and prevention, yet fail to make this an aspect of any of the recommended actions. The discussion emphasizes the problem that certain groups, particularly transgender women and gay men, have not been receiving appropriate and competent medical treatment due to the lack of understanding, discomfort, and discrimination from health care providers. All of that said, the recommended steps in this section do not address the need for better-trained health care providers for transgender patients or more accepting health care environments for populations deemed “vulnerable.” The Strategy could have taken a more proactive stance, articulating these issues as they are critical pieces that reinforce and even increase HIV vulnerability among key groups.
The relevance of the updated US Strategy for global AIDS policy:
The updated US Strategy is well articulated and comprehensive of many of the factors that contribute to the continuation of the HIV epidemic in the USA. It shows important progress and promise, especially in conveying the many structural factors that perpetuate HIV, the importance of a strong commitment to human rights, and the need to dismantle inequalities. The document is not, however, without need of serious further consideration and research, particularly regarding the realization of a majority of the Strategy’s recommendations. Now is the time to go beyond recommendations and create a method of accountability for the implementation of these strategies. What is needed is a concentrated federal body or legislation created to oversee the nation’s HIV epidemic and the ways in which the myriad of federal, state, and local bodies are handling it. What’s more, it is equally important for activists and civil society groups to continue pushing back to ensure that the promises articulated in such documents are brought to reality in federal legislation, policy, and practice. This updated Strategy nicely demonstrates how far the USA has come in the past five years and how much further it has to go; but there will continue to be quite a considerable distance to go until a more concrete method of accountability is implemented by the federal government of the United States.
In the context of a global perspective, it should not be underestimated that the US is now moving towards a more clearly concentrated response. The US has been and continues to be the biggest donor in relation to global AIDS, and in exchange for aid money it has typically sought to influence how other countries should respond to the epidemic. The lack of a clear policy in the US in relation to its own epidemic for the majority of the past three and a half decades is understandably something that struck many other countries and observers as more than a little hypocritical. In this sense, the fact that the US is now moving forward with a more deliberately articulated plan for how to respond to the HIV epidemic within its borders is an important advance.
The Strategy itself could be interpreted as insular because it does not once mention the country’s position within the global epidemic. Is the US not part of global AIDS context? And shouldn’t national policies reflect on and be consistent with global policy recommendations? The White House has produced a strategy with a totally introspective lens, which is insufficient given its influence as a global leader. That the US Strategy does not position itself within the global context is a missed opportunity.