President Barack Obama released the first comprehensive national HIV/AIDS strategy for the United States on Tuesday, bringing to fruition a lengthy process that involved input from medical and social science experts, AIDS care and service providers, and people with HIV from across the country.
"This is the first real national HIV/AIDS strategy that the U.S. has ever had," said Judith Auerbach of the San Francisco AIDS Foundation, a founding member of the Coalition for a National AIDS Strategy, which won a commitment for an AIDS plan during Obama's presidential campaign. "This represents the work of thousands of individuals whose leadership and input over the last three years helped it take shape. Now it is up to all of us to ensure its full funding and implementation and hold our government accountable for progress."
Over the past year and a half, the White House Office of National AIDS Policy hosted 14 public community discussions with more than 4,000 participants and collected more than 1,000 comments through its website.
The NHAS vision statement reads, "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 socio-economic circumstance will have unfettered access to high-quality, life-extending care, free from stigma and discrimination."
"The vision statement says a lot about the current administration's philosophy, by framing the plan in terms of human rights, non-discrimination, and equity," said Auerbach. "This is quite different from past administrations, and is a welcome statement to all of us who have been waging this fight for three decades."
"We are excited to see evidence-based interventions a priority in the federal plan," added SFAF interim CEO Barbara Kimport. "In San Francisco, we learned a long time ago through experience with needle exchange programs that when you put science before ideology, you can make great progress against HIV."
Obama unveiled the strategy and its accompanying federal implementation plan at a morning press conference at the White House, followed later in the day by a reception for members of the HIV/AIDS community.
"[W]e have learned what we can do to stop the spread of the disease. We've learned what we can do to extend the lives of people living with it," Obama said. "So the question is not whether we know what to do, but whether we will do it."
While most HIV/AIDS advocates applauded the strategy's goals, many criticized the fact that the plan comes without any major new funding, instead shifting resources from existing programs.
Meeting the need
More than 1 million people are currently living with HIV �" including an estimated 20 percent who do not know they are infected �" and approximately 56,000 are newly infected each year.
The NHAS aims to reduce the number of new HIV infections by 25 percent, lower the rate of HIV transmission by 30 percent, increase the number of infected people who know their status by nearly 10 percent, raise the number of people accessing care within three months of diagnosis by 30 percent, and increase the proportion of gay and bisexual men, blacks, and Latinos with undetectable viral load by 20 percent.
A key theme of the strategy is allocating resources where the need is greatest. Gay and bisexual men make up a small percentage of the U.S. population �" estimated between 2 percent and 10 percent �" but account for more than half of all new HIV infections. Blacks make up about 13 percent of the population but nearly half of people living with HIV.
"After 29 years of neglect, gay and bisexual men are finally being given the attention they deserve," said Jim Pickett of the AIDS Foundation of Chicago. "We have so, so much work to do to realize the promise of this document, but being officially acknowledged and valued is a momentous step."
The plan calls for targeted care for the most heavily affected groups, but also for HIV/AIDS education for all Americans. Lack of awareness and stigma are major barriers to more widespread HIV testing and treatment.
"The amount of people with misconceptions about AIDS is essentially the same as it was in 1987," said Kate Sorensen of the Stop AIDS Project. "Baseline education to reduce stigma and the rate of high-risk behavior would be an accomplishment in itself."
The new strategy embraces a comprehensive approach to linking prevention, testing, and care �" but not necessarily immediate antiretroviral therapy �" that is increasingly being adopted by service providers. But it comes amid a growing debate about the public health and civil rights implications of promoting earlier treatment as a means of prevention.
"Ensuring that people with HIV disease are diagnosed early and linked to lifesaving medical care is central to the president's strategy," said Dr. Michael Saag, chair of the HIV Medicine Association. "A renewed focus on patient care is urgently needed to meet the increased demand for HIV care, which will grow under this effort."
Show us the money
Resources to support such expanded efforts are in short supply, however. The administration has dedicated $30 million from the Patient Protection and Affordable Care Act (the recently passed health care reform legislation) for NHAS implementation, but new money is not on the agenda.
"This strategy is a day late and a dollar short," said Michael Weinstein of the AIDS Healthcare Foundation. "Fifteen months in the making, and the White House learned what people in the field have known for years. There is no funding, no 'how to,' no real leadership."
Others also were critical.
"The Obama administration is spending only 4 percent of the National Institutes of Health AIDS research budget to find a cure, they're leaving 2,000 people without AIDS drugs because of a $100 million ADAP shortfall, and they're cutting AIDS treatment in Africa," said AIDS Policy Project Executive Director Kate Krauss. "That isn't a plan, it's a disaster."
In the days leading up to NHAS unveiling, the administration announced that an additional $25 million would be allocated to cash-strapped AIDS Drug Assistance Programs. But advocates argue that the need is closer to $125 million. Nearly 2,300 people are now on ADAP wait lists, according to the National Alliance of State and Territorial AIDS Directions' latest July 9 ADAP Watch.
"It is imperative that this nation has a comprehensive approach to HIV care and prevention," said Randy Allgaier, a member of the Coalition for a National AIDS Strategy. "The current ADAP crisis is a prime example of what is wrong with our current response to HIV/AIDS; it is fragmented and seems to move from crisis to crisis rather than to think strategically."
Obama stressed that while the government must do its part, "our ability to combat HIV/AIDS doesn't rest on government alone. It requires companies to contribute funding and expertise to the fight. It requires us to use every source of information �" from TV to film to the Internet �" to promote AIDS awareness. It requires community leaders to embrace all �" and not just some �" who are affected by the disease."
As a first step, the White House issued a memorandum asking federal agencies �" including the Department of Health and Human Services, Centers for Disease Control and Prevention, the Departments of Labor, Housing and Urban Development, and Veterans Affairs, and the Social Security Administration �" to develop plans to implement the strategy and reallocate funding within the next five months.
"This creates a roadmap for other administrations so that politics doesn't dictate strategy," said Sorensen. "It demands all sectors of society contribute. Certainly we could make that happen if we choose to. If the business sector, the public sector contribute, we can make that strategy happen."
The National HIV/AIDS Strategy for the United States and the accompanying federal implementation plan and presidential memorandum to federal agencies are available online at www.aids.gov/federal-resources/policies/national-hiv-aids-strategy.