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When one of our fellow citizens becomes infected with the human immunodeficiency virus (HIV) every nine-and-half minutes, the epidemic affects all Americans. It has been nearly thirty years since the first cases of HIV garnered the world’s attention. Without treatment, the virus slowly debilitates a person’s immune system until they succumb to illness. The epidemic has claimed the lives of nearly 600,000 Americans and affects many more.1 Our nation is at a crossroads. We have the knowledge and tools needed to slow the spread of HIV infection and improve the health of people living with HIV. Despite this potential, however, the public’s sense of urgency associated with combating the epidemic appears to be declining. In 1995, 44% of the general public indicated that HIV/AIDS was the most urgent health problem facing the Nation, compared to only 6% in March 2009.2 While HIV transmission rates have been reduced substantially over time and people with HIV are living longer and more productive lives, approximately 56,000 people become infected each year and more Americans are living with HIV than ever before.34 Unless we take bold actions, we face a new era of rising infections, greater challenges in serving people living with HIV, and higher health care costs.5
President Obama committed to developing a National HIV/AIDS Strategy with three primary goals: 1) reducing the number of people who become infected with HIV, 2) increasing access to care and optimizing health outcomes for people living with HIV, and 3) reducing HIV-related health disparities. To accomplish these goals, we must undertake a more coordinated national response to the HIV epidemic. The Strategy is intended to be a concise plan that will identify a set of priorities and strategic action steps tied to measurable outcomes. Accompanying the Strategy is a Federal Implementation Plan that outlines the specific steps to be taken by various Federal agencies to support the high-level priorities outlined in the Strategy. This is an ambitious plan that will challenge us to meet all of the goals that we set. The job, however, does not fall to the Federal government alone, nor should it. Success will require the commitment of all parts of society, including State, tribal and local governments, businesses, faith communities, philanthropy, the scientific and medical communities, educational institutions, people living with HIV, and others. The vision for the National HIV/AIDS Strategy is simple:
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.
Reducing New HIV Infections
More must be done to ensure that new prevention methods are identified and that prevention resources are more strategically concentrated in specific communities at high risk for HIV infection. Almost half of all Americans know someone living with HIV (43% in 2009).6 Our national commitment to ending the HIV epidemic, however, cannot be tied only to our own perception of how closely HIV affects us personally. Just as we mobilize the country to support cancer prevention and research whether or not we believe that we are at high risk of cancer, or just as we support investments in public education whether or not we have children, success at fighting HIV calls on all Americans to help us sustain a long-term effort against HIV. While anyone can become infected with HIV, some Americans are at greater risk than others. This includes gay and bisexual men of all races and ethnicities, Black men and women, Latinos and Latinas, people struggling with addiction, including injection drug users, and people in geographic hot spots, including the U.S. South and Northeast, as well as Puerto Rico and the U.S. Virgin Islands. By focusing our efforts in communities where HIV is concentrated, we can have the biggest impact in lowering all communities’ collective risk of acquiring HIV.
We must also move away from thinking that one approach to HIV prevention will work, whether it is condoms, pills, or information. Instead, we need to develop, evaluate, and implement effective prevention strategies and combinations of approaches including efforts such as expanded HIV testing (since people who know their status are less likely to transmit HIV), education and support to encourage people to reduce risky behaviors, the strategic use of medications and biomedical interventions (which have allowed us, for example, to nearly eliminate HIV transmission to newborns), the development of vaccines and microbicides, and the expansion of evidence-based mental health and substance abuse prevention and treatment programs. It is essential that all Americans have access to a shared base of factual information about HIV. The Strategy also provides an opportunity for working together to advance a public health approach to sexual health that includes HIV prevention as one component. To successfully reduce the number of new HIV infections, there must be a concerted effort by the public and private sectors, including government at all levels, individuals, and communities, to:
- Intensify HIV prevention efforts in communities where HIV is most heavily concentrated.
- Expand targeted efforts to prevent HIV infection using a combination of effective, evidence-based approaches.
- Educate all Americans about the threat of HIV and how to prevent it.
Increasing Access to Care and Improving Health Outcomes for People Living with HIV
As a result of our ongoing investments in research and years of clinical experience, people living with HIV can enjoy long and healthy lives. To make this a reality for everyone, it is important to get people with HIV into care early after infection to protect their health and reduce their potential of transmitting the virus to others. For these reasons, it is important that all people living with HIV are well supported in a regular system of care. The Affordable Care Act, which will greatly expand access to insurance coverage for people living with HIV, will provide a platform for improvements in health care coverage and quality. High risk pools are available immediately. High risk pools will be established in every state to provide coverage to uninsured people with chronic conditions. In 2014, Medicaid will be expanded to all lower income individuals (below 133% of the Federal poverty level, or about $15,000 for a single individual in 2010) under age 65. Uninsured people with incomes up to 400% of the Federal poverty level (about $43,000 for a single individual in 2010) will have access to Federal tax credits and the opportunity to purchase private insurance coverage through competitive insurance exchanges. New consumer protections will better protect people with private insurance coverage by ending discrimination based on health status and pre-existing conditions. Gaps in essential care and services for people living with HIV will continue to need to be addressed along with the unique biological, psychological, and social effects of living with HIV. Therefore, the Ryan White HIV/AIDS Program and other Federal and State HIV-focused programs will continue to be necessary after the law is implemented. Additionally, improving health outcomes requires continued investments in research to develop safer, cheaper, and more effective treatments. Both public and private sector entities must take the following steps to improve service delivery for people living with HIV:
- Establish a seamless system to immediately link people to continuous and coordinated quality care when they are diagnosed with HIV.
- Take deliberate steps to increase the number and diversity of available providers of clinical care and related services for people living with HIV.
- Support people living with HIV with co–occurring health conditions and those who have challenges meeting their basic needs, such as housing.
Reducing HIV–Related Health Disparities
The stigma associated with HIV remains extremely high and fear of discrimination causes some Americans to avoid learning their HIV status, disclosing their status, or accessing medical care.7 Data indicate that HIV disproportionately affects the most vulnerable in our society—those Americans who have less access to prevention and treatment services and, as a result, often have poorer health outcomes. Further, in some heavily affected communities, HIV may not be viewed as a primary concern, such as in communities experiencing problems with crime, unemployment, lack of housing, and other pressing issues. Therefore, to successfully address HIV, we need more and better community–level approaches that integrate HIV prevention and care with more comprehensive responses to social service needs. Key steps for the public and private sector to take to reduce HIV-related health disparities are:
- Reduce HIV-related mortality in communities at high risk for HIV infection.
- Adopt community-level approaches to reduce HIV infection in high-risk communities.
- Reduce stigma and discrimination against people living with HIV.
Achieving a More Coordinated National Response to the HIV Epidemic in the United States
The Nation can succeed at meeting the President’s goals. It will require the Federal government and State, tribal and local governments, however, to do some things differently. Foremost is the need for an unprecedented commitment to collaboration, efficiency, and innovation. We also must be prepared to adjust course as needed. This Strategy is intended to complement other related efforts across the Administration. For example, the President’s Emergency Plan for AIDS Relief (PEPFAR) has taught us valuable lessons about fighting HIV and scaling up efforts around the world that can be applied to the domestic epidemic. The President’s National Drug Control Strategy serves as a blueprint for reducing drug use and its consequences, and the Federal Strategic Plan to Prevent and End Homelessness focuses efforts to reduce homelessness and increase housing security. ONAP will work collaboratively with the Office of National Drug Control Policy and other White House offices, as well as relevant agencies to further the goals of the Strategy. The Strategy is intended to promote greater investment in HIV/AIDS, but this is not a budget document. Nonetheless, it will inform the Federal budget development process within the context of the fiscal goals that the President has articulated. The U.S. currently provides more than $19 billion in annual funding for domestic HIV prevention, care, and research, and there are constraints on the magnitude of any potential new investments in the Federal budget. The Strategy should be used to refocus our existing efforts and deliver better results to the American people within current funding levels, as well as highlight the need for additional investments. Our national progress will require sustaining broader public commitment to HIV, and this calls for more regular communications to ensure transparency about whether we are meeting national goals. Key steps are to:
- Increase the coordination of HIV programs across the Federal government and between federal agencies and state, territorial, tribal, and local governments.
- Develop improved mechanisms to monitor and report on progress toward achieving national goals.
This Strategy provides a basic framework for moving forward. With government at all levels doing its part, a committed private sector, and leadership from people living with HIV and affected communities, the U.S. can dramatically reduce HIV transmission and better support people living with HIV and their families.
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Presidential Advisory Council on HIV/AIDS
The Presidential Advisory Council on HIV/AIDS (PACHA) will play an advisory role in the implementation and monitoring of the NHAS.