July 30, 2015
Kevin Fisher is an AVAC staff member.
When the Obama administration released first US National HIV/AIDS Strategy (NHAS) in 2010 it was an overdue step forward and the product of years of advocacy. How could the US—with the eighth highest number of people living with HIV (PLWA)—have no strategy for getting more PLWA into care and reducing infections and health disparities?
Now on the fifth anniversary of the first NHAS, under the leadership of the Office of National AIDS Policy (ONAP), the NHAS is getting a reboot. The updated NHAS has renewed the focus on those most affected by HIV: gay and bisexual men of all races, but especially black men, heterosexual black women and men, young people, people who inject drugs and transgender women. There will be prioritization on places, like the southern US—where nationally 50 percent of new infections now occur—and key metropolitan areas. It takes responsibility for improving viral suppression and access to care in the US treatment cascade, which now lags behind many European, and some African countries. While not explicitly linked to the UNAIDS 90-90-90 goal, this new US strategy does align with the global focus on improving diagnosis, linkage to care and viral suppression. And, happily, this strategy puts the treatment cascade into the more comprehensive needs of primary prevention and addressing stigma and discrimination.
Even if the overall goals of the original NHAS—reducing infections, improving outcomes, eliminating disparities and a coordinated response—remain the same in the revised version, much has changed since 2010. In 2010 the iPrEx trial results first showed that pre-exposure prophylaxis (PrEP) is an effective HIV prevention option. In 2011 the HPTN 052 trial showed treatment and viral suppression can reduce risk of transmitting the virus and just recently, in 2015, data from both 052 and START showed that early treatment improves health outcomes for people living with HIV. The revised NHAS embraces these scientific advances adding new goals to improve the US treatment cascade, and making full access to PrEP services a cornerstone of the strategy. The full-throated endorsement of PrEP is welcome, needed, and will hopefully have impact.
The NHAS also importantly acknowledges the essential role of research in providing new tools and methods of achieving the goals of the strategy. The NHAS is unabashedly positive about research, with particular emphasis on research priorities for PrEP and innovative approaches to preventing new infections, importantly strengthening the case that now is not the time to scale back.
The updated strategy does make an important change from its predecessor, which raises some concern. The revised NHAS abandons incidence in favor of HIV diagnosis as a measure of the impact of prevention. ONAP believes it does not have the data to measure incidence, particularly in the context of increased testing. Do the data reflect higher rates of infection, or are more people being tested? This makes methodological sense but raises the question of how the impact of specific prevention interventions, or combination prevention, can be measured and assessed. The HIV field needs a tool to measure incidence to judge impact.
There will be more detail of the revised NHAS to come. A federal action plan for the revised NHAS is expected on Dec 1, 2015 and will operationalize the strategy. Now is the time for advocates and civil society to weigh in with ONAP on how these goals might be achieved in communities across the US.
Have a question about NHAS? Join the conversation on social media via #HIV2020 or Tweet your questions to @AIDSgov.