What would be the key elements of a New York Plan to End AIDS?
Following is a draft of a set of recommendations submitted by a coalition of activists and organizations to Courtney Burke, New York State’s Deputy Secretary for Health, in an effort to convince Governor Andrew Cuomo to establish a task force to end AIDS in the state.
New York State has borne the highest burden of HIV since the beginning of the AIDS pandemic in 1981.
Since then, New York State has been a center of activist, community, and scientific innovation and collaboration in responding to the crisis.
New York has the people, institutions, resources, and political will to end AIDS throughout the state, and to become a leader nationally and globally in showing how to end AIDS.
Therefore, New York State should make a long-term commitment to, and a strategic priority of, ending AIDS for all New Yorkers: ending the illness and death associated with HIV infection and the progression to AIDS; as well as the related suffering, stigma, and devastation of our communities and our people.
Ending AIDS in New York will rely on five related activities.
1. Twenty-first-century surveillance: Know your epidemic.
Know who is living with HIV and make sure they’re getting needed services. Know where HIV is being transmitted and intervene there quickly to stop chains of uncontrolled transmission. Use twenty-first-century surveillance tools such as fourth-generation simultaneous detection of HIV p24 antigen and antibodies to diagnose HIV infection and distinguish between acute and chronic infection. Disaggregate HIV transmission, incidence, and prevalence data by demographic, risk group, and geographic area to be able to map and target interventions rationally. Everyone should know his or her HIV status. People at highest risk for HIV should be testing more frequently (e.g., 2–4 times per year). We should link availability of home HIV testing to follow-up confirmatory testing and find ways to ensure that people who are undergoing acute infection—and thus would test negative on the home HIV test—could access a more accurate fourth-generation test quickly.
2. Evidence-based combination HIV prevention for both HIV-negative and HIV-positive persons.
Routine and voluntary universal HIV testing is a gateway to HIV prevention for those who test negative. Prevention services should be comprehensive and should include high-quality HIV-, reproductive health–, and sexual health education at all levels; nonoccupational and occupational postexposure prophylaxis (PEP) available on-site (for occupational) and in pharmacies and community health clinics (for nonoccupational) within two hours of exposure. Preexposure prophylaxis (PrEP) should be available for those who need it. Both PEP and PrEP candidates should be eligible for comprehensive prevention services, including drug treatment and harm reduction; depression; mental health; trauma and violence screening; treatment; housing; and other supportive services that can help them stay negative. Combination HIV prevention care and services should be required from all New York State providers—public and private—as essential services under the ACA prevention mandate.
3. Focus on filling the gaps in the HIV continuum of care to maximize the speed, proportion, and number of people able to successfully suppress their HIV as soon as possible once they are diagnosed.
New York State should implement a continuum of HIV care initiative in line with the one President Obama promulgated nationally on July 15, 2013:
In July 2010, President Obama released the first comprehensive National HIV/AIDS Strategy. The HIV Care Continuum Initiative calls for coordinated action in response to data that has been released since the Strategy three years ago, showing only a quarter of people living with HIV in the United States have achieved the treatment goal of controlling the HIV virus. In fact, along the entire HIV care continuum—the sequential stages of care from being diagnosed to suppressing the virus—there are significant gaps. To address this need, the HIV Care Continuum Initiative will mobilize Federal efforts in line with the recent advances in our understanding of how best to prevent and treat HIV infection. It will support further integration of HIV prevention and care efforts; promote expansion of successful HIV testing and service delivery models; encourage innovative approaches to addressing barriers to accessing testing and treatment; and ensure that Federal resources are appropriately focused on implementing evidence-based interventions along the HIV care continuum in relation to other scientifically proven approaches to combating HIV.
Scientific advances in the three years since the Strategy’s release highlight the importance of accelerating efforts to increase HIV testing, services, and treatment along the continuum:
Federal guidelines now recommend antiretroviral treatment for all adults and adolescents living with HIV in the United States. Instead of waiting for the immune system to show signs of decline, experts now recommend starting treatment right away. Evidence indicates that treating HIV as soon as possible reduces HIV-related complications.
Treatment reduces the risk of HIV transmission. Along with other proven prevention methods, such as condom use, abstinence, and comprehensive drug treatment, effective treatment reduces the risk of HIV transmission. An NIH-sponsored study showed that among heterosexual couples, starting treatment early reduced transmission risk by 96%.
Screening for HIV is now recommended for all persons 15–65 in the United States. About half of Americans have never been tested for HIV, and nearly 200,000 people living with HIV in this country are unaware that they are infected. Screening all persons between 15 and 65 years of age is now a grade "A" recommendation of the independent U.S. Preventive Services Task Force.
While New York State is doing better than the nation as a whole with respect to the HIV continuum of care, there is an urgent need for much greater success. According to the New York AIDS Institute in May 2012, reporting state data from in 2010:
156,287 people were estimated to be living with HIV;
128,653 or 82 percent of those infected were living with diagnosed HIV infection;
84,701 or 54 percent of those infected received any HIV care (any viral load or CD4 test) during the year;
73,634 or 47 percent of those infected received continuous care (at least two tests, at least three months apart) during the year; and
58,337 or 37 percent of those infected were successfully controlling their viral load (not detectable or <200 copies/ml) at test closest to midyear).
In other words, 18% of HIV-positive New Yorkers do not know their status, 46% are not receiving regular HIV care, 53% are not receiving continuous care, and 63% are not successfully controlling their viral load.
New York’s ongoing Medicaid reform and expansion, plus the advent of the Affordable Care Act (ACA) offer the opportunity to fill the gaps in the HIV treatment cascade. Those responsible for designing and implementing Medicaid expansion and the ACA rollout should design their programs to ensure that filling these gaps is a priority, and should use the experience and expertise of AIDS care providers in implementation of the ACA and Medicaid expansion.
4. Assure the availability of essential supportive services to ensure that New Yorkers, whether HIV-negative or HIV-positive, remain healthy and aviremic, and do not contract or transmit HIV; and support research needed to improve service delivery and optimize outcomes.
ACA and Medicaid expansion alone will not assure that all people and communities at risk for or living with HIV are able to stay healthy and avoid contracting or transmitting HIV. Continued reliance on Ryan White CARE Act– and HOPWA-funded services, as well as comprehensive prevention, care, and treatment for important comorbidities such as depression, diabetes, drug use, mental health, trauma, viral hepatitis (hepatitis A and B vaccination; hepatitis B and C treatment; hepatitis C cure) will be required to eliminate the risk of new HIV infections and to ensure that those receiving HIV care are retained and successfully treated. Housing is an essential part of these supportive services. Clean needles, harm reduction, and opiate substitution therapy are essential as well. Decriminalization of condom possession, nonviolent drug violations, and adult consensual sex work; reducing the burden of incarceration and entanglement with the correctional system for young men; and addressing other structural contributors to the HIV pandemic should also play a role.
Implementation science needs to be supported to determine the best way to deliver HIV prevention, treatment, and supportive services. New York State has some of the world’s foremost research institutions, which must work with government, providers, and affected communities to document the best practices for HIV surveillance, prevention, treatment, and supportive care. This science can help to direct interventions in the most high-impact and evidence-based ways to all who need them.
5. Commit political leaders and all New York communities to leadership and ownership of the New York Plan to End AIDS.
Community activism and service provision have been essential to the AIDS response from the beginning. We will not end AIDS in New York State without a combined commitment by New York State government at all levels, affected communities, private and nonprofit sectors, and service providers working together until there are no more new HIV infections and no more AIDS cases or deaths in New York State.
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1. White House. Accelerating improvements in HIV prevention and care in the United States through the HIV Care Continuum Initiative. 2013 July 15. Available from: http://www.aids.gov/federal-resources/national-hiv-aids-strategy/hiv-care-continuum-initiative-fact-sheet.pdf.
2. O’Connell D. HIV/AIDS in New York State. Revitalizing the New York State HIV/AIDS response: ending the AIDS epidemic in New York State. Presentation at consultation meeting at Columbia University; 2013 May 6; New York, NY.