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Comments by Mark Harrington, executive director of Treatment Action Group, for the Ford Foundation–hosted meeting on developing a national AIDS strategy for the United States

In April 2008, the Ford Foundation hosted a meeting of over 40 national AIDS leaders to discuss the elements of a national AIDS strategy for the United States. Amazingly, despite the fact that the United States insists that the foreign countries who receive U.S. international AIDS assistance develop and implement a national AIDS strategy, American leaders have never insisted that they develop one for the nation itself. Below are the suggestions TAG’s Mark Harrington—with input from Richard Jefferys, Sue Perez, and Tracy Swan— provided prior to the Ford Foundation meeting.

What Should a National AIDS Strategy Look Like?

A national AIDS strategy for the United States would include a serious effort to reverse and reduce the spread of HIV; provide high-quality treatment and care services to all HIV-infected people while preserving their rights and dignity; and intensify research to combat the epidemic, ultimately leading to a cure and a vaccine for HIV that can be disseminated to all who need them in the United States and around the world.

To be credible, a national AIDS strategy would need to have firm targets for reduction of transmission and for universal access and uptake of prevention, care, and treatment services.

To provide a clear picture of the epidemic a national AIDS strategy would need accurate and complete reporting of HIV transmission. Currently there are both structural and cultural barriers to such complete reporting, ranging from the patchwork of testing and counseling laws and regulations (structural barriers) to deep-seated and often well-justified mistrust of both government and the health system (cultural barriers) by many of the communities most affected by the pandemic.

To reverse this mistrust will require enormous changes, including a strong political commitment to reversing the spread of HIV using all scientifically proven and ethical methods of prevention; consultation and involvement of affected communities at all levels; significant efforts to overcome the patchwork and inefficient health care system in the United States; and intensified research efforts. Without new leadership, new resources, and new solidarity among those at risk, those who are HIV-positive, and society as a whole, a national AIDS strategy is unlikely to succeed.

There are also significant uncertainties that would need to be resolved through research and by monitoring and evaluating the progress of a national AIDS strategy as it unfolds. Among these uncertainties are:

  • We lack a clear, detailed picture of the current state of the HIV pandemic, including current HIV prevalence and current incidence. Without this more detailed picture of the current epidemic and where it is going it will be harder to develop an effective strategy.
  • We lack a clear picture of what the best strategies are for optimizing uptake of testing and counseling while protecting people’s rights, dignity, and privacy. Targeting only health care providers, who are often overworked and underresourced, or targeting only “prevention for positives,” leaves out many who are at risk as well as most of the recently infected—and up to (according to possibly inaccurate CDC estimates) one-third of the chronically infected.
  • We lack a clear quantitative understanding of how to maximize the effectiveness of the scientifically validated prevention tools we already have, such as sexual and reproductive health education including HIV, STI, and condom education; harm reduction, safe needle use, syringe exchange, and drug-substitution therapy; and use of antiretroviral therapy for prevention as well as for treatment (among, for example, pregnant and nursing mothers, discordant couples, or people episodically exposed to HIV). Therefore, how much prevention programming needs to be undertaken to radically reverse the epidemic—it would be reasonable at first to set a goal of reducing HIV transmission by 50%—is not clear. Nonetheless, it would clearly require a major expansion of resources and a reinvigoration of communitybased, peer-led prevention approaches that target the communities where transmission is most frequent, as well as general approaches involving universal HIV education and routine access to voluntary, opt-out HIV testing in health care and other institutional settings.
  • Without systemic health care reform the implementation of any strategy will be incomplete.
  • Without systemic reform of the nation’s failed “war on drugs” the implementation of any strategy will be incomplete.
  • Without reform of HIV prevention, care, and treatment programs in the nation’s correctional systems the implementation of any strategy will be incomplete.
  • To achieve universal access to care and treatment, all individuals at risk for or living with HIV need this to be guaranteed as a public good (similar to TB prevention and treatment, but better funded and ongoing).
  • Ultimately the solutions to the HIV pandemic will come from research that brings a better understanding of viral pathogenesis leading to the discovery of better interventions to prevent and treat HIV infection. Currently the nation’s health research system, led by the National Institutes of Health, is bearing the brunt of five years of budget stagnation, leading to what is effectively a shrinking biomedical research and AIDS research budget. The solution for medical research as a whole—and for AIDS research more specifically—depends on reinvigorating the NIH by providing it with a guaranteed multiyear sequence of budget increases that overreach biomedical inflation and allow a new generation of researchers to have careers in biomedicine and AIDS research. We are therefore proposing a 15% increase in NIH funding overall, and a concurrent 15% increase in AIDS research funding for at least five years, and thereafter for funding to outpace inflation.
  • Antiretroviral treatment will probably need to be initiated earlier, at both the individual and population levels, to have a greater impact on HIV transmission as well as length and quality of life. However, the evidence base for this needs to be strengthened.
  • A national AIDS strategy needs to foster greater inclusion of women and people of color at all levels of the biomedical research and care system so that leaders and participants in AIDS research efforts reflect the diversity of the populations most affected by the epidemic.
  • A national AIDS strategy will not succeed unless the people it is intended to benefit can receive integrated services for their health—including, when necessary, HIV care, prevention and treatment for coinfections such as viral hepatitis, tuberculosis, STIs, or other opportunistic infections; drug substitution therapy, if necessary; mental health services; and psychosocial support. Currently the infrastructure to provide these services is fragmented.

What Are Our Greatest Hopes for and Concerns about a National AIDS Strategy?

The United States has been a leader in some aspects of responding to the pandemic, such as research, while failing to serve many or most of the communities worst hit by the epidemic. A much stronger focus is needed to respond to the epidemic in the African American and Latino communities as well as among men who have sex with men, among women, and among younger people.

The lack of trust among the people, the government, and the health system is probably the biggest obstacle to change.

Institutional obstacles include the fragmented health system, lack of transparency by industry with respect to pricing, and the ongoing ineffective and punitive “war on drugs.”

Local and regional U.S. support for effective HIV programming is weak, especially in the South and in rural areas.

Racism and homophobia continue to drive the inequities that persist.

Overcoming these obstacles will be an enormous challenge, and will require a new kind of solidarity, new leadership, and a massive infusion of resources.

It is not clear that the United States is capable of rising, after 27 years of incomplete and sometimes contradictory responses, to the challenge of reversing and ultimately ending the epidemic.

However, a national AIDS strategy with measurable goals, a budget, and regular progress reports and improvements based on results is greatly needed. To be effective, however, it must set ambitious goals and deploy sufficient leadership, money, and people from affected communities to enable them to intervene.

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