The US moves its AIDS strategy into higher gear

By Regina McEnery

In an effort to revive an ailing domestic AIDS strategy, US President Barack Obama ordered his administration last month to review all federal AIDS counseling and testing programs and to recommend more effective ways of delivering treatment and care in the US.

A working group chaired by Grant Colfax, director of the Obama administration’s Office of AIDS Policy, and Department of Health and Human Services (HHS) Secretary Kathleen Sibelius have 180 days to deliver their recommendations.

The announcement came three years after the Obama administration unveiled the country’s first-ever National AIDS Strategy to combat the static US epidemic, where the annual number of new HIV infections is around 50,000. When he rolled out the strategy, Obama set a concrete goal to reduce the number of new infections by 25% within five years, increase access to care and optimize health outcomes for people living with HIV/AIDS.

Yet compared to how the US has responded to the international AIDS crisis—namely through its President’s Emergency Plan for AIDS Relief (PEPFAR) launched by George W. Bush and participation in The Global Fund to Fight AIDS, Tuberculosis and Malaria, the national strategy has been seen by critics as lacking in ambition and inadequately funded. Moreover, it paled in comparison to outgoing Secretary of State Hillary Clinton’s bold pledge to end AIDS around the world using evidence-based approaches.

“Not only is the US plan not on track to achieve its goals, but they are themselves far less ambitious than what has already been achieved in the past decade in some of the world’s poorest countries, such as Cambodia, Ethiopia, or Zambia,” remarked Mark Harrington, the executive director of the Treatment Action Group (TAG) in New York, in The Atlantic magazine last year.

In the US, only 25% of the 1.2 million HIV-infected people are on effective antiretroviral therapy with an undetectable viral load and only 33% are retained in care, Harrington noted. “Only 82% even know their HIV status—a number that’s much lower among young people with the virus,” Harrington wrote.

So what was Harrington’s reaction to the executive order? In a word, pleased. Harrington said he particularly liked the fact that the Obama administration recognizes the importance of aggressive testing and early treatment in preventing transmission of HIV, as shown in the landmark HPTN052 study of serodiscordant couples in Africa.

Harrington said he was also glad to see the White House all but embrace a model of care—known as the HIV treatment cascade—that identifies key opportunities to improve services for people with HIV. By identifying these “leakages” in care, clinical sites have a better shot of referring people for HIV care after being diagnosed, and making sure they are adhering to HIV treatment and therefore lowering their undetectable levels.

“I’m much more impressed,” said Harrington. “I’m feeling like [the administration] has been listening to the science.

Along with stressing a continuum of care, the HHS—which oversees federal HIV/AIDS programs—announced it would be investing US$8 million to $10 million a year to support health centers and local health departments in integrating public health practice and clinical care. The project will target areas with high numbers of racial and ethnic minorities disproportionately affected by the epidemic, and communities with a substantial unmet need for comprehensive HIV services.