Achieving and advancing the goals of the National HIV/AIDS Strategy for the United States.

Abstract

In July 2010, President Barack Obama released the National HIV/AIDS Strategy for the United States (NHAS) [1]. The NHAS contains ambitious but achievable goals to be obtained by 2015 in four areas: (a) reductions in HIV incidence and transmission rate, and improvements in awareness of HIV seropositivity; (b) better linkage to and retention in HIV care, treatment and housing services; (c) reductions in HIV-related health disparities among gay men and Black and Latino communities; and (d) improved service coordination at all governmental levels [1]. The vision of the NHAS was generally applauded by those working in HIV service delivery, research and advocacy, and has been central to the reinvigoration and refocusing of governmental and private sector HIV programs. However, the NHAS did not contain estimates of the costs necessary to scale up the recommended HIV prevention, care and housing services. Rather, researchers developed estimates of the cost of implementation and cost-effectiveness of such investments [2]. Since 2010 there have been marginal increases in federal support of HIV services in some agencies and some regions of the US (primarily in HIV care services in urban areas), but these increases are well below what has been estimated in the literature as necessary to achieve a full-scale implementation of the NHAS [2, 3]. Further, measures of key metrics necessary to monitor the success of NHAS implementation are three to four years behind the current calendar year [4], making realtime adjustments difficult. Researchers have attempted to overcome this limitation by using mathematical modelling techniques to project forward in time from the best available past data; these modeling exercises have suggested that without further substantial expansion of HIV prevention and care services, attainment of the 2015 NHAS goals is doubtful [2, 3]. The most recently available US statistics suggest that as of 2010 there are 1.14 million people living with HIV (PLWH) and roughly 47,500 estimated new HIV infections per year, the rate of HIV transmission per year per 100 PLWH is 4.15, and 84.2 % of PLWH have been diagnosed [4]. Among PLWH who are diagnosed, 79.8 % were linked to care within three months (2011 data), 50.9 % were retained in care (2010 data), and 43.4 % have achieved viral suppression (at most recent viral load test in 2010) [4]. In other words, only about 37 % of all PLWH in the US have suppressed viral load (.842 9 .434). Health disparities are very evident with the disease disproportionately impacting Black and Latino men and women, and the epidemic appears to be expanding among gay men generally, and among young Black gay men in particular due to a number of epidemiologic and social factors [3–7]. Given this current state of epidemiologic affairs and that the end of the NHAS in 2015 is nearly upon us, I wish to highlight for discussion several issues which I believe need the most urgent attention so as to make one last attempt to achieve the 2015 NHAS goals, substantially modify the course of the epidemic, and set the stage for a strategic planning discussion that extends through 2016 and beyond. First, while we must serve all communities affected by HIV, the epidemic among young Black gay men is clearly expanding and must be met with a comprehensive service delivery response that is proportional to the severity of this health disparity. While most federal agencies involved in HIV programming could highlight some program(s) they D. R. Holtgrave (&) Department of Health, Behavior & Society, Johns Hopkins Bloomberg School of Public Health, 624 N Broadway, Baltimore, MD 21205, USA e-mail: dholtgra@jhsph.edu; david.r.holtgrave@jhu.edu