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Changing the Landscape of HIV Prevention: What a Difference a Year Makes

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Health Protection PerspectivesOn July 13, 2010, President Obama released the National HIV/AIDS Strategy (NHAS).  The Strategy outlines bold new steps for responding to the domestic HIV epidemic at a critical time in the U.S. HIV incidence has been stable, but health inequalities are worsening, and many Americans no longer feel that HIV is a serious health threat. The NHAS addressed the long-expressed need to refocus national attention on the domestic HIV epidemic. It established a bold vision, clear goals, and concrete steps for implementation.

The NHAS was indeed the game changer we had hoped for. Yet a strategy would be only words on paper if it is not accompanied by broad-based support, a willingness to re-examine current approaches and robust measures for  accountability. The good news is that all of these elements are in place.  So at the one year anniversary of this landmark policy, let us reflect on how the NHAS is radically changing the landscape for HIV prevention as the epidemic, and our tools for addressing it, continue to evolve.

More people infected = potential for increased transmission of HIV. Despite the stable incidence, prevalence continues to increase, and today there are almost 1.2 million people currently living with HIV. Approximately 240,000 of those living with HIV are unaware of their infection—about 1 in 5 of all Americans with HIV. As the number of people living with HIV grows—including those who don’t know they are infected—the potential for increased transmission of HIV to others grows too.

It is smart to target resources where transmissions are occurring. Work from the CDC over the past year has confirmed the association between low socioeconomic status and HIV; the increasing burden of disease and changing risk behaviors among MSM of all races; the pervasive health disparities faced by African Americans and Hispanics/Latinos; the changing patterns of risk and prevalence among injection drug users; and the continued advances in reducing mother-to-child transmission of HIV. These data confirm and justify the need to target resources where transmission is greatest, while deliberately and comprehensively addressing the social and structural determinants of HIV acquisition.

New combination HIV prevention interventions are on the horizon. Over the last  year we’ve had tremendous advances in the HIV prevention field with the success of exciting new biomedical HIV prevention interventions, including Pre-Exposure Prophylaxis (PrEP) among MSM, and antiretroviral-containing microbicides in reducing HIV transmission among heterosexual women. Similarly, evidence regarding the benefits of early ARV treatment for individuals, and for reducing disease transmission, has yielded a heightened sense of urgency to understand the implications of these trials in the real-world setting, the impact on different population sub-groups, and how best they could be combined with other prevention approaches.

But HIV prevention basics are still important. The emerging data also challenge us to get back to the basics of HIV prevention, including “treatment as prevention.” These basics include scaling up HIV testing and awareness of serostatus; ensuring linkage to effective treatment and care; maintaining and re-engaging individuals in care; ensuring undetectable viral load;  reinforcing  prevention messages for persons living with HIV/AIDS; and intensive prevention counseling and support for individuals at highest risk of acquiring HIV.

Challenging times can make for new opportunities. However, these changes in the epidemic and scientific developments have taken place in the context of perhaps one of the most challenging times for prevention, treatment, and care programs since the beginning of the epidemic. The global economic downturn has placed enormous strains on individuals, communities, and programs at a time when the energy and will to respond to the NHAS has been greatest. The current economic circumstances create social and structural opportunities that could facilitate HIV transmission and acquisition among our most vulnerable populations in an environment of competing health priorities,  many have asked for guidance on the selection, prioritization, targeting, and scaling-up of interventions to ensure that we all continue to use scarce resources most efficiently. In addition, concomitant transformation of our health care system presents opportunities and challenges for HIV prevention—many of which are still becoming apparent.

So the first year of NHAS implementation has taken place within a dynamic context of rapid change, cautious optimism, and growing uncertainty. Nevertheless, I have been tremendously encouraged to see our partners forging ahead to take full advantage of new opportunities. Whether scaling up HIV testing and linkage to care; implementing new prevention programs in the community setting; leveraging connections between HIV, STD, hepatitis, or TB programs and services; or implementing new demonstration projects on enhanced comprehensive HIV prevention program (ECHPP), our partners across the country are taking stock of the urgent realities; refocusing efforts; and maximizing existing and new resources for greatest impact. It is this resoluteness that will be critically important as we move into the second year of NHAS implementation and beyond.

Partnerships are key. The NHAS clearly states that the federal government alone cannot achieve the reductions in HIV that we all seek. We must continue to build upon the lessons learned from partnering across federal agencies at the national and local level, with the private sector, with prevention program implementers, and with communities across this country.

The global AIDS pandemic must be addressed locally. To save the greatest number of lives possible and prevent further HIV transmission, we must know our local epidemics and focus our efforts on key populations at greater risk, including gay and bisexual men of all races and ethnicities, Black men and women, Latinos and Latinas, and people struggling with addiction (including injection drug users). By focusing our prevention and testing efforts in communities where HIV is most heavily concentrated, we can have the biggest impact in lowering all communities’ collective risk of acquiring HIV. We can also reduce HIV-related health disparities by reducing HIV-related deaths and onward transmission in these communities, especially if we are able to connect HIV-positive individuals with prevention, care, and treatment.

High-impact prevention saves lives. Finally, and perhaps most importantly, we must take this unique opportunity provided by the NHAS to fundamentally redefine our approach to HIV prevention. A commitment to high impact prevention—ensuring that the right interventions are targeted and brought to scale with the right populations, for maximal impact—remains a commitment for the CDC and is a core principle for HIV prevention programs we fund. HIV prevention, whether through testing or other evidence-based interventions, saves lives and resources. Each HIV infection averted saves an estimated $367,000 (2009 dollars) in lifetime medical costs.

The first anniversary of the release of the National HIV/AIDS Strategy is a time for reflection. But most of all, it is a time to be grateful that we have a strategy that reflects the diversity of our community and our efforts, one that brings us together with a single vision. Working together across agencies, across sectors, across communities, and among all Americans, we can share the responsibility for HIV prevention in communities with the heaviest burden of disease, reduce HIV-related health disparities, and, ultimately, stop the spread of HIV in the United States.

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