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Plans for Ending the HIV Epidemic

National Efforts to End the Epidemic by 2030

Since the beginning of the epidemic, HIV experts have noted the importance of having a plan that would set clear goals for the United States and coordinate efforts to address the epidemic across government agencies.1 The first such plan, the National HIV/AIDS Strategy, was implemented in 2010 and has been credited with helping to reduce rates of new HIV infections.2

Today, there are two national plans in place to help end the HIV/AIDS epidemic by 2030—Ending the HIV Epidemic in the United States: A Plan for America and the HIV National Strategic Plan: A Roadmap to End the Epidemic—both of which share the goal of bringing new HIV infections down 75% by 2025 and 90% by 2030.2,3

These plans take separate but complementary approaches to ensuring widespread access to prevention, treatment, and care, and they guide different aspects of the government’s response.2,3

ENDING THE HIV
EPIDEMIC IN THE UNITED STATES: A PLAN FOR AMERICA

Ending the HIV Epidemic (EHE) in the United States: A Plan for America, known as The Initiative, is a federal effort designed to reduce new HIV infections by 90% over 10 years. The Initiative, launched in 2019, has three phases.

Phase I, which is already underway, focuses on those US jurisdictions hardest hit by the HIV epidemic. There are 57 target jurisdictions, which include the 48 counties with the highest number of new HIV diagnoses in 2016 and 2017; San Juan, Puerto Rico; and Washington, DC. More than 50% of new HIV diagnoses occurred in those locations during that time period. Also included as target jurisdictions are seven states with a substantial rural burden, with over 75 cases and 10% or more of their new HIV diagnoses occurring in 2016 and 2017 in rural areas.3,4

Phase II of The Initiative, which begins in 2026, will expand to address needs across the country, and Phase III will be more focused on case management to keep the number of new HIV infections at fewer than 3000 per year.3,5

Pillars of The Initiative

The Initiative is organized around four pillars of action3:

Diagnose. The Initiative aims to reduce the number of people living with HIV who are unaware of their status.6 As of 2019, it is estimated that about 13% of people living with HIV did not know they were infected, and that nearly 40% of new infections in 2016 involved someone who was unaware of their status.6-8 The Initiative is working to increase access to HIV testing in target areas to help diagnose new infections as quickly as possible6

Treat. The Initiative aims to ensure that everyone living with HIV is getting the treatment they need with the goal of helping everyone achieve viral suppression.* Everyone who is diagnosed with HIV should see a healthcare provider as soon as possible. Today’s treatments have been shown to be effective at suppressing the virus if used as prescribed by a healthcare provider. This can help those with HIV live longer, healthier lives and can help reduce the chance of passing HIV to others through sex. While strides have been made in getting treatment to more people, in 2019 just over half (57%) of people living with HIV were virally suppressed or undetectable.* Experts also recognize Treatment as Prevention (TasP) and understand that access to it is a vital part of ending new HIV infections6,9

Prevent. The Initiative aims to increase prevention efforts, including pre-exposure prophylaxis (PrEP) medicine. PrEP is a prevention strategy for people who are at risk for HIV. It involves using a prescription medicine to reduce the risk of HIV infection. Research shows that PrEP medicine is highly effective if used correctly. The Centers for Disease Control and Prevention (CDC) recommends PrEP medicine for anyone who is at high risk of getting HIV, but as of 2019, only 23% of the estimated 1.2 million people who qualify for the medication are using it6,10,11

Respond. The Initiative aims to improve the public health response to new outbreaks. New testing techniques and more sophisticated disease tracking systems, such as molecular surveillance, allow public health officials to pinpoint potential HIV outbreaks. The federal government can then work with local health departments in those areas to provide a timely response with tailored interventions and increased testing, treatment, and prevention services in those areas most in need6,12

The Department of Health and Human Services (HHS) coordinates The Initiative through the Office of the Assistant Secretary for Health (OASH). The Initiative is a collaboration between many agencies within the department, including the CDC, the Health Resources and Services Administration (HRSA), Indian Health Service (IHS), National Institutes of Health (NIH), and Substance Abuse and Mental Health Services Administration (SAMHSA).3

*Viral suppression means the amount of virus in the blood is so low it cannot be measured by a test (<200 copies/mL). This is sometimes referred to as undetectable. Viral suppression is the ultimate goal of HIV care and treatment.13

Plans and Programs of The Initiative

The Initiative is guiding new plans and programs on the national, state, and
local levels.

  • National Level. National programs include Ready, Set, PrEP and America’s HIV Epidemic Analysis Dashboard (AHEAD). Ready, Set, PrEP is a service for individuals who are eligible for the prevention protocol but do not have prescription drug coverage. Participants can choose to have the PrEP medicines delivered directly to their home, pick it up at one of more than 32,000 participating pharmacies, or have it sent to their healthcare provider’s office (in participating states).14-16 The hope is that by removing cost and access barriers, more people will choose this prevention method.14 AHEAD is a data visualization project that tracks public health goals via six indicators in target jurisdictions to help highlight progress and pinpoint areas that still need more help17
  • State Level. States with high HIV rates—including Alabama, Arkansas, Kentucky, Mississippi, Missouri, Oklahoma, and South Carolina—have worked with federal agencies to develop coordinated plans to bring down transmission and increase testing and care in the most highly impacted areas4,18
  • Local Level. The federal government is also working with each of the target jurisdictions to develop local plans to reduce HIV transmission. Plans are already underway in three Jumpstart Sites: East Baton Rouge Parish, LA; DeKalb County, GA; and Baltimore City, MD. East Baton Rouge Parish has increased the HIV testing capacity at five community-based organizations. DeKalb County has trained 30 nurses to implement a jail-based HIV testing program, and Baltimore City has added HIV testing capacity to its mobile syringe-services program (SSP)19

These areas highlight how different communities are struggling with varying aspects of the epidemic and why interventions need to be specifically tailored to the population and issues they’re facing. These programs will help inform best practices as other priority areas create their plans and as The Initiative expands to cover more areas of the country in Phase II.19

THE INITIATIVE:
PHASE I TARGET JURISDICTIONS

Map of the US Showing Phase 1 Target Jurisdictions
Source: Adapted from the Office of Infectious Disease and HIV/AIDS Policy (OIDP) at Department of Health and Human Services (HHS). Priority Jurisdictions: Phase I, 2020. 
About Ending the HIV Epidemic in the U.S.

Funding for The Initiative

To meet the goals of this plan, the government has steadily increased funding for HIV prevention, treatment, and care. The funding goes to a number of federal agencies that run national programs and distribute the funds to state and local governments and organizations across the country.5

For fiscal year 2021 (which runs from October 1, 2020 to September 30, 2021), Congress allocated $404.5M for implementation of The Initiative. This included20:

  • $175M for the CDC to reduce new HIV infections
  • $105M for HIV care through the Ryan White HIV/AIDS Program
  • $102M to provide HIV testing, linkage to care, and prescription of PrEP medicine and associated medical costs through the Health Centers program
  • $1.5M for rural HIV technical assistance through the Bureau of Primary Health Care (BPHC)–funded primary care associations (PCAs)
  • $5M to the IHS for an initiative to treat or reduce the transmission of HIV and HCV (hepatitis C)
  • $16M to the NIH for evaluation activities to identify effective interventions to treat and prevent HIV

The proposed budget for 2022 increases the total allocation to $670M. The biggest increase has been allocated to the CDC, which would receive $275M to fund efforts in the target jurisdictions.20

Progress on The Initiative

As of 2020, The Initiative had made significant progress with its national programs and its state and local efforts.3,19

  • All 57 jurisdictions have developed and submitted EHE plans
  • Jumpstart Sites have provided treatment for those living with HIV, increased HIV testing, and expanded preventative services, including PrEP medicine
  • Ryan White HIV/AIDS Program EHE–funded providers engaged nearly 6300 clients for the first time and re-engaged an additional 3600 clients from March to August 2020
  • BPHC–funded health centers prescribed PrEP medicine to nearly 63,000 patients in 2020
  • NIH provided funds to stand up six implementation science coordinating centers and consultation hubs

HIV NATIONAL STRATEGIC PLAN: A ROADMAP TO END THE EPIDEMIC

The National HIV/AIDS Strategy, released in 2010, identified priorities, coordinated resources, and offered clear and measurable targets for prevention and care interventions. This was the first national plan to address HIV and it has been credited with increasing collaboration and coordination of efforts between the many agencies and groups that are working to end the HIV epidemic. The original strategy was updated in 2015 and again in 2020, when the name was changed to the HIV National Strategic Plan 2021-2025.21,22

The Strategic Plan focuses on four goals that are similar to, though not the same as, the pillars in The Initiative. They are2:

  • Prevent new HIV infections. The plan aims to increase awareness of HIV, knowledge of HIV status, and implementation of effective prevention interventions such as PrEP medicine, post-exposure prophylaxis (PEP), and syringe services programs (SSPs)
  • Improve HIV-related health outcomes of people with HIV. The plan aims to link people living with HIV to care immediately after diagnosis, remove barriers to HIV treatment, and increase the capacity of healthcare delivery systems to engage and retain people in care
  • Reduce HIV-related disparities and achieve health equity. Marginalized communities—including men who have sex with men (MSM), transgender women, and people of color—have been disproportionately impacted by HIV/AIDS since the beginning of the epidemic. The plan acknowledges these disparities and seeks to reduce stigma and discrimination, and address the policy issues and social determinants of health that exacerbate HIV in some communities
  • Achieve integrated, coordinated efforts among all partners and stakeholders. The plan also aims to integrate HIV prevention and treatment efforts across all levels of government (state, federal, community-based, local, and territorial) with those of organizations (public, private, academic, community-based, and faith-based) working on these issues. It also notes the importance of coordinating efforts between organizations working to prevent HIV and those working on interrelated health issues, such as sexually transmitted infections (STIs), viral hepatitis, substance use, and mental health disorders

Rather than focus on priority geographic areas like The Initiative, the Strategic Plan focuses on priority groups—those who are disproportionately impacted by the epidemic. These groups include2:

  • MSM (in particular Black Americans, Hispanic/Latino Americans, and American Indian/Alaska Native men)
  • Black American women
  • Transgender women
  • Young people ages 13 to 24
  • People who inject drugs

The Strategic Plan identifies viral suppression* as the main indicator of success in addressing reducing health disparities and achieving health equity among these groups; viral suppression helps improve the health of individuals and reduces HIV-related deaths while also helping to prevent new HIV infections. As the Strategic Plan explains, “Monitoring progress on these disparities indicators also helps ensure that the nation is making progress with all populations, leaving no groups behind.”2

These coordinated efforts have been credited with some of the recent successes in controlling the HIV epidemic. Between 2010 and 2018, the number of people living with HIV who achieved viral suppression* increased nearly 30% (from 28% to 56%), the number of new diagnoses declined about 11%, and annual HIV-related deaths dropped more than 7%.2

The Strategic Plan has also helped change the policies around how HIV programs are funded to ensure that resources are going to the places and populations that need them most. Prior to the plan, funding was often allocated based on cumulative HIV cases, which skewed toward those cities that were most impacted early in the epidemic but left new hotspots underfunded. The Strategic Plan has also guided increases in health insurance coverage rates for people living with HIV, as well as investments in NIH research focused on new HIV treatment and prevention options, vaccine development, and ultimately, a cure.2

*Viral suppression means the amount of virus in the blood is so low it cannot be measured by a test (<200 copies/mL). This is sometimes referred to as undetectable. Viral suppression is the ultimate goal of HIV care and treatment.13

Different Priorities and Same Goal

Ending the HIV Epidemic in the United States: A Plan for America and The HIV National Strategic Plan are both working toward the goal of reducing new HIV infections by 2030 and are designed to complement each other. The Initiative recognizes that the current epidemic can best be viewed as diverse micro-epidemics with different underlying causes and, therefore, different solutions. The Initiative is focused on those areas most in need and allows the federal government to work closely with local authorities to tailor prevention and treatment efforts.2,3,5

In contrast, the Strategic Plan takes a broader look at the epidemic in this country and focuses on those groups of people that continue to be disproportionately impacted by HIV. It recognizes that these disparities are driven by society-wide issues from racism and discrimination to housing and education, and envisions whole-of-society solutions.2

Both plans are making progress, but the COVID-19 pandemic has created additional challenges for the agencies charged with implementing them. Public health professionals—such as front-line healthcare providers, researchers, and trained contact tracers—have been pulled away from HIV work to focus on COVID-19 efforts. And there is a fear that individuals may have stopped treatment or put off testing during the pandemic and subsequent economic downturn. Congress allocated additional funds to both the Ryan White HIV/AIDS Program and the Housing Opportunities for Persons with AIDS (HOPWA) Program to help those impacted by the pandemic.5,23

Despite the added challenges brought on by the global pandemic, experts believe we are on track to meet our goal of reducing new HIV infections 90% by 2030.24

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  1. Fauci AS, Lane HC. Four decades of HIV/AIDS — much accomplished, much to do. N Engl J Med. 2020;383(1):1-4.
  2. US Department of Health & Human Services. HIV national strategic plan: a roadmap to end the epidemic for the United States: 2021-2025. Washington, DC; 2021. Accessed July 31, 2021. 
    https://hivgov-prod-v3.s3.amazonaws.com/s3fs-public/HIV-National-Strategic-Plan-2021-2025.pdf
  3. Office of Infectious Disease and HIV/AIDS Policy, HHS. Overview: what is Ending the HIV Epidemic in the U.S.? Updated June 2, 2021. Accessed July 31, 2021. 
    https://www.hiv.gov/federal-response/ending-the-hiv-epidemic/overview
  4. HIV.gov. Ending the HIV epidemic: a plan for America. Flashcard. February 2020.
    https://www.cdc.gov/endhiv/docs/ending-HIV-epidemic-overview-508.pdf
  5. Dawson L, Kates J. The U.S. Ending the HIV Epidemic (EHE) Initiative: what you need to know. Published February 9, 2021. Accessed July 31, 2021. 
    https://www.kff.org/hivaids/issue-brief/the-u-s-ending-the-hiv-epidemic-ehe-initiative-what-you-need-to-know/
  6. Office of Infectious Disease and HIV/AIDS Policy, HHS. Key strategies in the plan. Updated May 8, 2020. Accessed July 31, 2021.
    https://www.hiv.gov/federal-response/ending-the-hiv-epidemic/key-strategies
  7. Centers for Disease Control and Prevention. CDC fact sheet: HIV in the United States and Dependent Areas. July 2021. Accessed August 25, 2021. 
    https://www.cdc.gov/hiv/pdf/statistics/overview/cdc-hiv-us-ataglance.pdf
  8. Li Z, Purcell DW, Sansom SL, Hayes D, Hall HI. Vital signs: HIV transmission along the continuum of care—United States, 2016. MMWR Morb Mortal Wkly Rep. 2019;68(11):262-272.
  9. HIV.gov. U.S. Statistics. Accessed June 2, 2021. 
    https://www.hiv.gov/hiv-basics/overview/data-and-trends/statistics
  10. Centers for Disease Control and Prevention. Pre-exposure prophylaxis (PrEP) care system. Reviewed September 10, 2020. Accessed July 31, 2021. 
    https://www.cdc.gov/hiv/effective-interventions/prevent/prep/index.html
  11. Centers for Disease Control and Prevention. Monitoring selected national HIV prevention and care objectives by using HIV surveillance data United States and 6 dependent areas, 2019. Reviewed May 20, 2021. Accessed July 22, 2021.
    https://www.cdc.gov/hiv/library/reports/hiv-surveillance/vol-26-no-2/content/national-profile.html
  12. Centers for Disease Control and Prevention. HIV cluster and outbreak detection and response. Reviewed February 3, 2021. Accessed July 31, 2021. 
    https://www.cdc.gov/hiv/programresources/guidance/cluster-outbreak/index.html
  13. Centers for Disease Control and Prevention. HIV treatment. Updated May 20, 2021. Accessed July 30, 2021.
    https://www.cdc.gov/hiv/basics/livingwithhiv/treatment.html
  14. Office of Infectious Disease and HIV/AIDS Policy, HHS. Ready, Set, PrEP. Updated March 26, 2021. Accessed July 23, 2021.
    https://www.hiv.gov/federal-response/ending-the-hiv-epidemic/prep-program
  15. Office of Infectious Disease and HIV/AIDS Policy, HHS. Ready, Set, PrEP pharmacies. Updated November 12, 2020. Accessed July 22, 2021.
    https://www.hiv.gov/federal-response/ending-the-hiv-epidemic/prep-pharmacies
  16. HIV.gov. Mail order now an option for Ready, Set, PrEP. Published January 25, 2021. Accessed July 23, 2021.
    https://www.hiv.gov/blog/mail-order-now-option-ready-set-prep
  17. US Health and Human Services. America’s HIV Epidemic Analysis Dashboard (AHEAD). Accessed July 31, 2021. 
    https://ahead.hiv.gov
  18. Centers for Disease Control and Prevention. Ending the HIV epidemic in the U.S. (EHE): local Ending the HIV Epidemic in the U.S. plans. Reviewed July 27, 2021. Accessed July 29, 2021. 
    https://www.cdc.gov/endhiv/action/local-ehe-plans.html
  19. Centers for Disease Control and Prevention. Ending the HIV epidemic in the U.S. (EHE): EHE in action. Reviewed April 1, 2021. Accessed July 29, 2021. 
    https://www.cdc.gov/endhiv/action/jumpstart.html
  20. Office of Infectious Disease and HIV/AIDS Policy, HHS. Ending the HIV epidemic funding. Updated July 30, 2021. Accessed July 31, 2021.
    https://www.hiv.gov/federal-response/ending-the-hiv-epidemic/funding
  21. Office of Infectious Disease and HIV/AIDS Policy, HHS. National HIV/AIDS strategies (2010-2020). Updated January 15, 2021. Accessed July 31, 2021. 
    https://www.hiv.gov/federal-response/hiv-national-strategic-plan/national-hiv-aids-strategies-2010-2020
  22. Office of Infectious Disease and HIV/AIDS Policy, HHS. HIV national strategic plan (2021-2025). Updated January 15, 2021. Accessed July 23, 2021. 
    https://www.hiv.gov/federal-response/hiv-national-strategic-plan/hiv-plan-2021-2025
  23. Dawson L, Kates J. Delivering HIV care and prevention in the COVID era: a national survey of Ryan White providers. Published December 16, 2020. 
    https://www.kff.org/hivaids/issue-brief/delivering-hiv-care-prevention-in-the-covid-era-a-national-survey-of-ryan-white-providers/
  24. C-SPAN. National Institutes of Health fiscal year 2022 budget request. May 25, 2021. Accessed July 23, 2021.
    https://www.c-span.org/video/?512007-1/national-institutes-health-fiscal-year-2022-budget-request

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