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 through 2019.²

As the HIV epidemic has changed over the last decade, there have been a few iterations of this plan and the introduction of another. Today, these two national plans—Ending the HIV Epidemic in the United States: A Plan for America and the National HIV/AIDS Strategy for the United States 2022–2025—guide and coordinate efforts to help end the HIV epidemic across the country. Both plans 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.⁴

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% by 2030. The Initiative, launched in 2019, has three phases.³

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.^3,5

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.^3,6

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.⁷ 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.^7-9 The Initiative is working to increase access to HIV testing in target areas to help diagnose new infections as quickly as possible⁷

• 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 infections^7,10

• 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 it^7,11,12

• 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 need^7,13

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 very low or cannot be measured by a test (<200 c/mL). Viral suppression is the goal of HIV care and treatment.¹⁴

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).^15-17 The hope is that by removing cost and access barriers, more eligible people will have access to this prevention method.¹⁵ AHEAD is a data visualization project that tracks public health goals via six HIV indicators in target jurisdictions to help highlight progress and pinpoint areas that still need more help¹⁸
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 areas^5,19
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)²⁰

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.²⁰

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.⁶

For fiscal year 2022 (which runs from October 1, 2021 to September 30, 2022), Congress allocated $473.2M for implementation of the Initiative. This included²¹:

$195M for the CDC to reduce new HIV infections
$125M for HIV care through the Ryan White HIV/AIDS Program
$122M to provide HIV testing, linkage to care, and prescription of PrEP medicine and associated medical costs through the Health Center program
$5M to the IHS for an initiative to treat or reduce the transmission of HIV and HCV (hepatitis C virus)
$26M to the NIH for the implementation of research facilities in target jurisdictions

The proposed budget for fiscal year 2023 increases the total allocation to $850M, which would be an increase of $377 million more than the previous year. The document states that the increased budget focuses on the need "...to aggressively reduce new HIV cases by increasing access to HIV prevention and care programs and ensuring equitable access to support services.”^21,22

Progress on the initiative

As of 2020, the Initiative had made significant progress with its national programs and its state and local efforts.^3,20

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

THE NATIONAL HIV/AIDS STRATEGY FOR THE UNITED STATES

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 across the many agencies and groups that are working to end the HIV epidemic. The original strategy was updated in 2015 and twice in 2021.^2,23 The current National HIV/AIDS Strategy for the United States 2022–2025 builds on the decade of work under previous iterations.²

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

Prevent new HIV infections. The Strategy aims to increase awareness of HIV, knowledge of HIV status, and implementation of safe and effective prevention interventions such as PrEP medicine, post-exposure prophylaxis (PEP), and syringe services programs (SSPs). It also aims to increase the diversity and capacity of healthcare delivery systems as well as community health, public health, and the health workforce to prevent and diagnose HIV.²
Improve HIV-related health outcomes of people with HIV. Among other things, the Strategy aims to link people living with HIV to care immediately after diagnosis, remove barriers to HIV treatment, identify those who are not in care or not virally suppressed to engage or reengage them in care, provide integrative HIV services for HIV-associated comorbidities, coinfections, and complications, and increase adherence to HIV treatment and retention in care to achieve and maintain long-term viral suppression.* It also aims to expand the capacity to provide whole-person care to long-term survivors and older adults living with HIV, advance the developments of next-generation HIV therapies, and accelerate research for an HIV cure.²
Reduce HIV-related disparities and health inequities. Marginalized communities—including men who have sex with men (MSM) and people of color—have been disproportionately impacted by HIV/AIDS since the beginning of the epidemic.²⁴ This disproportionate impact is especially evident in Black women, who accounted for 55% of new HIV diagnoses among women in the US in 2019.²⁵ Similarly, transgender women are also highly impacted, with an HIV prevalence of 14.1% compared to an estimated <0.5% of US adults overall, according to data published in 2019.²⁶ The Strategy acknowledges and seeks to reduce these disparities as well as stigma and discrimination, and address the policy issues, social and structural determinants of health, and co-occurring conditions that impede access to HIV services and exacerbate HIV in some communities. The Strategy aims to achieve these goals by employing and providing public leadership opportunities for people living with or at risk for HIV, training and expanding a diverse HIV workforce, advancing HIV-related communications to achieve improved messaging and uptake, and addressing misinformation and healthcare mistrust.²
Achieve integrated, coordinated efforts among all partners and interested parties. Among other things, the Strategy 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 suggests a holistic approach to prevention and treatment of HIV in the context of other often co-occurring health conditions such as STIs, viral hepatitis, substance use, and mental health disorders. Moreover, it seeks to integrate HIV awareness with outreach and services for other intersecting issues such as intimate partner violence and housing instability. Finally, it seeks to improve the quality, accessibility, sharing, and uses of HIV prevention, care, and other data, and to advance methods of measuring, monitoring, evaluating, and using these data to course correct as needed to achieve the Strategy's goals.²

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

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

The current Strategy places an added emphasis on older adults living with HIV and long-term survivors. Objectives include identifying models of care that meet the needs of people with HIV who are aging, implementing best practices related to addressing psychosocial and behavioral health needs of older adults living with HIV and long-time survivors, and promoting research and collaboration to address specific aging-related conditions in people living with HIV.²

The Strategy also acknowledges that other populations need specific attention and tailored services based on their unique circumstances, such as sex workers, immigrants, people experiencing housing instability, individuals with disabilities, and those involved with the justice system.²

The Strategy identifies viral suppression* as the main indicator of success in 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 Strategy explains, “Monitoring progress on these disparities indicators also helps ensure that the nation is making progress with all populations, leaving no groups behind.”²

Coordinated efforts under earlier versions of the Strategy have been credited with some of the recent successes in controlling the HIV epidemic. Between 2010 and 2019, the number of people living with HIV who achieved viral suppression* increased nearly 30% (from 28% to 57%), the number of new HIV diagnoses declined about 14%, and annual HIV-related deaths dropped by about 7%.²

Earlier versions of the Strategy 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. Earlier in the epidemic, funding was allocated on a discretionary basis or based on cumulative AIDS cases, which skewed toward cities that were most impacted early in the epidemic but left new hotspots underfunded. The Strategy has also facilitated 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 very low or cannot be measured by a test (<200 c/mL). Viral suppression is the goal of HIV care and treatment.¹⁴

Different Priorities and Same Goal

Ending the HIV Epidemic in the United States: A Plan for America and the National HIV/AIDS Strategy for the United States 2022–2025 are both working toward the goal of reducing new HIV infections by 2030 and are designed to complement each other.^2,4 The Initiative recognizes that the current epidemic can best be viewed as diverse microepidemics 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.³

In contrast, the Strategy 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 implementation.^2,3,21,23 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.⁶

Emerging research on the early months of the pandemic suggests that both HIV testing rates and PrEP medication use were down.^27,28 For example, four large metropolitan areas showed a 27% to 59% reduction in the total number of HIV tests conducted at outpatient settings in 2020 compared to the previous year.²⁷ Similarly, a national pharmacy-based analysis estimated there was a 22% decrease in the total number of PrEP prescriptions and a 25% decrease in the total number of new PrEP users between March 2020 and March 2021 compared to predicted data had the COVID-19 pandemic never occurred.²⁸

During the pandemic, 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 COVID-19.⁶

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 2030.²⁹

Fauci AS, Lane HC. Four decades of HIV/AIDS — much accomplished, much to do. N Engl J Med. 2020;383(1):1-4.
The White House Office of National AIDS Policy. National HIV/AIDS Strategy for the United States 2022–2025. Washington, DC. Published 2021. Accessed April 15, 2022.
https://www.whitehouse.gov/wp-content/uploads/2021/11/National-HIV-AIDS-Strategy.pdf
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 April 15, 2022.
https://www.hiv.gov/federal-response/ending-the-hiv-epidemic/overview
The White House Office of National AIDS Policy. National HIV/AIDS Strategy (2022-2025). Updated December 14, 2021. Accessed April 15, 2022.
https://www.hiv.gov/federal-response/national-hiv-aids-strategy/national-hiv-aids-strategy-2022-2025
HIV.gov. Ending the HIV Epidemic: A Plan for America. Flashcard. February 2020. Accessed April 15, 2022.
https://www.cdc.gov/endhiv/docs/ending-HIV-epidemic-overview-508.pdf
Dawson L, Kates J. The U.S. Ending the HIV Epidemic (EHE) Initiative: what you need to know. Published February 9, 2021. Accessed April 15, 2022.
https://www.kff.org/hivaids/issue-brief/the-u-s-ending-the-hiv-epidemic-ehe-initiative-what-you-need-to-know/
Office of Infectious Disease and HIV/AIDS Policy, HHS. Key strategies in the plan. Updated May 8, 2020. Accessed April 15, 2022.
https://www.hiv.gov/federal-response/ending-the-hiv-epidemic/key-strategies
Centers for Disease Control and Prevention. CDC fact sheet: HIV in the United States and Dependent Areas. July 2021. Accessed April 15, 2022.
https://www.cdc.gov/hiv/pdf/statistics/overview/cdc-hiv-us-ataglance.pdf
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.
HIV.gov. U.S. Statistics. Updated June 2, 2021. Accessed April 15, 2022.
https://www.hiv.gov/hiv-basics/overview/data-and-trends/statistics
Centers for Disease Control and Prevention. HIV pre-exposure prophylaxis (PrEP) care system. Reviewed March 18, 2022. Accessed April 15, 2022.
https://www.cdc.gov/hiv/effective-interventions/prevent/prep/index.html
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. Published May 2021. Accessed April 15, 2022.
https://www.cdc.gov/hiv/library/reports/hiv-surveillance/vol-26-no-2/content/national-profile.html
Centers for Disease Control and Prevention. HIV cluster and outbreak detection and response. Reviewed March 2, 2022. Accessed April 15, 2022.
https://www.cdc.gov/hiv/programresources/guidance/cluster-outbreak/index.html
Centers for Disease Control and Prevention. HIV treatment. Reviewed May 20, 2021. Accessed April 15, 2022.
https://www.cdc.gov/hiv/basics/livingwithhiv/treatment.html
Office of Infectious Disease and HIV/AIDS Policy, HHS. Ready, Set, PrEP. Updated March 18, 2022. Accessed April 15, 2022.
https://www.hiv.gov/federal-response/ending-the-hiv-epidemic/prep-program
Office of Infectious Disease and HIV/AIDS Policy, HHS. Ready, Set, PrEP pharmacies. Updated November 12, 2020. Accessed April 15, 2022.
https://www.hiv.gov/federal-response/ending-the-hiv-epidemic/prep-pharmacies
HIV.gov. Mail order now an option for Ready, Set, PrEP. Published January 25, 2021. Accessed April 15, 2022.
https://www.hiv.gov/blog/mail-order-now-option-ready-set-prep
US Department of Health & Human Services. About Dashboard | AHEAD. Accessed April 15, 2022.
https://ahead.hiv.gov/about
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 April 15, 2022.
https://www.cdc.gov/endhiv/action/local-ehe-plans.html
Centers for Disease Control and Prevention. Ending the HIV epidemic in the U.S. (EHE): EHE in action. Reviewed April 1, 2021. Accessed April 15, 2022.
https://www.cdc.gov/endhiv/action/jumpstart.html
Office of Infectious Disease and HIV/AIDS Policy, HHS. Ending the HIV Epidemic funding. Updated April 5, 2022. Accessed April 15, 2022.
https://www.hiv.gov/federal-response/ending-the-hiv-epidemic/funding
The White House Office of Management and Budget. Budget of the U.S. Government: Fiscal Year 2023. Washington, DC. Published 2022. Accessed May 6, 2022.
https://www.whitehouse.gov/wp-content/uploads/2022/03/budget_fy2023.pdf
Office of Infectious Disease and HIV/AIDS Policy, HHS. Prior national HIV/AIDS strategies (2010-2021). Updated December 1, 2021. Accessed April 15, 2022.
https://www.hiv.gov/federal-response/national-hiv-aids-strategy/national-hiv-aids-strategies-2010-2021
AIDS.gov. A timeline of HIV/AIDS. Accessed May 2, 2022.
https://www.hiv.gov/sites/default/files/aidsgov-timeline.pdf
Kaiser Family Foundation. The HIV/AIDS epidemic in the US: the basics. Published June 7, 2021. Accessed May 2, 2022.
https://www.kff.org/hivaids/fact-sheet/the-hivaids-epidemic-in-the-united-states-the-basics/
Centers for Disease Control and Prevention. Issue brief: HIV and transgender communities. Reviewed April 22, 2022. Accessed May 2, 2022.
https://www.cdc.gov/hiv/pdf/policies/data/cdc-hiv-policy-issue-brief-transgender.pdf
Moitra E, Tao J, Olsen J, et al. Impact of the COVID-19 pandemic on HIV testing rates across four geographically diverse urban centres in the United States: an observational study. Lancet Reg Health Am. 2022;7:100159. doi:10.1016/j.lana.2021.100159
Huang YLA, Zhu W, Wiener J, Kourtis AP, Hall HI, Hoover KW. Impact of coronavirus disease 2019 (COVID-19) on human immunodeficiency virus (HIV) pre-exposure prophylaxis prescriptions in the United States—a time-series analysis. Clin Infect Dis. 2022;ciac038. doi:10.1093/cid/ciac038
C-SPAN. National Institutes of Health fiscal year 2022 budget request. Published May 25, 2021. Accessed April 15, 2022.
https://www.c-span.org/video/?512007-1/national-institutes-health-fiscal-year-2022-budget-request