This World AIDS Day, federal health agencies and health providers should take time to reflect on the progress we’ve made in eradicating HIV, while acknowledging the work that lies ahead.
In 2019, the Department of Health and Human Services created a powerful benchmark with the Ending the HIV Epidemic in the U.S. initiative (EHE). This ambitious plan, which was recently updated, set the goals of reducing new HIV infections by 90 percent and increasing viral suppression by 90 percent by 2030.
Thanks to inventions like Pre-Exposure Prophylaxis (PrEP), clean needle access and condom availability, we’ve already made great progress and are set in the right direction to reach these thresholds. But, as the strategy indicates, eradication goes deeper than making such resources available. Achieving these goals requires consideration of the specific communities impacted by HIV and addressing their holistic needs at the granular level. Doing so will create informed, relevant benchmarks for success and provide a pathway for meaningful community-centered interventions.
A new lens for addressing HIV prevention and care
Health is complex, and many factors outside of a person's genetics and traditional medical care, like their income, experience of discrimination, and proximity to public transit, impact their well-being. Such factors are typically referred to as social determinants of health (SDOH), and addressing these factors is essential to eradicating HIV and increasing viral suppression rates.
Understanding the everyday realities of the communities most impacted by HIV is key to adopting a SDOH lens. In the U.S., the populations with the highest incidence rates of HIV are gay, bisexual, and other men who have sex with men; Black and Hispanic people; transgender women; and people who inject drugs. Conditions created by structural racism, homophobia, transphobia and persistent poverty, such as a lack of access to high quality care, employment and educational opportunities, and affordable housing, are associated with an elevated risk of HIV. Those living with HIV also face increased barriers to accessing care services.
As such, members of these communities often have concerns beyond HIV prevention and care because they struggle to have their basic needs met. For example, those who are experiencing homelessness are likely to be more concerned with where they’re sleeping and where their next meal is coming from than with their risk of HIV. For people who are transgender, the fear of discrimination and violence may be their primary concern. Once affected communities have their more pressing needs met, we are more likely to see dramatic changes in HIV transmission and viral suppression rates.
Improved benchmarks for success
Understandably, resource allocation has often been heavily influenced by incidence and prevalence levels, with the most funding going to the communities with the most cases. By also including a SDOH lens in the allocation formulas, federal agencies may be able to better anticipate where the need will be greatest.
A SDOH approach will also lead to improved benchmarks that better reflect the health of these communities. Instead of only looking at transmission rates, new benchmarks could include questions such as: How many people did a program help find stable housing? How many people were connected to behavioral health services? How many people received transportation support to attend appointments?
Increasingly, we’re seeing examples of effective holistic approaches. In Denver, an HIV clinic integrated housing support into its HIV prevention and care services as a way to ensure its patients were taking their medications. And in Alabama, the Birmingham AIDS Outreach organization provides comprehensive services for anti-discrimination support as well as testing, care, and harm reduction. Local and state governments should follow these best practices to adopt a more community-driven approach and work closely with relevant departments and agencies, such as housing and transportation, to collaborate on efforts.
Championing community
Public health leaders and federal programs should work to integrate affected communities in all facets of HIV prevention and care programs and initiatives, from creation to implementation and evaluation. Incorporating their perspective into the decision-making process provides invaluable insights into the intricacies and dynamics of a particular community, helping to ensure programs are tailored to their specific needs.
Federal, state and local health agencies can work collaboratively with people in the most affected communities to help identify which organizations are likely to be the most effective at reaching those at greatest risk. Such organizations may be too small to have been eligible for federal funding in the past, and/or may not even have had a history of HIV-related activities. But their deep roots and trust within the affected communities may make them the most effective agents for prevention and care services.
In addition, public health leaders should ensure there is representation from affected populations in decision-making roles whenever possible. This will enable the lived experiences of those impacted by HIV to shape programs and policy decisions, bringing a perspective that may not be immediately obvious to others without that background. Community members will also be more likely to engage in efforts and trust new programs if they see themselves reflected in the decision makers.
Achieving the goal of eradication
Tackling the HIV epidemic is a massive and complex undertaking. The vision of eradicating HIV in the EHE federal strategy is ambitious, but achievable. But it can’t be done without targeted resources and a holistic approach. This approach must address both the immediate threat of infection or treatment and the social and economic factors that contribute to an elevated risk of contracting HIV or that inhibit people from receiving treatment. The north star of a 90 percent reduction of new infections by 2030 is within sight if we seize the moment and double down on efforts in pursuit of this goal.
Kate Musgrove is director of Public Health at ICF, where John Auerbach is senior vice president of Federal Health.
