To end AIDS in the United States, stay true to the National HIV/AIDS strategy

Ten years ago, hundreds of organizations and individuals signed a petition calling on all presidential candidates to create a national AIDS strategy. We knew the approach to HIV in the U.S. had to change. If you read about AIDS in the paper, then it was likely about the horrifying scale of the global epidemic; the epidemic at home had largely become invisible. The national HIV response we saw was a patchwork: uncoordinated, without clear goals, underinvested where the challenge was most acute, with interventions delivered well below the scale necessary for impact. And the science of HIV prevention was changing dramatically without sufficient efforts to put it into practice.

By the end of 2007, most presidential candidates, including John McCain, Hillary Clinton and Barack Obama, had accepted the challenge to create a strategy. In June 2010, President Obama issued the first comprehensive National HIV/AIDS Strategy for the United States.

Five Things We Learned From Implementation of the National HIV/AIDS Strategy

1) A commitment to being strategic provides political cover to do tough things.

The Strategy itself was full of smart analysis of the epidemic and laudable goals, but its real impact came in how it was used. With strong leadership by Jeff Crowley, head of the White House Office of National AIDS Policy (ONAP), and his deputy Greg Millett, a series of epidemiologically necessary but politically challenging policy innovations were undertaken, each justified by the new Strategy.

This included:

• Increased investment in HIV prevention for gay men, which had been seriously under-financed relative to that population's share of the epidemic.

• A new, "high impact" approach to HIV prevention emphasizing evidence-based programming at scale.

• Reallocation of funds to areas of the country most affected by HIV.

• Streamlining of data reporting to track progress more effectively.

A new emphasis was placed on federal agency coordination that has shown some success and remains a work in progress, as well on the most affected communities, which are now at the leading edge of progress in the U.S. response.

2) Changing the conversation is important, and it's just the first step.

The Strategy helped put the domestic epidemic back on the radar and galvanized the AIDS services community around a new approach to tackling the epidemic focused on epidemiologic impact. Beyond assuring the availability of services, the focus shifted to outcomes, and people asked how a policy would lead to accomplishing the Strategy's prevention and treatment targets. Conversely, observing that an approach would fail to advance the Strategy's goals was now a tool to fight bad policy. Using the "care continuum" as a framework for assessing service delivery helped bring focus to the Strategy goal of greater equity.

All of these were advances, but they only took us so far. The Affordable Care Act (ACA) -- which led to a marked increase in Medicaid coverage among people living with HIV -- as well as increased investments in appropriate services expanded access to lifesaving and infection-preventing measures.

3) It matters that the effort grew from the community.