Ending the Epidemic: The Biggest Test of Our Movement

February 15, 2019

The administration’s plan to end the domestic HIV epidemic will also be the biggest test of our movement’s leadership. Can we work with this administration? I have real concerns but waiting means 40,000 more cases per year with the majority being people of color.
The administration’s plan to end the HIV epidemic in America is a biomedical solution. It will prioritize U=U and PrEP. The federal plan was developed by:

  1. Dr. Brett Giroir (Assistant Secretary for Health)
  2. Dr. Tony Fauci (NIH)
  3. Dr. Robert Redfield (CDC)
  4. Dr. George Sigounas (HRSA)
  5. Rear Admiral Weakhee (Indian Health Service)

Community is core to the solution because the plan needs to reach people living with HIV (PLWH) who have fallen out of care and people who need PrEP from communities highly impacted by HIV. Politico says the President will request $250 million in his 2020 budget. We were told this is new money and not shifting resources. There would be a new line item in the budget called Ending the HIV Epidemic. Existing HIV appropriations for CDC, HRSA, and the MAI will stay at 2019 levels. Now we need to make sure Congress approves or increases this request.
The new funding will go primarily to 48 counties, plus Washington, DC, San Juan, Puerto Rico, and seven states (Alabama, Arkansas, Kentucky, Mississippi, Missouri, Oklahoma, and South Carolina). The states were selected because of the rural Southern epidemic and Oklahoma will be part of the response in Indian country. These regions drive over 50 percent of the new HIV cases. Here is a list. The goal is to reduce new HIV diagnoses by 75 percent by 2025. Based on the success or failure of these initial sites during the first five years, the program will roll out more broadly so that all HIV transmissions are reduced by 90 percent by 2030.

Community planning groups will be set-up in these jurisdictions to determine local priorities. The details of this process will hopefully be shared at this year’s National HIV Prevention Conference (NHPC). The federal government realizes that one size does not fit all, so local communities will be empowered to determine priorities. NMAC will work with these state and country health departments to make sure that all the communities highly impacted by HIV are at the table. These planning groups must have real leadership from the transgender community, young gay men of color, black women, and people over 50 who are living with HIV.
The plan has an overarching goal of 1.2 million people on PrEP. It will pay for drug in those counties that do not have expanded Medicaid. NMAC wants to work with our federal partners to ensure that the people enrolled through this initiative are reflective of the demographics of the epidemic. Currently, 70 percent of the people on PrEP are white, yet the majority of new cases are people of color and the majority of PLWH are people of color.
In the first year most of the money will go to CDC, HRSA and IHS. Specific implementation plans are still a work in progress and community is encouraged to share their perspectives during the Feb. 22 feedback session. HRSA will expand the work at their health centers in the 48 counties to enroll clients who could benefit from being on PrEP. As noted above, we want to work with them to support efforts to reach those communities that have not received the promise of PrEP. We also hope health centers will have programs that link PLWH back into care and onto medications. Individuals who have fallen out of care need to be reconnected because HIV needs to be medically monitored so that people live.
NIH/NIAID will work via their Centers for AIDS Research (CFARs) to review and document the implementation science needed to access hard to reach communities. Their model will be based on existing work in Washington DC.  Implementation science for PrEP and U=U is key to ending the epidemic. NMAC hopes to work with the CFARs to help them reach communities that have truly been difficult to reach, particularly young gay men of color and the transgender community.
Indian Health Service
Indian Health Service will focus on tribal communities, particularly in Oklahoma. It was good to see IHS at the table and the plan’s commitment to American Indians and Alaska Natives. The IHS’s implementation plan needs to include real community leaders with a special outreach to the two-spirit community.
According to Dr. Giroir, this is Secretary Azar’s number one priority for 2019. They were very excited about the possibilities and view this as an historic initiative, similar to President Bush’s Global PEPFAR work. Obviously, the devil is in the details. They have set these overarching principles, but the implementation is still to be determined. Community needs to work closely with HHS, CDC, NIH, HRSA, and IHS.

There are lots of concerns because of President Trump’s tweets and statement about many of the communities that are highly impacted by HIV. NMAC completely understands and supports the groups who protest; however, for organizations committed to ending the HIV epidemic, what is our alternative? Forty thousand new cases every year. This is our best chance for parity in HIV outcomes. Two hundred and fifty million dollars will be one of the largest increases in domestic HIV funding (with the new Congress it could get an even bigger increase).
As you consider your alternatives, NMAC recommends the following:

  • Focus on biomedical HIV prevention (U=U & PrEP)
  • Participate in the local planning process (TBD)
  • Align your service model with the plan
  • Document your ability to reach “hard to reach” communities

We strongly encourage any group that wants to be part of this process to attend the National HIV Prevention Conference March 18-21 in Atlanta. It will be the next big opportunity to learn about the federal plan. There are many details still to be worked out.  This year’s United States Conference on AIDS will focus on the federal plan, U=U, PrEP, and how to reach communities that have so far eluded HIV prevention efforts. NMAC understands and is committed to training the HIV workforce on this next phase of our work.
In many ways the federal plan is exactly what NMAC has been promoting. It’s based on biomedical HIV prevention, targeting efforts in the 48 counties that are driving the majority of new HIV diagnoses with significant new money and a commitment to community. However, we have to do it with this administration. This will be the biggest test of our movement’s leadership.
Yours in the struggle,

Paul Kawata
30 Years of Service
Photo is with my friend Reggie Williams, the founder of the HIV programs for Black and White Men Together that would later be renamed the National Task Force on AIDS Prevention.

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