Amy Killelea, Natalie O. Cramer, and Michael Weir Comment

Earlier in 2019, the Trump administration announced a goal to end the HIV epidemic in the United States by 2030 (“Ending the HIV Epidemic: A Plan for America” [EHE]; https://bit.ly/2DW9Deb). The initiative has the potential to mobilize resources, political will, and community engagement to dramatically scale up HIV prevention and treatment options. Initial funding detailed in the president’s budget and congressional appropriations bills allocated new resources to the Centers for Disease Control and Prevention HIV programs, the Ryan White HIV/AIDS Program, and the Community Health Centers Program. The success of the initiative hinges on the ability to harness additional resources and political momentum to support new approaches to our work. The ambitious goals outlined in the initiative call for innovation, coordination, and meaningful partnerships across a range of traditional and nontraditional stakeholders.

The initiative builds on important work already happening in jurisdictions across the United States. Over the past several years, community stakeholders and health departments in multiple jurisdictions have announced jurisdictional plans to end new HIV infections. These plans are frequently developed by a coalition led by community stakeholders with health department support. Consistent elements of plans include HIV testing; access to preexposure prophylaxis; access to, uptake of, and adherence to antiretroviral therapies; and retention in care. In total, more than 40 jurisdictions have developed plans.¹

These existing plans provide a foundation for the federal EHE initiative and replicable strategies for community engagement and a broad stakeholder approach to planning. Addressing the complex dynamics of state, county, and city funding streams, programs, and activities will be particularly important to the success of the federal initiative. The federal initiative also provides an opportunity to critically examine community engagement at the state and local levels. We must be bold and ambitious to ensure that new communities and stakeholders are at the table.

The new funding for HIV programs and infrastructure is critical to the initiative’s success. However, ending the HIV epidemic will require engaging every aspect of the US health care system, including Medicare, Medicaid, and private insurance. Federal policies that limit access to Medicaid or that weaken private insurance protections are directly at odds with goals to end new HIV infections. At the state level, expanding Medicaid under the Affordable Care Act is the single most impactful intervention for ending new HIV infections, because access to medical and biomedical interventions is an essential element of all EHE plans; however, 14 states have opted not to expand their Medicaid programs. Similarly, policies and positions that contribute to stigma and discrimination against lesbian, gay, bisexual, and transgender people; immigrants; and populations disproportionally affected by HIV are counter to ending the HIV epidemic.

The success of EHE also rests on the ability to firmly elevate and enable strong stigma-free, whole-health policies, particularly ones that meaningfully include sexually transmitted diseases, hepatitis, and drug user health. Integrated approaches to HIV will require innovative partnerships with community-based organizations, syringe services programs, and harm reduction programs most able to address social determinants of health, including housing, employment, and transportation. Similarly, expanding preexposure prophylaxis and linkage to care activities will require engaging sexually transmitted disease clinics in new ways.

Although the first part of the initiative will focus on the jurisdictions identified as having the greatest need, we urge federal partners to ensure that the initiative is used to harness momentum and resources to end new HIV infections nationwide. It will be important to meaningfully engage jurisdictions with low and moderate HIV prevalence at all stages of the initiative and to ensure that innovation is encouraged and supported through existing funding mechanisms. Moreover, states have a key role in ensuring the success of the initiative both statewide and working with partners at the local levels, being well positioned to assess, coordinate, and leverage resources to maximize access to quality care and prevention services. Finally, this initiative should be a long-term investment in HIV programs and infrastructure beyond 2030. If the progress envisioned under this initiative is to be sustainable, then there must be a long-term commitment from the federal government to support innovative and increased programs.

Ending the HIV epidemic is a major public health challenge. The significant strides made by jurisdictional ending the epidemic initiatives show that it is finally within reach.