The Evolution of the Secretary’s Minority AIDS Initiative Fund: The US Department of Health and Human Services Responds to the National HIV/AIDS Strategy

The federal Minority AIDS Initiative came into being in 1998 in response to concerns raised by community advocates about the disproportionate impact of HIV/AIDS on America’s racial/ethnic minority populations.¹ Since that time, Congress has appropriated Minority AIDS Initiative funds annually to the Centers for Disease Control and Prevention (CDC), the Health Resources and Services Administration, the Substance Abuse and Mental Health Services Administration, and the Office of the Secretary of the US Department of Health and Human Services (HHS). The latter appropriation, known as the Secretary’s Minority AIDS Initiative Fund (SMAIF), is managed by the Office of HIV/AIDS and Infectious Disease Policy on behalf of the Office of the Assistant Secretary for Health and the Office of the Secretary.² SMAIF resources are used to support HHS offices and agencies in the development of innovative projects to reduce HIV-related disparities among racial/ethnic minority populations.

When the National HIV/AIDS Strategy was released in July 2010, the accompanying Federal Implementation Plan called upon HHS to work across the department with relevant agencies “to consider ways to enhance the effectiveness of prevention and care services provided for high-risk communities, including services provided through the Minority AIDS Initiative.”³ In part, this directive arose in response to feedback received at community listening sessions that were held to inform the development of the National HIV/AIDS Strategy; advocates attending these sessions called for “a more focused response” to HIV prevention and care programs targeting African American, Hispanic, and other vulnerable communities of color.⁴

The 2010 publication of the first comprehensive national plan to address HIV/AIDS in the United States was an important milestone in America’s response to its domestic epidemic and served as a stimulus to embracing new—and more targeted—approaches to HIV prevention and care in federal, state, tribal, and local programs.⁵ After the National HIV/AIDS Strategy was released, successive changes in the process by which SMAIF projects were solicited, evaluated, and prioritized reflected many bedrock principles inherent in the National HIV/AIDS Strategy—especially the call for a stronger focus on outcomes, enhanced coordination across federal agencies, and increased transparency of effort.³

When fiscal year 2011 SMAIF projects were solicited within HHS, applicants were required to submit proposals aligned with specific National HIV/AIDS Strategy priorities, and preference was given to submissions that involved cross-agency collaboration.⁶ Applicants were also informed that they would be required to use standard HIV testing metrics, consistent with those used by CDC, when reporting on annual outcomes. These changes, which reflected the direction set by the National HIV/AIDS Strategy, were also a response to the findings of a federally funded evaluation of SMAIF, which was completed in spring 2010. That evaluation recommended that HHS undertake the following actions to improve SMAIF project outcomes: tighten project scope and focus, improve cross-agency collaboration, and adopt uniform reporting requirements.⁷

More substantial changes were made the following year when, for the first time, a detailed internal funding opportunity announcement was developed to solicit fiscal year 2012 SMAIF projects in 4 program areas: (1) preventing HIV, (2) improving HIV health outcomes, (3) mobilizing communities to reduce HIV health disparities, and (4) developing capacity in support of National HIV/AIDS Strategy goals.⁸ Each subsequent year has resulted in further refinements to the internal funding opportunity announcement, which strives to solicit and fund innovative activities across HHS that will bolster current priorities. For example, in fiscal year 2013, emphasis was placed on efforts to “reduce drop-offs along the HIV treatment cascade,” thereby improving health outcomes for racial/ethnic minority groups living with HIV.⁹ This modification was made in response to an Executive Order released that same year that called on federal agencies to prioritize efforts to address gaps in the continuum of HIV care by, among other actions, encouraging novel approaches to improving access to HIV testing and care.¹⁰

Another noteworthy enhancement to the strategic management of SMAIF began in 2011, when $15.5 million in funds was carved out of the total allotment of $53.9 million to support a cross-agency collaboration involving CDC, the Health Resources and Services Administration, and the Substance Abuse and Mental Health Services Administration.¹¹ CDC used SMAIF resources to support a systematic review and reprioritization of “HIV-related activities across all funding sources” in 12 metropolitan areas with a high prevalence of AIDS.¹² In addition to providing data for CDC’s comprehensive review of federally funded HIV-related activities in these 12 metropolitan areas, the Health Resources and Services Administration used SMAIF resources to work collaboratively with CDC to implement prevention case-management services in 3 of the 12 metropolitan areas (New York City, Miami, and San Juan).¹² The Substance Abuse and Mental Health Services Administration also used SMAIF resources to support a funding opportunity announcement designed to support the integration of behavioral health into HIV primary care and, conversely, support the integration of HIV testing and prevention services into behavioral health services.^13,14 This joint effort, called the 12 Cities Project, was the first cross-agency collaboration funded by SMAIF; each successive project improved on the preceding project in goals, population focus, and projected outcomes.

This supplemental issue of Public Health Reports is devoted to the Care and Prevention in the United States (CAPUS) Demonstration Project (hereinafter, CAPUS), a SMAIF-funded, multiyear demonstration project that began in fiscal year 2012.¹⁵ CAPUS was informed by lessons learned during the 12 Cities Project and was conceptualized as a direct response to disturbing reports of the disproportionate burden of HIV disease and worse survival outcomes, especially among black people, in the southern United States.^16,17 The goals of CAPUS were to (1) increase the proportion of racial/ethnic minority groups living with HIV who are diagnosed in a timely manner and linked to consistent care and (2) intensify efforts to retain and reengage infected people in HIV care. A major innovation in CAPUS was the requirement that grantees focus on key social and structural factors (eg, stigma, unstable housing, joblessness) that fuel suboptimal HIV health outcomes. By design, only those 18 jurisdictions with the following characteristics were eligible to apply for CAPUS funding: a high burden of HIV disease (ie, >5000 cumulative HIV cases) among African American and Latino populations, a disproportionate AIDS diagnosis rate in these populations (>6 AIDS diagnoses per 100 000 population in 2010), and evidence that social and structural drivers were having a negative effect on overall health outcomes in the jurisdiction (as indicated by a rate of >25 teen births per 1000 population). Six of the 8 final CAPUS grantees were in the southern United States.¹⁵

As shown in this supplemental issue of Public Health Reports, CAPUS comprised a wide array of activities ranging from using HIV/AIDS surveillance data to identify people who had fallen out of HIV care, to developing culturally competent navigation services to assist clients in moving through the systems of HIV care. Despite their seeming heterogeneity, all efforts supported by CAPUS had the same raison d’être: the fundamental recognition that health outcomes are mediated by the conditions within the communities in which people live and work and by the circumstances of their daily lives. The influence of these conditions extends beyond the clinic and physician’s office and demands that we take a broad view of health—especially if we want to end HIV/AIDS disparities related to race/ethnicity, gender, sexual orientation, age, and socioeconomic circumstance. Embracing a view of health that reaches beyond the mere absence of disease does not mean that public health practitioners must solve all the world’s social ills to attain an AIDS-free generation. But it does require that we intervene in those instances when social, situational, or structural circumstances are increasing a person’s risk for acquiring HIV or interfering with one’s ability to receive life-saving care. And, as the articles in this supplement illustrate, such efforts require stronger cross-agency collaborations at the federal and state level and the development of innovative partnerships at the community level.

In the future, SMAIF will continue to evolve based on America’s changing HIV epidemic and congressional funding priorities. Hopefully, demonstration projects that support the functional integration of systems providing medical, behavioral, public health, social, and other human services will be a key factor in our nation’s drive to achieve an AIDS-free generation. Efforts such as CAPUS, which embrace a holistic view of health by endeavoring to mediate the social determinants influencing HIV outcomes, are important laboratories for innovation. Ensuring access to HIV testing services, preexposure prophylaxis, culturally competent HIV clinical care, and behavioral health services that are welcoming to vulnerable populations (eg, young people and those in sexual minority groups) are important priorities.¹⁸ But accumulating evidence confirms that we must develop interventions to confront the social drivers fueling America’s HIV/AIDS epidemic in order to meet the goals of the National HIV/AIDS Strategy.³ Of necessity, our efforts must be enlightened by many disciplines of thought and practice, involve diverse agencies and organizations providing various human and clinical services, and always be informed by the needs and preferences of the communities for whom these efforts are intended. This undertaking is not easy, to be sure, and it will require policies and structures that incentivize coordination and integration of services across all sectors of society. However, innovation comes from need as well as trial, and SMAIF demonstration projects such as CAPUS move us closer to understanding how to create and sustain comprehensive, integrated systems of HIV prevention and care in the United States.