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Shaping the Next Administration's Response to HIV in the U.S.

Reasonable people may disagree on the details of how best to address the U.S. epidemic through 2025, but we hope that everyone will agree it is time to truly "end AIDS" in the U.S., and that the next administration has an absolutely critical role to play in writing that history.
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Cork, Ireland
Cork, Ireland

Co-authored by Robert Bonacci, Perelman School of Medicine, University of Pennsylvania Jordan Medical Education Center, Philadelphia PA

What do we want the next administration to do to reduce the burden of the HIV epidemic in the United States? Thus far, two of the presidential candidates have published HIV policy statements online, and have agreed to meet with HIV advocates and stakeholders in the days ahead. That is an encouraging start, but we hope all of the candidates will share their views on HIV, and we think it is time for all candidates to get a bit more detailed on what goals need to be met in the years ahead. Here we share our partial wish list for the next administration (and we hope that others working to address HIV in the U.S. will add to or refine this list in commentary).

Looking toward the year 2020, we believe that first and foremost, the next administration should adopt and carry forward the current, updated National HIV/AIDS Strategy (NHAS). The NHAS covers the time period from 2015 through 2020 and sets out critically important goals around access to HIV care, reductions in deaths among persons living with HIV, and alleviation of health disparities (among other goals). However, it does not include targets for HIV incidence (i.e., the number of new infections), nor an estimate of the resources needed to achieve the goals of the strategy. Therefore, we would argue that the NHAS 2020 goals should be augmented by a goal to reduce HIV incidence in the U.S. to no more than 23,000 new infections per year, and that no community share a disproportionate burden of these new infections (as is the case now for gay men, transgender people, young people, African-American and Hispanic communities, and those living in the Southern U.S.). Based on what we know about the differential rates of HIV transmission for persons living with HIV across the care continuum, we assert that this goal of 23,000 new infections per year by 2020 is achievable if all of the other service delivery goals of the NHAS are met. Further, we call on the next administration in its first year to invite multiple independent estimates of the costs necessary to achieve these NHAS goals (and the proposed additional incidence goal), and to then work closely with Congress to appropriate the necessary resources to deliver expanded HIV services. We have previously published estimates of the resources needed to meet the goals of the first NHAS (from 2010 through 2015). While some progress has been made in recent years to make additional HIV care services available, funding for HIV prevention services and housing has unfortunately stagnated. If we are to meet these important HIV impact goals, the requisite investments will have to be made.

Though looking ahead to 2020 is important, we believe that the next Administration should take the long view and also propose goals through 2025. Of course, this would entail publishing an additional update of the NHAS in 2020. While it is impractical at this point to outline a vision for the entire NHAS through 2025, we assert that a few key factors should be included. We believe that it will be important to set our sights on achieving a "95/95/95" set of goals for 2025 in the U.S. (i.e., 95% of all persons living with HIV will know their HIV status; 95% of all persons diagnosed with HIV will receive sustained, high quality care; and 95% of all persons on antiretroviral therapy will achieve viral suppression). Our analyses suggest that if a 95/95/95 set of goals could be achieved, along with all necessary, concomitant HIV diagnostic, prevention, housing and related support services, then an appropriate HIV incidence goal would be no more than 12,000 new HIV infections per year by 2025. Again, the level and type of necessary resources would have to be carefully estimated and made available, but assuming that were the case, it would appear such a goal is epidemiologically achievable. We also emphasize again that all goals should be achieved in such a way that persistent health disparities across communities are truly eliminated. We must not only meet the central epidemiological goals, but also do so in a way that addresses fundamental issues of social justice. Further, to ensure we are meeting these goals, we need a real-time epidemiologic and service delivery "dashboard" to inform ongoing mid-course corrections in programs. Relatedly, we need expanded implementation research to ensure that evidence-based services are reaching the intended communities, meeting the needs of these communities, and having the desired impact on the epidemic in all communities. We need to understand how to make the maximum public health impact with available resources.

Perhaps the most vital set of "asks" for a new administration would be for public recognition that HIV continues to be a critical issue in the U.S.; that it very disproportionately impacts certain communities; that everyone in our country has a role to play regarding promotion of HIV-related knowledge, reduction of HIV-related stigma, and support of necessary service delivery; that while we have critical tools for addressing the epidemic, for far too many people these tools now sit on the shelf; and that while "ending AIDS" is a nice phrase, to achieve any semblance of that goal by 2025 will require a sustained and intensified national commitment. Reasonable people may disagree on the details of how best to address the U.S. epidemic through 2025, but we hope that everyone will agree it is time to truly "end AIDS" in the U.S., and that the next administration has an absolutely critical role to play in writing that history.