Comments on draft HIV national strategic plan for the United States: A roadmap for elimination 2021-2025
Acting Director, Office of Infectious Disease and HIV/AIDS Policy (OIDP)
Office of the Assistant Secretary for Health (OASH)
U.S. Department of Health and Human Services
200 Independence Avenue, S.W.
Washington, D.C. 20201
Dear Ms. Hayes,
Thank you for the opportunity to provide comments on the draft HIV National Strategic Plan for the United States: A Roadmap for Elimination 2021-2025 (HIV Plan). The HIV+Hepatitis Policy Institute is a leading HIV and hepatitis policy organization promoting quality and affordable healthcare for people living with or at risk of HIV, hepatitis, and other serious and chronic health conditions. HIV+Hep congratulates the U.S Department of Health and Human Services (HHS) for updating the HIV Plan with bold and ambitious targets that will put the entire nation on the path to eliminating HIV. Now we, as a country, must turn to implementing the strategy once it is finalized.
HIV+Hep is appreciative of the significant process HHS undertook to receive community input into the update of the HIV Plan. It is clear that the messages from the community meetings and listening sessions were heard and have been infused into this update. The HIV Plan, updated through 2025, builds upon the previous two iterations released in 2010 and 2015, and accurately reflects and incorporates new initiatives, technologies, and best practices from federal agencies and HIV-focused programs providing services. The indicators have been updated and aligned with the Ending the HIV Epidemic: A Plan for America (EHE) initiative. This allows the wide-range of federal implementing departments, agencies, and bureaus to follow a roadmap to eliminate HIV across the U.S., not just in the 57 jurisdictions that are the focus of EHE.
In response to OIDP’s questions in the Federal Register, we agree that the draft plan’s goals, objectives, and strategies appropriately address the HIV epidemic. You have done an excellent job of laying out a strategy to end HIV in the United States and have included all the key elements needed to achieve it, along with bold targets that must be met. The positive elements of the draft are too numerous to detail. We wholeheartedly support the vision; the priority populations; key focus areas; and each of the four primary goals and their related objectives, strategies, and indicators of progress. As discussed below, financial resources, continued leadership, and a focus on the nation’s overall healthcare system will be critical to ensure that the bold goals are achieved in the five- and ten-year periods outlined in the HIV Plan.
Please find below specifics comments on the plan, along with suggestions on ways we believe it can be strengthened.
Executive Summary and Introduction
HIV+Hep is pleased there is a similar focus on priority populations as past iterations, as we believe this is where the data continues to tell us where we most focus. We appreciate the importance of focusing on sexual and gender minority populations, specific racial and ethnic groups, and the continued focus on youth aged 13-24. Additionally, we commend you for including people who inject drugs as our nation continues to see a growing number of new HIV infections related to drug use in many communities. HIV+Hep applauds the specific attention to people aging with HIV and their unique needs throughout the document. We also commend HHS for including a disparity indicator looking at viral suppression rates stratified by priority population. This will provide the community, implementers, and policymakers with key data to ensure resources and new initiatives and programs are most appropriately focused and aligned and disparities are closed.
The HIV Plan’s focus on syndemics, including viral hepatitis, sexually transmitted infections (STIs), substance use, and mental health disorders, will also be critical as programs continue to develop whole-health approaches that will be critical to achieving the goals of the Plan.
In the Progress to Date section of the HIV Plan (page 11), we believe that the transformational role of the Affordable Care Act (ACA) including expanded coverage and affordability options, preventative services, and Medicaid expansion should be highlighted. Studies have shown that people who have access to health insurance and Medicaid have better outcomes related to HIV and the other syndemics mentioned in the Plan. It is critical to continue to highlight the need to expand Medicaid in those states which have not yet done so. Robust insurance options and expanded Medicaid are critical to creating a health system that is less fragmented and provides comprehensive HIV prevention, care, and treatment services.
Goal 1: Prevent New HIV Infections
HIV+Hep believes the section on HIV prevention provides a comprehensive view of the biomedical tools, such as pre-exposure prophylaxis (PrEP), post-exposure prophylaxis (PEP), condom use, syringe service programs, and other prevention tools such as primary prevention needed to prevent new HIV infections. Communities need education about the variety of tools and how to access to them to prevent HIV infections so that they can make informed choices about what works best for them.
We commend the plan for including on page 28 the importance of school-based health education, noting that “[s]uitable primary prevention approaches focused on youth should be age-appropriate, linguistically and culturally informed, community-centered, inclusive, stigma-reducing, and grounded in science and medicine.” In addition, HIV+Hep believes that school-based health approaches must include LGBTQ-affirming messages and suggest that it be included in the final plan.
HIV+Hep also appreciates the inclusion of research and development into new prevention tools such as long-acting injectables and new formulations of existing drugs as future tools to provide even more options for people to prevent HIV infection.
Syringe service programs (SSPs) are a critical place to prevent HIV transmission and to co-locate services such as screening, vaccination, and testing for hepatitis and HIV. Unfortunately, SSPs are still not legal in every state despite overwhelming evidence of their benefits to individuals and communities. HHS notes that “[n]early 30 years of research shows that comprehensive SSPs are safe, effective, and cost-saving; do not increase illegal drug use or crime; and play an important role in reducing the transmission of viral hepatitis, HIV, and other infections.”1 The strategy should include action steps to reduce barriers to SSPs.
Goal 2: Improve HIV-Related Health Outcomes of People with HIV
HIV+Hep believes this goal has excellent objectives and strategies but does not recognize the fractured healthcare system in the U.S., and its effects on health outcomes for people with HIV. Nor does it provide adequate attention to the programs that serve the great number of people with HIV including the Ryan White HIV/AIDS Program, Medicaid, Medicare, and private insurance. We believe the “Challenges” section on page 36 should include a mention of the fragmented healthcare system and payers which make navigating and affording the complex system of care and treatment difficult for people with HIV. This can often lead to people dropping out of care or suboptimal health outcomes.
HIV+Hep suggests additional emphasis placed on the critical and successful role of the Ryan White Program in providing care, developing best practices, and engaging with the community in this section. We suggest a text box that discusses the key role of the program and their remarkable achievements over the years. Additionally, this section does not adequately discuss the role of the federally qualified health centers, Medicaid, and Medicare in providing HIV care and treatment services. Expounding on the role of these programs will be helpful as agencies move towards creating implementation plans and taking action to support people with HIV.
HIV+Hep also believes it is critical to acknowledge the disparate levels of public health and healthcare infrastructure across the nation. The Ryan White funding allocations have not changed in many years, despite Medicaid expansion and continued regional and racial disparities in new HIV diagnoses and HIV outcomes such as viral suppression. To end the HIV epidemic across the nation, the federal government must work closely with states and localities to increase health infrastructure and capacity, including addressing public health capabilities and healthcare workforce shortages.
Goal 3: Reduce HIV-Related Disparities and Health Inequities
HIV+Hep appreciates the inclusion of the importance of addressing social determinants of health and stigma throughout the document. As stated earlier, HIV+Hep supports the continued focus on health disparities and health inequities in the HIV Plan. This includes mentions of how lower levels of health insurance, lack of trust in healthcare providers, and lack of continuous health insurance coverage (page 44 and objective 3.4) impact new HIV diagnoses and health outcomes. However, even with insurance we must ensure that people are able to access medications via policies that ensure affordability. It will be important in the agency implementation plans that address these matters.
Goal 4: Achieve Integrated, Coordinated Efforts that Address the HIV Epidemic among All Partners and Stakeholders
HIV+Hep applauds the inclusion of Objective 4.1: “Integrate programs to address the syndemics of viral hepatitis, HIV, STIs, and substance use disorders.” Public health programs have made strides in the past several years to integrate funding, services, and capacity; but more can be done to ensure co-located prevention and care services across HIV, hepatitis, STI, substance use, and behavioral health services. This is particularly important for hepatitis C as we continue to see lagging cure rates for hepatitis for people who also have HIV. Everyone with HIV should be tested, vaccinated, and treated, if appropriate, for hepatitis. We look forward to the specifics on integration of the syndemics in the implementation plan.
Implementation and Accountability
HIV+Hep eagerly anticipates the implementation process and the agency implementation plans. We believe that in order to reach the goals in the HIV Plan, resources need to be invested throughout our health system, including dedicated funding for the Office of Infectious Diseases and HIV/AIDS Policy to coordinate the government’s response, develop and disseminate best practices, and bring together stakeholders to further the conversations and solutions in addressing HIV.
Again, the HIV+Hepatitis Policy Institute applauds and is grateful for all the hard work across the federal government on this draft plan. We know that federal agencies are already hard at work addressing HIV. We look forward to the finalization and implementation of the HIV Plan.
Should you have any questions or comments, please feel free to contact me at firstname.lastname@example.org or (202) 462-3042. Thank you.
Carl E. Schmid II