Health Disparities, Hurdles and Hope: Ending the HIV Epidemic in the U.S.

Sheryl Zwerski, MSN, CRNPActing Director, Prevention Sciences Program, NIAID, NIH

July 22, 2012

AIDS in America: Forgotten, But Not Gone

Alabama

Arizona Arkansas

California

Colorado

Florida

Georgia

Idaho

Illinois Indiana

Iowa

KansasKentucky

Louisiana

Maine

MassachusettsMichigan

Minnesota

Mississippi

Missouri

Montana

NebraskaNevada

New Hampshire

New Mexico

New York

North Carolina

North Dakota

Ohio

Oklahoma

Oregon

Pennsylvania

South Carolina

South Dakota

Tennessee

Texas

Utah

Vermont

Virginia

Washington

West Virginia

Wisconsin

Wyoming

Connecticut

Delaware

Maryland

New Jersey

Rhode Island

Alaska

Hawaii

25,001-199,402

4001-8000

2001-4000

1001-2000

273-1000

8001-25,000

No. of AIDS Cases

El-Sadr, W. et al. N Engl J Med 2010

EfficacyEffectiveness: The Path to Combination Prevention

Basic science

Proof of concept

Efficacy Study

Proof of Activity

Scale-up to populations

Implementation

How do we move from single products to integrated combination prevention programs?

“Real-life” implementation

Testing combinations

Reducing HIV incidence

Increasing access to care and optimizing health outcomes

Reducing HIV-related health disparities

NIH Research Support

NIH is committed to fostering the research that address the goals of the President’s National HIV/AIDS Strategy

Clear disparity between populations in level of risk for HIV infection

NIH is committed to supporting studies that define details within the US epidemic and test interventions to decrease HIV incidence in the populations at highest risk

Vaccine

Harm Reduction

STI Treatment

PrEP

PMTCT

Condoms

Combination HIV

PreventionMicrobicides

Male Circumcision

Drug/Alcohol Treatment

Treatment as Prevention

Testing/ Counseling

The National HIV/AIDS Strategy

Grant Colfax, MDOffice of National AIDS Policy

The White House

HIV Prevention Trials NetworkSatellite Conference

Health Disparities, Hurdles and Hope: Ending the HIV Epidemic in the U.S.(7/22/12)

The National HIV/AIDS StrategyOverview

Goals

1. Reduce the number of people who become infected with HIV

2. Increase access to care and optimize health outcomes for people living with HIV

3. Reduce HIV-related health disparities

4. Achieve a more coordinated national response to the HIV epidemic

Facets of the Strategy• Small number of action steps• five-year targets• Emphasis on evidence-based approaches and populations at greatest risk• Multiple Federal agencies charged with Strategy implementation: HHS, HUD, VA, DOJ,

DOL, SSA– HHS lead coordinating agency.

• Roadmap for all public and private stakeholders responding to the domestic epidemic• Focus on improving coordination and efficiency across and within Federal, state, local and

tribal governments• Catalyst for all levels of government and stakeholders to develop their own implementation

plans for achieving their goals

As part of the NHAS, President Obama and his Administration have…

• Supported and increased investment in domestic HIV prevention and care.– Over $22 billion budgeted for HIV efforts– $2.5 billion increase during administration

• Directed resources to populations at greatest risk for HIV infection.– Focus on gay men, communities of color

• Implemented the Affordable Care Act.– Medical coverage extended to tens of thousand of persons living with HIV – Prevention services extended to millions of Americans

• Provided robust Federal funding to ADAP ($933 million, with $1 billion in 2013).– Waitlists have dropped by 80%– Federal share of funding sufficient to end waitlists with States doing their share

• Addressed HIV-related stigma and discrimination.– Lifted the HIV entry ban– Affordable Care Act prohibits denial of coverage based on pre-existing conditions, including

HIV• Supported groundbreaking NIH research in HIV prevention and care.

– Breakthroughs include: treatment as prevention, pre-exposure prophylaxis, vaccines, microbicides, cure research

Ongoing Challenges to Implementing the National HIV/AIDS Strategy

• Fiscal – Ensuring wise investments– Linking investments to health

outcomes

• Coordination among agencies– Metrics– FOAs– Traditional siloed approach

• Coordination across Federal, State, and local levels

– Higher you go, less understanding of issues on the ground

– Inadequate funding or staffing at some levels

• Ability of organizations to adapt to a changing environment

– Capacity– Technical assistance needs– Creating new models of prevention and

care delivery

• Will to allocate funds for interventions that are

– Achievable– Sustainable – Effective

• Educating providers about HIV prevention and care

– Number of HIV care providers decreasing– Reluctance to care for HIV+ patients– Reimbursement