"The NHAS provides new opportunities for private philanthropy to make strategic investments that can impact the epidemic."

Jennifer Kates, Vice President and Director of HIV Policy at the Kaiser Family Foundation

In 2007, following a 2006 report on HIV/AIDS Policy in the United States, The Open Society Institute (OSI) produced Improving Outcomes: Blueprint for a National AIDS Plan for the United States, with a goal to, “Offer policymakers concrete recommendations for a more strategic approach to HIV/AIDS programming and policy.”

This blueprint became the focal point around which many AIDS advocates convened at a planning meeting hosted by Ford Foundation.  This resulted in the formation of the Coalition For a National AIDS Strategy (CNAS), funded in part by Broadway Cares/Equity Fights AIDS and the M·A·C AIDS Fund.  Bristol Myers Squibb hosted regular CNAS meetings, which helped keep advocacy on course.

CNAS and other advocates kept the idea of a national strategy in the forefront of the 2008 presidential campaign, resulting in both major candidates promising a national strategy should they be elected. 

In 2008, under the leadership of President Obama, the coalition was invited to help the White House Office of National AIDS Policy (ONAP) frame the  National HIV/AIDS Strategy, which was unveiled in July 2010. 

Learn More:

Read a more detailed description from AIDS.gov of how the NHAS was developed.

“The Strategy is intended to be a concise plan that will identify a set of priorities and strategic action steps tied to measurable outcomes.”
National HIV/AIDS Strategy

Developed by ONAP, the NHAS has three principal goals, each with measureable targets established for 2015.  (Numbers of HIV infections may change.  View the most recent epidemiological statistics at Henry J. Kaiser Family Foundation.)

REDUCING NEW INFECTIONS

• Lower the annual number of new infections by 25% (from 56,300 to 42,225)
• Reduce the HIV transmission rate by 30%
•  Increase from the percentage of people living with HIV who know their serostatus

INCREASING ACCESS TO CARE AND IMPROVING HEALTH OUTCOMES FOR PEOPLE LIVING WITH HIV

• Increase the proportion of newly diagnosed patients linked to clinical care within three months of their HIV diagnosis from 65% to 85% (from 26,824 to 35,078 people)
• Increase the proportion of Ryan White HIV/AIDS Program clients who are in continuous care (at least 2 visits for routine HIV medical care in 12 months at least 3 months apart) from 73% to 80% (or 237,924 people in continuous care to 260,739 people in continuous care)
• Increase the number of Ryan White clients with permanent housing from 82% to 86% (from 434,000 to 455,800 people). (This serves as a measurable proxy of efforts to expand access to HUD and other housing supports to all needy people living with HIV.)

Reducing HIV-Related Disparities and Health Inequities

• Improve access to prevention and care services for all Americans
• Increase the proportion of HIV diagnosed gay and bisexual men with undetectable viral load by 20%.
• Increase the proportion of HIV diagnosed Blacks with undetectable viral load by 20%
• Increase the proportion of HIV diagnosed Latinos with undetectable viral load by 20%

An unofficial, but no less important, fourth goal is “coordination of efforts” among Federal agencies and others first outlined in a Presidential memo in 2010.  It includes, “The Secretary, or the Secretary’s designee, shall be responsible for convening inter-agency efforts to improve coordination of HIV/AIDS programs and activities.”

Implementation of the NHAS is the responsibility of six lead Federal agencies, each with its own operational plans to help implement the strategy. They include:

• Department of Health and Human Services
• Department of Justice
• Department of Labor
• Department of Housing and Urban Development
• Department of Veterans Affairs
• Social Security Administration

Overall coordination of the NHAS is the responsibility of ONAP and the White

House Office of Management and Budget. The Presidential Advisory Council on HIV/AIDS (PACHA) is responsible for monitoring and evaluating the implementation of the strategy.  Operationalizing the NHAS is the responsibility of The Department of Health and Human Services (HHS).  Dr. Howard Koh, MD, MPH, Assistant Secretary for Health and Dr. Ron Valdiserri, M.D., M.P.H., Deputy Assistant Secretary for Health, Infectious Diseases, lead the HHS National HIV/AIDS Strategy Implementation Group. 

Learn More:

Review a two-page Executive Summary of the strategy’s development, goals, objectives and action steps.

Read an overview of all Federal Agency Operational Plans.

“One of the goals of the National HIV/AIDS Strategy is to refocus existing efforts and deliver better results to the American people within current funding levels, as well as make the case for new investments.”
Jeffrey S. Crowley, Director of the Office of National AIDS Policy

Perhaps the greatest challenge to the success of the NHAS will be the cost of implementing and sustaining the plan.  It is estimated that an investment of $15.175 billion will be required over a five year period for the NHAS to meet its goals.  It is also estimated that the strategy could pay for itself with over $17 billion in healthcare savings over the same five year period if all its prevention goals are met.  There are indeed resources for HIV/AIDS, just not a whole lot of new resources for the specific goal of NHAS implementation.

ONAP cannot solicit funds for its own operations and no new Federal money has yet been allocated to implementing the strategy.  The approach to funding the NHAS is to repurpose existing funds in a more strategic and coordinated way.  The NHAS states “The United States currently provides more than $19 billion in annual funding for domestic HIV prevention, care, and research, and there are constraints on the magnitude of any potential new investments in the Federal budget.”     

The President’s Fiscal Year 2012 budget proposed a special fund to support the implementation of the Strategy by transferring one percent of the HHS domestic HIV/AIDS spending (approximately $60 million) to promote “new, collaborative efforts in support of the goals of the NHAS.”  Learn more about the proposed special fund and a stakeholder-defined list of principles for the repurposing of existing Federal money.

In September 2010, HHS announced “$30 Million in new resources for the NHAS” by reallocating funds from the Affordable Care Act’s Prevention Fund for State and local health departments.

The Social Innovation Fund (SIF), discussed later, awarded AIDS United a $3.6 million grant.  If fully matched, it will bring $10.8 million of new money to support Access to Care, a primary goal of the NHAS.  

“The AIDS community has been offered a golden opportunity: to serve thousands of people with HIV/AIDS and bring us one step closer to ending the AIDS epidemic… it is one we cannot miss.”
Mark Ishaug, President & CEO, AIDS United

The Social Innovation Fund (SIF) is an initiative of the Corporation for National and Community Service (CNCS) and was established in 2009 under the Edward M. Kennedy Serve America Act with the primary goal to improve the lives of people in low-income communities. It does this “by mobilizing public and private resources to grow promising, innovative community-based solutions that have evidence of compelling impact in three areas of priority need: economic opportunity, healthy futures and youth development.” 

According to CNCS, SIF employs an operating and program model that is itself innovative and truly represents a “new way of doing business” for the federal government. This model is distinguished by four key characteristics:

• Reliance on outstanding existing grantmaking “intermediaries” to select high-impact community organizations rather than building new government infrastructure.
• Emphasis on rigorous evaluations of program results not only to improve accountability but also to build a stronger marketplace of organizations with evidence of impact.
• Effective leverage of the grant program through supplementary initiatives that advance social innovation more generally in the nonprofit sector.
• The requirement that each federal dollar granted be matched 1:1 by the grantees and again by their sub-grantees with money from private and other non-federal sources, thereby increasing the return on taxpayer dollars and strengthening local support.

In July 2010, AIDS United was awarded a $3.6 million SIF grant to expand its Access to Care (A2C) initiative “to ensure that PLWHA have access to primary medical care and HIV-specific care, improve individual health outcomes for PLWHA, and strengthen local services systems.”  The AIDS United focus on Access to Care, supports one of the three principal goals of the NHAS. 

The game-changing SIF requirement that “each federal dollar granted be matched 1:1 by the grantees and again by their sub-grantees with money from private and other non-federal sources”, has created an opportunity to bring new public and private financial resources to the field of AIDS - the first such opportunity in many years and, possibly, the last opportunity of such scale for the foreseeable future.

Learn More:

Watch the FCCA’s Funders Briefing on SIF 

Read John Barnes’ entry in the Council on Foundation’s re: Philanthropy Blog

Read more about the A2C initiative which was originally funded through AIDS United partners Bristol-Myers Squibb and the Wal-Mart Foundation.

Contact Mark Ishaug at AIDS United

Read why Daniel Lee, Executive Director of the Levi Strauss Foundation recently committed $100,000 to the AIDS United A2C initiative

Read How Any Grantmaker Can Support the Social Innovation Fund, a new tool from the Council on Foundation’s Public-Private Partnerships Initiative

“The success of the 12 Cities Project – like the success of the Strategy itself – will depend upon the active participation and support of many different voices and sectors, including other Federal departments, state and local government, community advocates, faith and business leaders, and persons living with HIV/AIDS. Each must share in the responsibility of working with their respective communities to achieve the vision of the National HIV/AIDS Strategy.” 
Miguel Gomez, Director, AIDS.gov

In 2007 the U.S. Centers for Disease Control and Prevention (CDC) launched the “Enhanced Comprehensive HIV Prevention Plans” (ECHPP).  The intent of ECHPP was to concentrate CDC prevention resources in 12 communities throughout the United States with the highest prevalence of established AIDS cases and develop model prevention programs that could, in the future, be implemented in other communities. 

When charged with implementing the NHAS, HHS chose to build on ECHPP by adding the prevention, treatment and care resources of other Federal agencies to create the 12 Cities Project.  According to HHS, this demonstration project is a significant component of the HHS National HIV/AIDS Strategy Operational Plan and embodies many of the key principles of the NHAS, to:

• Concentrate resources where the epidemic is most severe
• Coordinate federal resources and actions across categorical program lines
• Scale-up effective HIV prevention, care and treatment strategies
• Innovate

Overall, the 12 Cities Project offers an innovative response to the AIDS epidemic by:

• Concentrating heretofore segregated resources
• Fostering unprecedented collaboration among traditionally siloed agencies
• Encouraging broader collaboration between Federal agencies, local governments and the private sector
• Linking HIV prevention with treatment, care and research to provide improved and more highly-coordinated services
• Developing models among diverse communities impacted by HIV/AIDS that can be applied across the nation

While many consider the 12 Cities Project a game-changing approach to eradicating HIV, it is not without controversy.  Some activists have expressed concern that:

• Prioritizing communities based on cumulative cases of AIDS will exclude women infected with HIV; although the spread of HIV infection began later among women than in MSM and IDU communities, the current rate of new infections among women of color is alarming. 
• Reductions in funding to lesser impacted communities and communities that have successfully stemmed the rate of new infections will lead to increased infection rates in those communities.
• Concentrating resources on just twelve cities could lessen the national scope of the NHAS.

Learn More:

Review a deeper overview of the 12 Cities Project from AIDS.gov

Listen to Dr. Ronald Valdiserri of HHS discussing the goals of the 12 Cities Project

Read “A Step Forward in Tackling America's AIDS Epidemic (Now the Work Begins),” an editorial from Chris Collins, Vice President and Director of Public Policy at amfAR that discusses the 12 Cities Project from an activist’s perspective.

NHAS and Healthcare Reform

“Health care reform is a significant step forward in meeting the care and treatment needs of hundreds of thousands of people living with HIV and AIDS and millions of other Americans.”
Robert Greenwald, Director, Harvard Law School Center for Health Law and Policy Innovation and Treatment Access Expansion Project

On March 23, 2010 the Patient Protection and Affordable Care Act was signed into law.  The Affordable Care Act is the first successful attempt to overhaul the U.S. health care system and guarantee access to medical insurance for tens of millions of Americans.  The health care law seeks to extend insurance to more than 30 million people, primarily by expanding Medicaid and providing federal subsidies to help lower- and middle-income Americans buy private coverage. It will create insurance exchanges for those buying individual policies and prohibit insurers from denying coverage on the basis of pre-existing conditions. To reduce the soaring cost of Medicare, it creates a panel of experts to limit government reimbursement to only those treatments shown to be effective, and creates incentives for providers “bundle’' services rather than charge by individual procedure.

The Patient Protection and Affordable Care Act supports the access to care goals of the NHAS in several ways including:

• Eliminates the disability eligibility requirement for Medicaid (starting in 2014) and expands access to most uninsured individuals with income below 133% of the federal poverty level (approximately $14,000 for an individual and $28,000 for a family of four).
• Improves access to private health insurance by eliminating discrimination based on health status: prohibits the ability to deny coverage to people living with HIV or AIDS (for children starting in 2010 and adults in 2014); eliminates insurers’ ability to cancel or rescind coverage (unless they can show evidence of fraud in an application; eliminates lifetime caps on insurance benefits; and requires insurers to provide access to preventive services with no cost sharing.
• Creates new state-based private insurance exchanges (starting in 2014) for the purchase of individual and small group insurance.  These new exchange plans cannot charge higher premiums based on health status.  They must include a new essential health benefits package that among other benefits includes prescription drug coverage, chronic disease management, laboratory services and mental health and substance abuse treatment. And, individuals and families with income up to 400% of the federal poverty level (approximately $44,000 for an individual and $88,000 for a family of four) are eligible for subsidies that will increase affordability and reduce health-related bankruptcies.
• Funds from the Affordable Care Act’s Prevention and Public Health Fund have been reallocated to support prevention efforts in the 12 Cities Project.
  

Learn More:

Review a fact sheet about how the Affordable Care Act impacts people with HIV/AIDS.

Review an in-depth look at the Affordable Care Act

Read “How Does the Affordable Care Act Impact People Living with HIV/AIDS?” at AIDS.gov

Read FCAA’s interview with Robert Greenwald on the connection between HIV and Health Reform

Read “Securing Health Care for People with HIV and AIDS: An Advocate’s Roadmap on Implementing Health Care Reform and Bridging Current and On-going Access to Care Gaps” a concise review of the Affordable Care Act’s impact on PLWHA from Treatment Access Expansion Project (TAEP)

Review a summary of the new law prepared by Henry J. Kaiser Family Foundation

Review the HIVHealthReform.org website developed by Project Inform, AIDS Foundation of Chicago and TAEP/Harvard Law School Center for Health Law and Policy Innovation with a grant from MAC AIDS Fund

NHAS and Ryan White

"The Ryan White HIV/AIDS programs are critical to the success of the National HIV/AIDS Strategy, specifically the Ryan White Program continues to increase access to care and improve health outcomes for people living with HIV."

Dr. Deborah Parham Hopson, Associate Administrator for HIV/AIDS, Health Resources and Services Administration, HHS

Video: The President talks about the legacy of Ryan White as he reauthorizes the landmark bill named in his honor that helps provide medical treatment to more than half a million Americans living with HIV/AIDS. October 30, 2009.  

The 1990 Ryan White Comprehensive AIDS Resources Emergency (CARE) Act, was based in large part on the Robert Wood Johnson Foundation AIDS Health Services program that supported and evaluated a San Francisco community-based model of providing holistic prevention and treatment services for PLWHA.

Named for a young activist who died of AIDS, the Ryan White CARE Act is the only Federal legislation to address services for a particular disease.  Reauthorized four times, the latest iteration of the bill is called The Ryan White HIV/AIDS Treatment Modernization Act (Ryan White) and is scheduled to expire in October 2013. 

Although its future is uncertain, the NHAS infers support for another reauthorization with target language that includes:

By 2015:

• Increase the proportion of Ryan White HIV/AIDS Program clients who are in continuous care from 73 percent to 80 percent.
• Increase the percentage of Ryan White HIV/AIDS Program clients with permanent housing from 82 percent to 86 percent.

Part of the greater coordination efforts called for by the 12 Cities Projects and the NHAS will also involve Ryan White: “CDC’s review will consider whether HIV prevention planning processes should be streamlined and where feasible, combined with Ryan White HIV/AIDS Program planning efforts. “

Many activists anticipate that the Ryan White Program will cease to exist after 2013 and that many of its current provisions will be absorbed by Medicaid, The Affordable Care Act, CDC, HUD and other government agencies.  However, there is wide-spread concern that, as long as HIV/AIDS remains an area of stigma and discrimination and a disease that requires specialized treatment, the loss of Ryan White will recreate the gaps in services that the act was originally intended to fill. 

Learn More:

Read more about Ryan White programs and the federal agencies responsible for its management and implementation from the CAEAR Coalition.

Read more about healthcare programs funded by Robert Wood Johnson Foundation that became state or national programs.

Review Health Care Reform: What Ryan White Grantees Need to Know, a power point presentation from TARGET Center: Technical Assistance for the Ryan White Community

Review a 2009 Ryan White fact sheet from Henry J. Kaiser Family Foundation

Read more about Ryan White himself

NHAS and ADAP

“Gaps in essential care and services for people living with HIV will continue to need to be addressed along with the unique biological, psychological, and social effects of living with HIV. Therefore, the Ryan White HIV/AIDS Program and other Federal and State HIV-focused programs will continue to be necessary after the [Affordable Care Act] law is implemented.”
National HIV/AIDS Strategy

The AIDS Drug Assistance Program (ADAP) provides HIV-related prescription drugs, directly or through health insurance, to PLWHA in U.S. States and Territories.  It is a critical component of the NHAS, particularly for the goal of Increasing Access to Care.

Federal ADAP funds are provided through Part B of the Ryan White HIV/AIDS Treatment Modernization Act (Ryan White Program) (cross reference) and administered through HRSA.  States also have the option to contribute state general revenue funding to ADAP; 38 ADAPs received state general revenue support in FY2010.

In FY2010:

• The national ADAP budget was $1.79 billion.
• The average annual cost per ADAP client for medications was $11,388.
• There were approximately 136,000 ADAP clients served in June 2010.

Over the past two fiscal years, ADAPs have been challenged to meet an ever-increasing need and, as of October 2011, 11 states currently have waiting lists.  Reasons for increased demand include:

• State budget cuts in response to the national economic crisis;
• Increased HIV testing and access to care for PLWHA;
• Retention efforts that result in more PLWHA remaining on ADAP for longer periods of time;
• Increased number of PLWHA who are unemployed and underinsured; and
• New science that encourages PLWHA to start treatment at earlier stages than ever before.

Ryan White Program legislation will be up for reauthorization in 2013, but can continue as long as Congress continues to appropriate funds.  Provisions in the Affordable Care Act increase Medicaid eligibility for PLWHA and prohibit private insurers from denying coverage to PLWHA which will help relieve some of the stresses on an already overburdened Ryan White Program system.

The National Alliance of State and Territorial AIDS Directors (NASTAD) monitors developments in ADAP and provides a wide range of programs and public health advocacy initiatives.

Learn More:

Review the National ADAP Monitoring Project Annual Report from NASTAD

Read about the NASTAD Programs and Public Health Advocacy Initiatives

Read about components of the ADAP from NASTAD

Read about ADAP advocacy efforts from ADAP Advocacy Association

Watch the State and Future of HIV podcast from AIDS.gov

Review a resolution from PACHA about the needs of ADAP vis-à-vis the Affordable Care Act - “Regarding Timely Access to Life-Saving Care and Treatment”

Review a list of ADAPs with waiting lists and/or cost containment strategies from Henry J. Kaiser Family Foundation.

"The NHAS set out a critical pathway for the country to follow to alleviating the epidemic in the U.S.  However, to ensure that we are >progress rapidly on that pathway, we need a very strong array of process, outcome and impact evaluation activities so as to ensure program accountability and continuous improvement of service delivery.  The country needs, and deserves, a truly strategic dashboard that will allow the policy and program management necessary to achieve the NHAS goals."
Dr. David Holtgrave, Professor and Department Chair, Johns Hopkins Bloomberg School of Public Health

While it is early days to begin evaluating the impact of the NHAS, (operational plans were unveiled in July 2011), there are several mechanisms in place.  On the Federal level, PACHA has been charged with overall monitoring and evaluation of the NHAS.  In addition, each implementing agency has a monitoring and evaluation component built into it operational plan.

Advocates, funders and consumers have already begun to analyze the NHAS plans from gender, race, sexual orientation and other perspectives.

Learn More:

Review members of the PACHA subcommittees

Read Dr. David Holtgrave’s presentation on the national evaluation plans for the AIDS United’s SIF grant

Explore the NHAS Gender Audit conducted by WORLD

Read a White House blog on the one-year review of the NHAS

Read an AIDS.gov blog on the one-year review of the NHAS by implementing agencies

“The purpose of State plans would be to enhance coordination between planning and resource allocation activities, which are often siloed in a way that separates prevention and care…In developing their plans, States will also be encouraged to identify all Federal, State, and local resources, and to the extent feasible, private and nonprofit resources to ensure that all HIV/AIDS resources are allocated in the most efficient manner to address the full range of prevention, care, and social service needs."
The U.S. National HIV/AIDS Strategy

Key to the success of the NHAS is coordination of efforts on a State and local.  Some states have begun to explore the development of Statewide HIV/AIDS plans that align with the national strategy.

California

The San Francisco AIDS Foundation (SFAF) co-founded the Campaign for a National AIDS Strategy in 2007 and helped provide input on core priorities in HIV prevention, treatment, care and research that became part of the NHAS.  Since the introduction of the NHAS, the foundation has established logic models for all of its programmatic activities that align its own strategic goals with those of the national strategy.

They have also begun to develop a blueprint for a California State Strategy.  The development process they have outlined includes:

• First, commit to the NHAS goals
• Assess and revisit existing systems of care and prevention
• Examine capacity of payers and needs of clients
  ·   Collect and analyze data (HIV/AIDS prevalence and incidence, census data, GIS data, socio-economic data) ·  Map where resources are in relation to the epidemic ·  Align resources to populations with high prevalence and risk
• Identify State agency responsibilities
  ·    Recommend opportunities for coordination and delivery across and within agencies and programs (Medi-Cal, DHS, Office of AIDS, HCD, DOJ, VA)
• Regional Group Impact Analysis
  ·    Convene regional meetings of stakeholders (including providers, clients, community leaders, DPH, philanthropy, private sector, pharma ·    Each group creates recommendations for the CA plan and identifies 2-3 reps to be part of a working group
• CA Statewide strategy group formed
  ·    Comprised of the working group and representatives from relevant State departments ·    Examines regional findings and applies them to the State level ·    Writes the CA HIV/AIDS Strategy
• CA HIV/AIDS Strategy adopted by the State
  ·   Impacts budget decisions, legislation, public health policy, and serves as a model for other State plans ·   Acts as advocacy tool to influence policymakers and redirect resources where most needed

Illinois

On September 13, 2011, the Illinois Department of Public Health (IDPH) released a draft Illinois HIV/AIDS Strategy.  According to AIDS Foundation of Chicago, “The release capped nearly a year of work led by Dr. Mildred Williamson, Chief of the IDPH HIV Section, and a dedicated group of community leaders who met for months to outline the plan.   The draft Illinois Strategy is a companion to the National HIV/AIDS Strategy.”