The campaign to create a National HIV/AIDS Strategy (NAS) for the United States has been a remarkable success so far. Over the last two years, the concept has won support from hundreds of organizations and more than 1,000 individuals. They all endorsed a Call to Action demanding a more coordinated, accountable, and results-oriented response to AIDS in our country. President Obama has committed to developing an NAS with the primary goals of bringing down HIV incidence, increasing care access, and reducing health disparities. (1)

The NAS has become the centerpiece of a growing effort to bring attention to the AIDS epidemic at home, but what the NAS actually accomplishes depends on what comes next from the new administration and – even more – from us, the communities most directly affected by HIV/AIDS. We have been down this road before, creating well-intentioned plans full of good ideas that do little more than gather dust. If this NAS is going to have real impact, it will have to be different from the planning efforts of the past.

How? First, this NAS needs to focus the federal government and all of us squarely on the bottom line: improving outcomes on the president’s three central goals. Everyone engaged in the response to AIDS is already working for better outcomes, but in many ways, the systems that we have established do not do enough to measure results effectively, encourage us to assess what is working, or ask how to have broader impact. Even if an NAS does nothing more than challenge us to continually examine our programming and policy in terms of how it will lead to better outcomes, it will have done something good.

For example, on the issue of treatment access, an NAS would likely promote increased resources for programs like the AIDS Drug Assistance Program (ADAP), but it would also drive us to better understand the bigger issue of why 50 percent of people living with HIV/AIDS are not in care. Using that knowledge, an NAS would then lay out steps to deliver a coordinated set of interventions, including ADAP, to increase the percentage of people with access to care. On prevention, an NAS would call not only for more good behavioral interventions but also for bringing the best interventions to a scale where they can have true population impact on reducing incidence. This would include looking beyond behavioral interventions to structural and network-level approaches to prevention by, for example, improving housing as one strategy to reduce vulnerability to HIV and other health problems.

Second, an effective NAS has to begin with the acknowledgement that simply doing more of the same will not get us the results that we need. The domestic AIDS response has been flat funded, which effectively means it has received decreased funding, for years. Resources need to increase, and evidence-based polices must be implemented. But more money and a few improved policies are insufficient to the challenge. Domestic HIV/AIDS programming is largely uncoordinated, unaccountable, and limping along without a comprehensive strategic plan driven by clearly defined goals. It is time to step back, take a systematic look at the federal response, and identify concrete ways to make it more effective.

Third, the NAS should be an operational tool for the federal government rather than merely a list of recommendations. It has to help all those engaged in the effort set priorities and identify opportunities to have maximum impact. A strategy that devolves into a laundry list of all the things that we could do with limitless resources will not accomplish anything. Instead, the NAS should serve as a roadmap for the federal government, working with state and local private and public organizations for a more effective effort. Jeff Crowley, Director of the White House Office of National AIDS Policy (ONAP), has identified the NAS as a top priority for President Obama. Whether ONAP or another office in the government is assigned to lead implementation of the NAS, that office should eventually have some level of oversight (and perhaps even budget) authority to successfully promote strategic coordination and use of resources across agencies.

Fourth, the NAS has to bring far more accountability and transparency to the system. The NAS should set a few ambitious but achievable targets for reducing incidence, increasing access to care, and reducing racial disparities. It should require an annual report on progress toward these goals. The NAS needs to set timelines and assign responsibility for follow-up on all of its major action items. When we fail to meet our targets, we must be ready to ask difficult questions about what can be improved. To make such an accountability system work, we will need to build better information systems to track incidence and understand barriers to care utilization. We will need to have readier access to information about how the government spends AIDS funding, too. The Web site for the Global Fund to Fight AIDS, Malaria, and TB (www.theglobalfund.org) provides a wealth of data on funding sources, allocations, and governance. Why can we not have the same level of access to information about publicly funded programming in the domestic AIDS response?

Finally, an effective NAS will require decisive presidential leadership along with buy-in from a range of stakeholders. The president should dedicate all or part of a speech in the near future to the domestic response to AIDS, laying out his goals for an NAS and calling on all of us engaged to recommit to a response that is coordinated, accountable, and results oriented.

The group involved in planning the NAS will need to include leaders from all government agencies engaged in the response to AIDS along with stakeholders from provider and advocacy groups, academia, and people living with or at risk for HIV/AIDS. President Obama should ask these individuals to take their institutional hats off and collaborate to construct a better prevention and care effort (this is true for those outside of government, but also for government employees on the panel who should be asked for their “professional judgment” rather than their agency’s judgment). If the individuals on the NAS panel only represent the narrow interests of their agencies, it will be the death of an effective NAS.

Designers of the NAS will have a challenging job ahead of them. They will need to diagnose what is not working optimally in the domestic AIDS response and chart a course for improvement. They will need to be willing to say when an agency’s programming needs reorganization, when current approaches are outdated or not based in evidence, or when contracts and funding streams do not have sufficient evaluation and incentive structures. In other words, those involved in creating an NAS will need to be willing to think beyond half measures and quick fixes.

The panel’s work might start by identifying the questions that need to be asked:

• What are ambitious but reasonable targets for reducing incidence, increasing care access, and reducing racial disparities – and what will it cost to achieve these targets?
• What laws, policies, and program management practices need to be changed to create a more accountable and effective HIV prevention and care system?
• How should the federal response be structured and managed to optimize strategic coordination and use of resources across government agencies?
• How can federal agencies best promote delivery of large-scale, coordinated, and strategic prevention campaigns in the highest incidence areas? For example, how can federal agencies work with state and local groups to devise “proof of concept” pilots of intensive “combination prevention” packages that include HIV testing and screening, HIV treatment, sexually transmitted infections and other medical care, and targeted behavioral and social interventions?
• How can we better track HIV care utilization and barriers to care access and then address those barriers effectively?
• What prevention intervention research is most urgently needed from the Centers for Disease Control and Prevention and the National Institutes of Health to reduce transmission among groups at elevated risk, including (a) young African-American men who have sex with men and (b) young African-American women?
• Where should HIV/AIDS services be more fully integrated into general health delivery systems?
• What are the most effective ways to ensure access to and delivery of appropriate and comprehensive HIV care and treatment in the United States in the context of general health care reform?

If we do this right, it is going to be challenging, because an effective NAS will require doing business differently. The strategy process should focus all of us on improving outcomes rather than simply expanding programs, and on finding evidence-based solutions rather than arguing about ideology. A successful NAS process will force us to ask tough questions about funding and priorities, it will insist that all responders collaborate toward common goals, and it will ensure that we hold ourselves accountable for concrete results. The ultimate goal is not creating an official plan on paper but establishing a sustained process of learning what works, refining efforts, and steadily improving outcomes.

A recent review of U.S. government strategic planning efforts (2) over the last few years concluded that some of these efforts were successful and some were less so. The process of developing a strategic plan, in some cases, appears to have been the most valuable aspect of the effort: “It creates a dialogue among stakeholders around developing a common direction….” An NAS that engenders such a dialogue and then backs it up with greater transparency and accountability could represent a major step forward in the domestic response to AIDS. As such, the NAS is wholly consistent to the new administration’s investment in health reform and is a critically important opportunity to demonstrate commitment to fresh approaches to management of our public health resources.

* Another earlier version of this posting originally appeared in HHSWatch, published by CHAMP.
 

References

1) Office of National AIDS Policy. Retrieved June 23, 2009, from http://www.whitehouse.gov/administration/eop/onap/.

2) Kamensky, J.M. Making big plans: Bush expands use of “national strategies.” IBM Center for the Business of Government. Retrieved December 22, 2008, from www.businessofgovernment.org.

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