10 Ways to Maximize High-Impact HIV Prevention

By Murray Penner December 15, 2015

Earlier this month, I had the privilege of moderating a panel on High-Impact Prevention (HIP) initiatives at the state and local level at the 2015 CDC National HIV Prevention Conference (NHPC) in Atlanta.

The panelists were: Randy Mayer, Iowa Department of Public Health; David Ernesto Munar, Howard Brown Health Center; Chi-Chi Udeagu, NYC Department of Health and Hygiene; Terrell Parker, of The Damien Center; and Diana Jordan, Virginia Department of Health.

The panelists shared their experiences with adapting HIV prevention programs to incorporate HIP approaches, and with setting priorities and leveraging resources to improve outcomes. They also discussed stigma-reduction efforts, strategies to retain clients in care, and the need to focus on maximizing health equity for people living with HIV. I took the opportunity to share 10 ways to maximize high impact prevention that really emphasize the theme of the conference to Accelerate Progress, Prevent Infections, Strengthen Care and Reduce Disparities.

1. First, we must Envision a world free of HIV. Dr. Anthony Fauci, Director of the National Institutes of Allergy and Infectious Diseases (NIAID), shared that there is no scientific reason that this can’t be done. We HAVE the tools. And Dr. Eugene McCray, Director of the CDC Division of HIV/AIDS Prevention emphasized that we are seeing movement in this direction. But there is MUCH to be done. We must think and work differently and be creative and diligent, more than ever, in order to get different results. I applaud states and cities such as New York, Washington State, Colorado and Denver, San Francisco and others who have done the hard work and committed resources to create bold, transformative plans to end new HIV infections. 

2. Second, we must address structural inequalities. We have the tools we need but that does not mean that we have everything in place to put those plans into action. Not all people have access to health care services in their communities that are responsive to their experiences. Not all Black and Brown people in this country live a life free of racism and fear. Not all governors have done the right thing and expanded Medicaid to allow access to comprehensive services for millions of low-income people. In order to end new infections, we must end structural inequalities that exist in all sectors of our society. Public health programs can’t exist in a bubble, just as HIV does not exist in a bubble. 

3. Third, we must prioritize key populations. We know that we haven’t gotten it right in providing services to specific populations most impacted by HIV. We must do far more to ensure that the transgender community and gay men, particularly young gay and bisexual men of color, are receiving services that are impactful. This does not mean that we will ignore other populations. We must focus on leveraging digital tools and technologies such as social media and mobile apps to reach people where they are. The role of public health’s Disease Intervention Specialists (DIS) also need to be reimagined to more effectively serve these populations.

We must also address the needs of people who inject drugs and in particular, the epidemic of opioid abuse; public health, law enforcement and substance use programs must collaborate in new ways. And WE MUST END the Congressional ban on the use of federal funds for syringe access programs.

4. Next, we must use data to improve health outcomes. We all know that we collect a lot of data in our programs. But in order for that data to work for us and inform the most effective interventions we must break down data siloes and improve collection, timeliness and accuracy in order to make decisions that improve outcomes and keep people engaged in the health system. Our surveillance system, for example, must “talk” to our programmatic databases and inform such steps along the continuum of care including linkages to and especially retention in care. We need to move our data collection systems forward so that they can be more responsive to the changing landscape and the opportunities in front of us. 

5. Fifth, we must rapidly scale up PrEP, treatment as prevention and access to STD treatment and prevention. The thrilling advances of PrEP and treatment as prevention have ushered in a new prevention paradigm - one that requires collaboration across HIV care and prevention and one that depends on culturally appropriate clinical providers. Despite their promise, we will not be successful in capitalizing on these interventions if we can’t expand access to medications to the individuals and populations who need them the most. Everyone who is living with HIV should have access to and be taking antiretroviral treatments to achieve viral suppression. I know it’s saved my life. Our federal and state governments must change policies and allow PrEP services AND medication to be purchased with public funds. Only 1 in 3 providers even know about PrEP. We must increase our work with providers to be more comfortable talking with their patients about sex – we ALL have it and we need to be talking about it.  

6. Next we must better integrate our health systems. The ACA has expanded insurance coverage to millions of Americans and transformed our health care system. Now more than ever, we must identify new and different public health partners, including public and private payers and ensure that our partners interact seamlessly. Our goals have shifted to include ending the HIV epidemic, but we can’t do that with categorical funding and siloed programming. We must engage every part of our health care system to work in partnership with public health programs and providers to leverage new resources, scale up access to PrEP and HIV treatment, and monitor quality. And finally we MUST ENSURE that the Ryan White Program remains strong and fills gaps in services.

7. Seventh, As the National HIV/AIDS Strategy (NHAS) so eloquently points out, we must focus on the right people, the right places with the right practices. I’ve already mentioned the right people and the right practices, but we need to ensure that our entire country has the tools necessary to end the epidemic. This is especially true in the South and in our rural communities. We can’t focus only on cities, as evidenced by the recent and unfortunate 184 new HIV infections (which also included many hepatitis C infections) in rural Indiana. And while approximately 75% of our citizens live in cities, 100% of our cities are within states. States are constitutionally responsible for protecting the health of its citizens. States and cities together must coordinate in bold new ways, like New York City and the State of New York and like Denver and Colorado to create change and move toward ending new HIV infections.

8. We must strengthen the way communities work with government and cultivate meaningful community engagement.  People living with HIV, sex workers, transgender individuals, gay men, people who use drugs and many other groups of people must be at the table in our collective work to shape our new paradigm of working together. We all must be bold, courageous and take risks to work differently together and be a part of ending the epidemic. And our plans must be integrated. The fourth goal of the National Strategy emphasizes a coordinated response. I applaud CDC and HRSA for their work to develop an integrated plan and we must continue to move toward better coordination to incorporate community into our collective planning.

9.  We must reform broken policies. Public health professionals must be at the table to create more equitable policies around employment, housing and mental health and substance use services, which must be central to our programs. All states must have electronic lab reporting to feed into data systems to help us determine where to focus our resources and our work. And we must end the criminalization of people living with HIV as well as END the Congressional ban on the use of federal funds for syringe access programs. Decisions and policies need to be based on science and what works and NOT on political ideologies.

10. And finally, we must reinvigorate social action as we have done so many times before in our movement. In the early days of the epidemic when there was no action from our government and people rallied tirelessly to Act Up and create change, we must institute our generation’s social action. As Dr. Fauci reminds, WE are who will end this epidemic and WE must end HIV. And as Thomas Jefferson said “"If you want something you have never had, you must be willing to do something you have never done.“  The time to act is now.