Responding to the National HIV/AIDS Strategy-setting the research agenda.

The National HIV/AIDS Strategy (NHAS) has three goals: (1) reduce the number of people who become infected with HIV, (2) increase access to care and improve health outcomes of people living with HIV, and (3) reduce HIV-related health disparities. [1] In addition the plan and its implementation strategy call for achieving more coordination of HIV programs across the Federal government and between federal agencies and state, and local governments. [2] Accompanying the Strategy is an Implementation Plan that identifies the steps to be taken by Federal agencies as well as all parts of society to support the priorities outlined in the Strategy and sets target for the three goals to be achieved by 2015 (e.g. lowering the number of new HIV infections by 25%). [3] Herein we lay out a role for the National Institutes of Health in facilitating research that supports and informs the goals of the National HIV/AIDS Strategy. Though the potential benefits of the National HIV Strategy for HIV-infected persons and the broader society are substantial, three important challenges must be addressed to effectively bring the strategy to scale in the United States. First, although virtually everyone who is HIV-infected is eventually identified, diagnosis often occurs too late in the disease to provide optimal benefit to the individual. In addition, until persons know they are infected, they are more likely to transmit their infection to others. Thus, it is critical to detect HIV-infected individuals earlier in their disease. Second, once HIV-infected individuals are identified, it is crucial that they quickly receive and then remain in care. Third, if the individual and society are to benefit from antiretroviral therapy, infected persons must receive and be adherent to treatment in order to maintain long-term virologic suppression to achieve better health outcomes and reduce HIV transmission rates. While an emphasis on testing and treatment sounds primarily biomedical, the three challenges depend on behavioral, social, systems, and structural factors important to address in implementation of the NHAS. Early identification of HIV infection, especially for populations with greatest disease incidence, requires community- and provider-level interventions to make frequent HIV testing normative, easy to obtain, and free of stigma. Engaging and maintaining HIV-infected persons in care requires the development and implementation of practical interventions—at health care system, community, and individual levels—targeted toward those marginalized patient groups least likely to enter and remain without disruption in care. Well-maintained HIV virologic suppression, a cornerstone of treatment-as-prevention approaches, can be achieved only when patients likely to be nonadherent are identified and receive behavioral and social interventions to improve their long-term medication adherence. Much is known about individual interventions that can achieve some of these goals, but we know much less about how to combine multiple approaches to have the greatest impact on a wide scale. Consensus among researchers is emerging on the need for “combination prevention,” by which we mean multilevel interventions that combine evidence-based individual social, behavioral, and biomedical approaches to produce a community-level impact on the HIV/AIDS epidemic. [4, 5] It is time to move beyond studying social, behavioral, and biomedical HIV prevention interventions in isolation and instead evaluate the impact of comprehensive, integrated, multilevel approaches implemented on a wide scale. In this editorial, we will describe some current barriers to implementation of the National HIV/AIDS Strategy, present strategies to address them, and outline research needs relevant to the successful implementation of the Strategy.