Plan to End HIV Epidemic in U.S. Must Contend With Uneven State Health Care Systems

Ace Robinson
Terri Wilder

Over the past few months, there's been national buzz around the Department of Health and Human Services plan to end the HIV epidemic in the U.S. by 2030. Federal officials have presented their preliminary strategies at several national conferences and meetings, including the March 2019 National HIV Prevention Conference in Atlanta. That's where I spoke to Ace Robinson, senior director of the Fast-Track Cities initiative with the International Association of Providers of AIDS Care (IAPAC), where he's leading support of the global network of cities that are attempting to achieve the global 90-90-90 targets by 2020.

Terri Wilder: I'm curious about your reaction to what is being laid out to us about ending the epidemic by 2030. First of all, do you think that's possible?

Ace Robinson: I think when they're trying to define what does it mean to end the epidemic, and what is realistic, and then what is it going to take to make that all happen, it's realistic if you put a lot of resources into it. I think recently Bill Gates said the one indicator that has been shown to prove a reduction in HIV incidence is money. If you put more money in, a lot more resources, you get more work done -- and your results are usually better than expected.

TW: So, you may have just answered my next question, which is: What do you think is missing from the current convo, if you will?

AR: The big conversation is related to access to sustainable health care. So, one of the questions that haven't been clearly delineated is: How are we going to support people who do not have access to things like Medicaid, due to the fact that they're not in Medicaid expansion states, or that they are immigrants, whether they're documented or they're undocumented?

If you're a documented immigrant and you've been in the country for less than five years, do you actually have access to any of these resources? Oh, and then, by the way, the new [HIV] rate for the Latino population is going through the roof. So how are we going to support that population when we all know that people love across document status, across racial lines, across gender identities? How are we going to support everyone at the same time? Otherwise, we're never going to get to where we want to be.

TW: Can you tell me about your work and how you are contributing to our efforts to end the epidemic? We're just trying to get a sense of this announcement that has come out. But there's a mix of approaches that are already in progress.

AR: I'm the senior director of the Fast-Track Cities initiative. The whole goal of Fast-Track Cities is: How are you going to align policy makers, health departments, lead clinicians, and invested community stakeholders, whether they're people living with HIV, people affected with HIV, or just generally people who care about health care? How are you going to get everyone behind one auspice and mission in a high-burden jurisdiction? In some places that means a city; in some places that means a county; in some places that means, like, the entire state -- which falls, coincidentally, directly in line with the federal plan.

So, one thing that I've seen -- not just in this initiative, but in all the work that we do -- best practices don't necessarily come from one particular place. We need to make sure that we're taking the best practices that are coming from Malawi, and coming from Botswana.

If Botswana, as a country, has been able to completely turn around the HIV epidemic and do what they need to do to make sure that HIV infections are plummeting, then we take the best practices from them. Scott County, [Indiana,] became a mess at one point; then they were able to do the work to turn the epidemic around. We're looking at what was happening in New York City in the '80s and '90s, and how are we going to develop entire systems like HASA? HASA is HIV/AIDS Services Administration of the New York City Department of Health and Mental Hygiene -- how HASA was able to create systems. That was like a medical home before we even called it a medical home, with Obamacare. How are we going to create systems that are going to directly support people living with or impacted by HIV? We didn't know U=U [undetectable equals untransmittable] at the time.

We didn't know that PrEP was coming down the pipeline sooner or later. But we did find that these individuals are living longer and healthier lives. They're also not transmitting the virus to other people. So, it was a win-win, because we created systems without knowing that Obamacare was coming 15 years later, or something to that effect. My goal is to bring that to other regions of the U.S. Once people see what's working, then that also begins to spread. It's like if New York City is having less infections, is predicted to have less infections in a few years, then other smaller cities? Those smaller cities are like, "Oh, we really need to keep up with the Joneses. We want to be like, 'O.K. They're able to do this here. There's no one dying in the hospitals. There's no new infections, relatively. How are we going to make that happen in a midsize city?'"

And a midsize city is going to get the work done. And then a town is going to be, like, "Oh, we can do this, too."

Case in point: There are cities and jurisdictions who are reaching out to me, speaking about, "Oh, we want to become a Fast-Track city" or, "We want to become a Fast-Track county. Because we know that is what is happening over here, in another city that's either with the state or in the same region. We see that it's working. And we want that to happen in our own jurisdiction."

Terri L. Wilder, M.S.W., has been part of the HIV community since 1989. She served on the New York Governor's Task Force to End AIDS, was recognized by POZ magazine for her work in HIV, and is highlighted in the book Fag Hags, Divas and Moms: The Legacy of Straight Women in the AIDS Community by Victoria Noe. She loves this community and will keep fighting until the epidemic is over.