The Biden administration recently released the National HIV/AIDS Strategy (2022-2025), an update from the 2010 and 2015 versions spearheaded by then-President Obama. Seeing this in my email inbox and social media timelines was a welcome sight, signifying that our federal government has not forgotten its commitment to ending the HIV epidemic, despite the persistent scourge of COVID-19. The 98-page document not only covers the major goals of the domestic strategy, but also describes how these goals will be implemented and how systems will be held accountable for achieving measurable outcomes.

What’s in the Plan?

First, the strategy aims to achieve a 75% reduction in new HIV infections by 2025, and a 90% reduction by 2030. This is similar to the goals in the 2019 End the HIV Epidemic (EHE) initiative. In fact, the updated strategy describes how the two initiatives work in concert, with the national strategy focused on the overall federal response and the EHE program targeting communities and areas disproportionately impacted by HIV.

The National HIV/AIDS Strategy includes four major goals:

• Prevent New HIV Infections: This strategy describes various approaches to increasing education, knowledge, and HIV prevention tools access, while also increasing diversity in the workforce.
• Improve HIV-Related Health Outcomes of People with HIV: They recommend ways to improve linkage to and engagement with clinical care; they also recommend providing holistic care that highlights substance abuse programs, mental health, and elder care for long-term survivors; and investing in next-generation antiretroviral therapy (ART) and cure research.
• Reduce HIV-Related Disparities and Health Inequities: Here they recommend approaches to reducing stigma based on race, sex, gender, sexual orientation, and HIV status, as well as improving workforce diversity (including people living with HIV) and developing innovative communication and marketing strategies to reach diverse populations.
• Achieve Integrated, Coordinated Efforts That Address the HIV Epidemic Among All Partners and Interested Parties: This strategy endorses a “syndemics” approach to understanding community vulnerability to HIV; encourages coordination and sharing of best practices between public, private, community-based organization (CBO) and academic sectors; and emphasizes improving the quality and accessibility of shared data, as well as ways to improve mechanisms by which we measure progress.

The updated strategy takes us in some new directions from previous iterations. It contains more information regarding the measurement of certain indicators, such as levels of knowledge, PrEP coverage, viral suppression rates, and even HIV stigma. There is a section on addressing HIV in the context of COVID-19, a discussion about the role of pharmacists, and commentary on better including people living with HIV in positions of leadership for programming and implementation. I was also pleased to see detailed consideration of the role racism plays in HIV care; aging concerns among people living with HIV; and a discussion about how to address the intersection of stigma, mental health, and substance abuse treatment.

Will the Updated HIV/AIDS Strategy Go Far Enough?

As I read through the document, the question of whether the updated strategy itself goes far enough wasn’t quite the right one to ask — instead, we should ask whether it will go far enough to meet the stated goals.

Our country continues to be ravaged by the COVID-19 pandemic, remains political and socially polarized, and still lacks a national healthcare plan to cover every citizen’s medical needs. Approximately 10% of American adults between the ages of 19 to 64 are without health insurance, with higher uninsured rates among Black and Latinx adults. Twelve states still have not approved Medicaid expansion to assist with HIV treatment and care access, with seven of those states in the deep south, where 51% of new HIV infections occur. Within this content, the updated strategy sounded good on paper, but we must hold our government accountable for executing this detailed plan to reduce HIV health inequities.

Carrying the plan out, however, seems like trying to use multiple Band-Aids to stop the bleeding of someone who was just shot multiple times with a machine gun. The medical infrastructure foundation on which this National HIV/AIDS Strategy rests is flawed and crumbling — starting with not having a national health plan. Indeed, this has negative implications for any U.S. citizen but is particularly obstructive for those living with HIV, trying to access and sustain healthcare coverage, many of whom rely on Medicaid, Ryan White, the AIDS Drug Assistance Program (ADAP), and others to meet their healthcare needs.

While the updated National HIV/AIDS Strategy contains many forward-thinking initiatives, I would’ve liked to see a few additional or expanded sections. First, while there was some lip-service paid to the intersections of mental health, stigma, and substance abuse, the plan lacked more tangible suggestions about the provision of HIV care in these contexts. Additionally, since the world of HIV prevention and treatment is primarily biomedical, the plan didn’t sufficiently address bias among healthcare systems and personnel, which is a known barrier to HIV prevention and treatment. Finally, “distrust” or “mistrust” was mentioned a few times regarding barriers to HIV care. I would have appreciated a review of the literature demonstrating the medical history and present policies and behaviors that foster distrust among Black communities and other medically marginalized subpopulations, rather than just a brief mention of distrust as an innate quality of certain demographic groups. This should have also included practical solutions for improving these relationships and an ask for the medical profession to be more introspective. Instead of asking, “Why don’t patients trust us?” ask, “What can we do better to gain the trust of the communities we serve?”

The COVID-19 pandemic has taught us the value of better public communication and how public-private sector collaborations are essential for moving forward. Importantly, these lessons apply to the HIV epidemic too — and President Biden’s strategy does an admirable job of checking all the boxes on the social, structural, and policy considerations necessary. Is it perfect? No. Does it get some things right? Yes. The plan offers an expansive roadmap with clear, measurable goals. But it will take a concerted effort to carry this from a PDF document of platitudes to tangible solutions in our neighborhoods and communities. The devil is truly in the details.

David Malebranche, MD, MPH, is a board-certified internal medicine physician, researcher, and sexual health/HIV prevention and treatment specialist.