Before the United States will consider giving AIDS funding to another country, the President's Emergency Plan for AIDS Relief requires the foreign government to create and implement a national AIDS strategy. "At the core of the implementation strategy," the requirements explain, "is a robust ongoing in-country planning effort" meant to "identify relevant U.S. government agencies, existing resources, needs, gaps, partners, programs, objectives, performance measures, staffing, and technical assistance requirements."
A national AIDS strategy, the requirements conclude, is "critical to the success" of the program. It is so critical, in fact, that U.S. officials might want to follow their own advice. More than a quarter-century since AIDS was detected in the United States the government has never fully implemented a strategic plan here at home. Meanwhile, domestic infection rates haven't fallen in more than a decade and, as recently as 2005, more than 17,000 people died from the virus.
"We don't really have in the United States a comprehensive, cross-agency strategic plan to do better in our own domestic AIDS epidemic," explained Chris Collins, the author of a blueprint for a national AIDS plan, released last year by the Open Society Institute. "There's been a realization that, 'Wow, we're doing great things overseas … but we really haven't attended to the epidemic at home sufficiently.'"
Instead, the domestic response is built on a loosely connected network of local, state, and federal programs. Authors and activists often describe this existing HIV/AIDS programming as a safety net. But the metaphor is not quite apt. There's only a tenuous connection between the organizations. There's little strategic coordination and no clear goals. The result is that people who are at risk or infected don't know where or how to access care. In 2002, an estimated half of people with HIV/AIDS were not receiving care.
"We have a lot of really successful, important HIV programming in this country," Collins said. "But we're not using it to full effect to actually accomplish specific outcomes." Rather than a net, the more appropriate imagery would be of life preservers, some large, some small, floating largely independent of each other.
"What we have right now in a lot of areas of HIV is much more a scattershot approach," he said. "Good programs happen, they're written about, perhaps. But there's no one in charge of bringing these programs to scale."
A coalition of leaders from several domestic AIDS activist organizations is working to change that. Spurred by the publication of Collins' blueprint, the group, National AIDS Strategy (NAS), formed with an agenda of mobilizing broader support for a national strategy, while also providing guidance for what that strategy should look like.
Drawing from Collins' report, the group drafted a list of seven requirements for a national strategy. That the guidelines -- improving outcomes through evidence-based programs, setting "ambitious and credible" national targets, identifying clear priorities, focusing on the communities most at risk -- read something like a business proposal is intentional.
"If the response to AIDS in the United States were a well-run business," Collins said, "you would set objectives for a certain time period in the future, you would identify strategies to accomplish those objectives, then you would measure how well you did and retool and reassess along the way."
A national AIDS strategy would help coordinate the various moving parts necessary to effectively stem the virus' impact -- care and prevention strategies, local and national interventions, statistical and on-the-ground efforts.
From a prevention perspective, it would encourage communities to identify particular areas of need and import successful programs from other parts of the country. It would also help prioritize funding for projects that are already successful and facilitate better research into promising prevention techniques. For patients who are already infected, it would streamline the process of getting appropriate treatment and ensure that they are covered.
For local organizations working within specific communities, the difficulty of doing work without a national strategy is that they face incredible obstacles in dealing with the "layer upon layer" of federal and state AIDS programs and multiple funding cycles, Mario Perez, the director of the Office of AIDS Programs & Policy in the Los Angeles County Department of Public Health, explained during a May congressional briefing. A national strategy would streamline the process of securing funding.
A national strategy, Collins said, "orients everybody: federal workers, people working in the public sector at the state and local level, but also people working in the community around really improving outcomes in particular areas."
In the meantime, NAS has already gotten to work on one of its key goals: involving "many sectors in developing the national strategy." It organized the congressional briefing and garnered money from the MAC AIDS Fund for a large-scale mobilization effort. The group's Web site features pledged support from more than 250 organizations and more than 850 individuals.
As Collins pointed out, though, the effectiveness of any national strategy will depend in large part on the backing of just one individual: either Barack Obama or John McCain. While grass-roots support is critical to the successful implementation of a national strategy, jumpstarting the effort will take leadership on a presidential level. The new president must be willing to convene a national task force to draft the strategy and willing to force cooperation and compliance from a cross-section of national agencies.
A president also has the capacity to focus federal efforts on the broader challenges to the national approach to HIV, beyond scaling up existing programming and strengthening research efforts. Addressing AIDS means helping to refocus prevention and treatment on the communities that are disproportionately affected, specifically African Americans. Though African Americans make up less than 15 percent of the United States population, in 2005 they accounted for 49 percent of new infections. A president can also push the health-care agenda, helping people who are at risk get access to care sooner, which can mean earlier diagnoses and better treatment opportunities.
NAS is pressuring the next president, whether McCain or Obama, to deliver on these issues quickly after the election. "I think that the next president, within the first month, needs to give a speech saying, 'I'm going to follow through on my commitment to have a national AIDS strategy, and here's the process,'" Collins said. "And within a year, I think the initial work on that strategy should be done and start to be implemented."
Obama, the presumptive Democratic nominee, lists implementing a national HIV/AIDS strategy as the top priority in his plan to combat the virus. His vision of the strategy aligns closely with the one already proposed.
In a 2006 speech on World AIDS Day, Obama got to the heart of the issue, announcing, "Neither philanthropist nor scientist, neither government nor church, can solve this problem on their own -- AIDS must be an all-hands-on-deck effort."
He seems to have a firmer commitment to addressing the issue domestically than his Republican counterpart. McCain has not committed to pushing for a domestic AIDS strategy. He's expressed a commitment to maintaining the President's Emergency Plan for AIDS Relief but has said little about a national HIV/AIDS plan. On World AIDS Day in 2007, he did close a speech by noting, "Our commitment [to AIDS assistance] must be sustained, and our nation must always be faithful to those at home and abroad as they cope with the ravages of HIV/AIDS." But a more detailed, comprehensive AIDS plan would go a long way toward demonstrating his commitment to addressing the issue.
"The time is right for people to realize that we've done great things as a country in addressing HIV internationally," Collins said. "And we need to also, without losing that focus, look back at the home front and realize that we've really neglected the epidemic here at home."