Women's Health Issues
Volume 21, Issue 6, Supplement , Pages S227-S236, November 2011

Recommendations from “Bringing Gender Home: Implementing Gender-Responsive HIV/AIDS Programming for U.S. Women and Girls”

  • Anna Forbes, MSS

      Affiliations

    • Corresponding Author InformationCorrespondence to: Anna Forbes, MSS, 3017 Fayette Road, Kensington, MD 20895, 301-946-426.

Consultant to the DHHS Office on Women’s Health, Kensington, Maryland

Received 22 July 2011; accepted 25 July 2011.

Article Outline

 

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Introduction 

On June 10 and 11, 2010, the Department of Health and Human Services (DHHS) Office on Women’s Health, in partnership with UNAIDS, convened a 2-day forum in Washington, DC, entitled “Bringing Gender Home: Implementing Gender-Responsive HIV/AIDS Programming for U.S. Women and Girls.” The meeting was designed to engage health care providers, U.S. policy makers, and governmental and nongovernmental organizations functioning in the United States in identifying gaps, highlighting needs, and cultivating increased capacity for implementation of gender-responsive HIV/AIDS strategies.

The stated purpose of the Office on Women’s Health Gender Forum was to promote increased leadership in gender-responsive programming for women and girls. Participants at the Forum were charged with recommending strategies for developing, integrating, and modifying existing interventions and programs for the prevention of sexually transmitted diseases (STDs) and HIV/AIDS to make them more responsive to the needs of women and girls. Forum participants also were asked to identify and address the various roles and behaviors of women and girls that increase their risk for contracting and/or transmitting STDs and HIV/AIDS.

The Forum started with a wide range of plenary presentations, which provided an overview of existing programming and prevention challenges in the United States and abroad. International gender experts were invited to present lessons learned and best practices developed in international programs, many of which the United States has supported and underwritten since 2004.

After these plenary presentations and discussion, Forum participants divided into break-out groups to discuss the needs, strengths and challenges faced by women and girls at high-risk for HIV in the United States. The break-out groups focused on:

•Prevention and risk reduction

•Care and treatment

•Violence

•Reproductive and sexual health

•Human rights

•Criminal justice

•Territorial perspectives (i.e., Puerto Rico and the U.S. Virgin Islands)

The diverse knowledge and expertise within these groups led to the development of specific recommendations for incorporating gender/sex-responsive approaches into HIV prevention, care, and treatment programming, as well as identifying gaps where such approaches are needed. The following summary of these recommendations was submitted to the DHHS Office of HIV/AIDS Policy for use in their development of an DHHS National HIV/AIDS Strategy (NHAS) operational plan due to the White House on December 9, 2010.

Disclaimer 

These recommendations reflect the opinions of the Forum participants and do not necessarily represent the views of the Federal employees who facilitated this meeting or the Federal agencies that sponsored it.

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About These Recommendations 

Released by the White House Office on National AIDS Policy on July 13, 2010, the United States NHAS “is intended to be a concise plan that will identify a set of priorities and strategic action steps tied to measurable outcomes.”1 As noted in its accompanying Federal Implementation Plan, it is designed to “serve as a catalyst for all levels of government and other stakeholders to develop their own implementation plans for achieving the goals of the National HIV/AIDS Strategy.”2

In an effort to contribute as directly and unambiguously as possible to the work of implementing this plan, we organized the Forum recommendations to correspond directly to the format of the NHAS. In the chart below, each recommendation or set of recommendations is preceded by the NHAS Implementation Plan Category and the NHAS Direction/Action to which the recommendation(s) refers. In most cases, these recommendations expand on points raised in the Implementation Plan and highlight aspects of implementation that, if adopted, would benefit women and girls. Some recommendations made during the Forum refer to issues not addressed in the NHAS. These are listed under the NHAS chapters to which they refer, noting that they address issues not specifically mentioned in that NHAS chapter. Clearly, a simple listing such as this one cannot address the nuances inherent in each of these complex issues. In-depth and nuanced discussions are provided in this Supplement to Women’s Health Issues.

The need, for example, to allow local jurisdictions to incorporate social and structural determinants data in their assessments of HIV services needs (see recommendation A in Chapter 1 below) was emphasized by Forum participants who felt that we must move beyond data collection systems that focus on demographics and personal risk as the primary factors shaping HIV service needs. More about their reasoning in this area is explored in the articles in this Supplement.

Similarly, the issue of cultural competency training for primary care providers (see Chapter 2, recommendation G) was identified as essential to improving their capacity to deal effectively with patients’ health care needs. Forum participants emphasized that a provider’s ability to listen and elicit information effectively, and make accurate assessments around the sensitive issues of sexuality and interpersonal violence, are as important to patients’ well-being as the provider’s biomedical skills, and must be cultivated as rigorously.

With regard to the need for gender-responsive standards of care and quality measures for the delivery of sexual and reproductive health (SRH) and HIV care (see Chapter 2, recommendation I), participants flagged for particular attention the issue of the amount of time patients have with providers during primary care visits. The amount of time allocated to general check-ups with healthy, HIV-negative patients is unlikely to be sufficient for the management of complex medical conditions such as HIV. More research is needed to develop an adequate standard in this area for HIV care.

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Appendix. 

Glossary 


•ACA: Affordable Healthcare Act (recently passed legislation also known as “health care reform” or “health insurance reform”)

•AETC: AIDS Education and Training Centers, federally mandated programs that train clinical staff on HIV/AIDS, funded through the Ryan White Care Act

•BOP: Bureau of Prisons, Department of Justice

•CDC: U.S. Centers for Disease Control and Prevention

•DHHS: Department of Health and Human Services

•DOJ: Department of Justice

•GBV: Gender-based violence

•HRSA: Health Resources and Services Administration (part of DHHS)

•HUD: Department of Housing and Urban Development

•HIS: Indian Health Service

•NGO: nongovernmental organization (private, nonprofit)

•NHAS: National HIV/AIDS Prevention Strategy

•OGAC: Office of the Global AIDS Coordinator, Department of State

•OMH: Office of Mental Health

•ONCHIT: Office of National Coordination of Health Information

•PEPFAR: President’s Emergency Plan for AIDS Relief, U.S. funding on global AIDS response

•RFA: Request for applications

•SAMHSA: Substance Abuse and Mental Health Services Administration

•SRH: Sexual and reproductive health

•STI: Sexually transmitted infection

•USAID: U.S. Agency for International Development

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Gender Forum Recommendations 

Chapter 1: Reducing New HIV Infections
NHAS Implementation Plan CategoryNHAS Direction/ActionForum Recommendations
IntroductionNHAS commits to “testing and growing our portfolio of interventions that incorporate such issues as sexual networks, income insecurity, and other social factors that place some individuals and populations at greater risk for HIV infection than others” (see page 10 of Implementation Plan).A. Explore how states and local jurisdictions currently record data on structural determinants such as income insecurity, food insecurity and homelessness so that they can be factored into calculations of the need for public services. Use this information to develop standardized reporting mechanisms that states and localities can use to collect and record social and structural determinants data for use in assessing HIV services needs and gauging the appropriateness of available interventions for their populations.
1.2.1 Prevent HIV among gay and bisexual men and transgender individualsNHAS directs the CDC to “expand its work evaluating adaptations of specific interventions for transgender populations and issue a fact sheet recommending HIV prevention approaches for transgender persons.”B. To develop a clearer understanding of how to shape appropriate interventions for transgender populations, modify all federal reporting systems—including those used in the provision of HIV, sexual and reproductive health (SRH) and gender-based violence (GBV) prevention services—to capture, track, and analyze data on transgender individuals’ met and unmet needs. This can be accomplished by adding “transgender MTF “and” transgender FTM” as accepted alternatives to “male” and “female” in all systems that record gender as a data element.
1.2.4 Prevent HIV among substance usersNHAS directs SAMHSA to “implement ways to improve integration of substance abuse and mental health screening into programs that serve communities with high rates of new HIV infections.”C. Integrate HIV prevention, testing, and treatment services, as well as substance abuse and mental health screening, into the SRH and GBV services provided to communities with high rates of new HIV infections – with highest priority placed on service integration in regions currently experiencing the greatest health care disparities.
1A.C-i. Replicate and scale up programs integrating HIV, SRH and/or GBV services and that have already been proven effective in the United States and elsewhere.3, 4, 5, 6, 7
B. C-ii Where services integration does not already exist, develop a range of suggestions (see above references) for providers on how to form integrative collaborations and link services. These could include co-location of services, providing coordinated care through inter-agency collaborative agreements, and referral systems that monitor client follow-through and delivery of referred services.
D. C-iii. Create collaborative grants to promote community partnerships for delivery of HIV, SRH and GBV prevention services.
1.3 Address HIV prevention in Asian American and Pacific Islander (AAPI) and American Indian and Alaskan Native (AI/AN) populationsNHAS directs CDC and IHS to “consult with tribes to develop and implement scalable approaches for effective prevention interventions for AI/AN populations to reach those at greatest risk”D. Invest in targeted and culturally competent outreach to build trust and increase uptake of HIV prevention and treatment services among people in AI/AN populations and other “minority” populations. This outreach should be a key part of the work undertaken with native and tribal organizations.
2.1 Design and evaluate innovative prevention strategies and combination approaches for preventing HIV in high risk communitiesNHAS states that “CDC, HRSA, SAMHSA will collaborate with States and localities on pilot initiatives for expanding the most promising models for integrating HIV testing, outreach, linkage and retention in care in high risk communities.”E. Demonstrable ability to retain the participation of women and girls in HIV and SRH programs should be considered as a positive factor in funding decisions. In addition to encouraging programs to re-engage consumers “lost to follow up” (those absent from medical appointments after treatment has been initiated), incentivize providers to design and implement programs that keep consumers engaged by meeting their specific needs effectively (e.g. the provision of childcare and “one stop shopping” health services for women with children).
NHAS directs NIH and CDC to “develop and implement a plan for evaluating promising community-generated (‘homegrown’) HIV prevention interventions”.F. Involve local experts from the outset in the design of mechanisms for evaluating locally developed interventions, as they are the most knowledgeable about indicators that are likely to accurately reflect whether an intervention meets the needs of women and girls where they are in their communities.
2.3 Expand access to effective prevention servicesNHAS directs agencies to “make recommendations for scaling up access to post exposure prophylaxis (PEP), with priority given to high prevalence jurisdictions. Consideration will be given to the role of emergency departments (if any), standardized treatment guidelines, and regimen selection.”G. Give high priority to expanding awareness of, and access to, PEP for sexual assault survivors. The roles of emergency departments, police, other first responders, and primary care providers in this effort are critical. Targeted education to these gate-keepers regarding this important option is essential and should be highlighted in AETC trainings (see recommendation G-ii in Chapter 2).
NHAS states that “BOP will expand access to HIV, STD, viral hepatitis screening to prisoners on entry, and CDC and BOP will promote risk reduction interventions for healthy reintegration of ex-prisoners back into community settings.”H. The Bureau of Prisons (BOP) should incorporate accurate, comprehensive HIV prevention education into all incarceration and post incarceration re-entry health programming.
H-i. BOP should ensure that all post-incarceration release kits include male and female condoms, hygiene items and specific information about available local HIV and other health resources, including current contact numbers for accessing those resources.
3.2 Promote age-appropriate HIV and STI prevention education for all AmericansNHAS directs the CDC to “develop a toolkit and work with States, localities and school boards to implement age-appropriate HIV health education programs”I. Require States and local jurisdictions to engage HIV and gender experts to evaluate their sexual and reproductive health education curricula to assure that they are comprehensive, involve the family appropriately, and deliver age- and gender-appropriate HIV prevention and sexual health education. These could be analogous to the HIV Materials Review Panels8 that CDC grantees are required to convene but comprised of panelists with specific expertise in education and gender issues.
Important Additional Prevention Issues Not Covered in the NHAS Implementation Plan
Female condomsThe need to expand the uptake and use of female condoms, a highly effective HIV prevention tool, is not mentioned in the NHAS.J. Expand education about, public dissemination of and use of female condoms through media and social marketing. Include training on female condom introduction and promotion as one of the first topics addressed in trainings provided to primary health care providers (see recommendation G in Chapter 2 below).
Gender Based Violence PreventionAlthough gender-based violence is mentioned in the NHAS, no mention of GBV prevention services or monitoring appears in the NHAS Implementation Plan.K. To address the demonstrable linkage between GBV and HIV risk among women in the United States,9, 10 integrate provision of HIV and GBV prevention services, increase funding for services to prevent GBV, and increase investment in shelter services and transitional support programming for survivors of GBV.
L. Standardize definitions and measures of GBV11, 12 to facilitate identification and data collection regarding its incidence and prevalence in the United States, societal drivers, and its connection to HIV risk and transmission among women and girls in the United States.
M. Create a federal plan within DHHS for measuring, documenting and reducing the number of violent acts against women and girls annually. Add these benchmarks to Healthy People 2020.
N. Create a joint Department of Justice (DOJ)/DHHS mandate addressing GBV as both a public health and a legal issue.
O. Package and disseminate GBV data, with “best practices” information on its reduction.
P. Require states to reassess their HIV/STD partner notification processes to assure that women receive adequate support to reduce their risk of GBV as a result of partner notification.
Q. Incorporate HIV and substance abuse prevention services language into the Violence Against Women Act (VAWA) during its 2011 reauthorization process. Specifically:
•Provide incentives for programs that cross-train providers of GBV, mental health and HIV services to build their capacity for appropriate client screening, education and referral across all three areas.

•Include earmarked funding for educational programming in jails, schools and community venues on GBV, HIV and mental health to raise awareness of the inter-connectedness of GBV, mental illness, and HIV risk; break down stigma; and change cultural norms and expectations.

•Establish a link between access to VAWA funding and states’ compliance with the provision of comprehensive sexual health education, including a GBV education component. in their public schools.

Gender-Sensitive ProgrammingThe NHAS acknowledges that negotiating safer sexual practices can be especially challenging for women who may be vulnerable to physical violence, or who may be emotionally or economically dependent on men.” (see page 12). It does not, however, include plans for creating gender-sensitive programming to address this and other gender-related barriers. A growing evidence base documents the effectiveness of well-designed interventions in this area.6, 13, 14, 15R. Fund peer-led and community-based programming that promotes open and expanded communication on issues of sex and gender among:
•women and girls;

•men and women;

•men and boys; and

•transgender individuals in the categories in which they self-identify.

R-i. Include elements of GBV awareness training, sexual health promotion, HIV risk reduction and non-violent communication methods in this programming.
R-ii. Involve relevant community leaders and opinion makers as appropriate (e.g. involve faith community leaders as violence prevention partners).
R-iii. While maintaining sensitivity to local cultural norms, these groups need to challenge harmful traditional practices and messages. They should, for example, encourage women and girls to explore safe ways of using woman-initiated HIV prevention tools even in the cultural context of male dominance during sexual interactions. They also need to communicate that GBV is a crime and a civil rights violation, not a normative act.
Criminal JusticeOne reference to HIV prevention for prisoners in the NHAS Implementation Plan concerns “access to HIV, STD, viral hepatitis screening to prisoners on entry” and “risk reduction interventions for healthy reintegration of ex-prisoners back into community settings.” (see page 15)S. The Plan does not mention prisoners’ other HIV prevention service needs. BOP should revise its guidance regarding medical services that must be provided as a condition of federal funding to require that all incarcerated people have access to comprehensive HIV-related health care and prevention services, including sexual health education, screening and treatment for HIV and other STDs (periodically during incarceration as well as at entry), and access to prevention tools including condoms (male and female) and dental dams. BOP should promote adoption of this guidance by non-federal systems, as well.
T. BOP should require federally funded correctional facilities to submit the institutional measurement tools they use to assess health care delivery for review and evaluation by federally-assembled panels with expertise on gender and corrections. These panels are needed to assess the adequacy of these tools with regard to measuring delivery of the HIV-related services specified above.
U. BOP should direct contracted providers to provide access to gender-responsive mental health and substance abuse screening and treatment services to all incarcerated women and girls, since these factors directly affect their HIV risk.
V. BOP should make federal funding to correctional facilities conditional on human rights and civil rights compliance, as well as the delivery of evidence-based programs to meet the correctional health care needs articulated in this document. BOP should also work with DOJ to create and implement mechanisms for effectively monitoring this compliance and service delivery.
MicrobicidesThe NHAS states that “effective vaccines and microbicides are not yet available and investments in research to produce safe and effective vaccines and microbicides must continue.” (see page 15). The Implementation Plan, however, makes no mention of microbicides.W. Continued federal investment in microbicide research and development. Discovery of the first safe, effective microbicide underscores the urgency of the need for products effective enough for use by women in the United States and globally.
Anonymous HIV TestingThe NHAS acknowledges that, “[p]eople at high risk for HIV cannot be expected to, nor will they seek testing or treatment services if they fear that it would result in adverse consequences or discrimination.” (see page 36). Research shows that the option of anonymous HIV testing is essential to encourage testing and risk reduction among people who are not yet ready to be tested confidentially.16, 17, 18, 19 While the Implementation Plan emphasizes the need to scale up HIV testing, the specific need for anonymous HIV testing services is not mentioned either in the NHAS or its Implementation Plan.X. Require all States and territories to fund and provide broad access to anonymous HIV testing services. Where such services are not currently available (as is the case in eleven states and in Native Communities), they should be established in consultation with the local organizations advocating on behalf of the populations at highest risk of HIV.
HIV Prevention Targeted to Sex WorkersNeither the NHAS nor its Implementation Plan makes any mention of sex workers or prostitution.Y. DHHS needs to re-assess its 13 May 2010 guidance regarding implementation of the “Anti-Prostitution Pledge” language in the Leadership Act (legislation authorizing PEPFAR). This guidance is not evidence-based and its burdensome “Organizational Integrity” rule hampers grantees’ ability to carry out the intent of the Leadership Act efficiently and effectively.20, 21, 22 Thus, it wastes scarce HIV prevention dollars and (pending litigation) may soon restrict the ability of U.S.-based NGOs to use proven methods and best practices to deliver HIV prevention services to sex workers.
Chapter 2: Increasing Access to Care and Improving Health Outcomes for People Living with HIV
1.1 Facilitate linkages to careNHAS states that “CDC, HRSA and SAMHSA and other relevant HHS agencies will work with States, tribal governments, localities and CBOs to promote co-location of providers of HIV screening and care services as a means of facilitating linkages to care and treatment, and to enhance current referral systems within CBOs.”A. Expand the range of HIV service provision sites (including prevention, voluntary counseling and testing, and treatment) to include integration of these services (by direct provision or referral) at:
•Federally Qualified Health Centers

•Other Federally-Funded Community Health Centers

•Indian Health Service centers

•GBV service provider sites

•mental health care provider sites

•SRH provider sites

A-i. Fund community-based programs and ongoing peer-to-peer support services that empower, educate and assist women and girls living with HIV in communicating fully with their health care providers.
1.2 Promoting collaboration among providersNHAS states that “HUD and other relevant federal agencies will develop joint strategies to encourage the co-location of, and enhance availability of, HIV-related services at housing and other non-traditional HIV care sites.”B. Develop and sustain substance abuse and HIV prevention programs in public housing developments and other venues heavily impacted by poverty, illegal drug trade and commercial sex.
B-i. Require local service providers implementing these programs to incorporate into them community-based outreach and education components on women’s and girls’ human and civil rights. This should include distribution of low literacy information regarding local sources of accessible legal assistance for those whose rights have been violated.
B-ii. Identify local public and community legal service organizations with demonstrable expertise in HIV, GBV and gender rights violations. List these as local sources of assistance in the program outreach materials described above. Scale up funding to these legal service providers to meet the increased need for their services generated by this outreach and referral system.
NHAS directs “CDC, SAMHSA, DOJ and HUD to identify and develop potential programs where there can be joint grant awards”C. Issue RFAs for joint grants to fund demonstration projects in the area of SRH/HIV/GBV integration. Fund and implement pilot projects particularly in epidemiological “hotspots” (areas with high numbers of new HIV infections). (This recommendation also applies to section 2.3 in Chapter 3 below)
1.3 Maintain people living with HIV in careNHAS states that “BOP will conduct a review of current policies and procedures and issue guidance to encourage all prisons to provide discharge planning to link HIV-positive persons to appropriate services upon release from incarceration in order to reduce interruptions in HIV treatment. This will include considering ways to promote broader adoption by nonfederal systems of BOP’s standards of providing a 30-day supply of HIV medications upon release.”D. Given that family reunification programs help to both reduce recidivism23, 24, 25 and assure continuity of care for HIV positive inmates upon release,26, 27 provide DOJ/DHHS funding to support family reunification programs in correctional facilities housing HIV positive people. Make the provision of these programs a condition of such facilities’ eligibility for DOJ block grant funding.
E. Given that sustaining family and community relationships during and following incarceration can reduce HIV risk-taking behaviors among incarcerated people and help assure continuity of care for HIV positive individuals upon their release (see references above), DOJ should:
•study and document the impact of peer-based support programs (both during incarceration and after release) on preventing recidivism and reducing HIV risk;

•require correctional facilities to fund tele-video services for use by inmates in dependency court appearances28 and general visiting with family members; and

•research programs that allow babies to stay with their mothers in correctional facilities29, 30, 31, 32 to determine their impact on:

•retention of HIV positive mothers in care following their release,

•family reunification after the incarcerated women’s release, and

•acquisition of effective parenting skills by HIV positive mothers.

2.1 Increase the number of available providers of HIV careNHAS directs HRSA, NIH and OMH to “develop a proposal to fund training programs to increase interest, representation and competence of health professionals, researchers, and racial/ethnic minority students in research, public health and HIV/AIDS care.”F. Require cultural competency qualification (with training and re-assessment for existing staff who fail to qualify) for all publicly funded health care providers and program staff to assure that these employees can accurately assess and respond to the needs of the populations they serve.
F-i. Diversify the staff within provider facilities to better reflect the communities they serve.
2.2 Strengthen the current provider workforce to improve the quality of HIV care and health outcomes for people living with HIV.NHAS states that the AIDS Educational and Training Centers (AETCs) will “expand training for HIV clinicians and provider organizations to address provider-associated factors (e.g. cultural competency, provider continuity) that affect treatment adherence.”G. Substantially strengthen the AETCs’ capacity to build cultural competency among primary health care providers, thus improving providers’ capacity for cross-cultural communication that correctly identifies and responds to their patients’ inter-related sexual health care, HIV, and violence prevention needs.
G-i Increase the AETCs’ use of instructors with specific expertise in culturally and linguistically appropriate communication around sensitive issues such as medical treatment adherence and the factors that may affect it (such as gender-based roles, stigma and violence).
G-ii. Highest priority for expanding this aspect of AETC trainings should be given to training providers in under-served and/or high HIV incidence areas.
NHAS directs HRSA to “increase the number of clinical providers who are engaged in innovative rural HIV/AIDS health care delivery systems (e.g. home health care, telehealth).”H. In addition to providing training to assure the cultural competency of these providers (see recommendation G above), invest in targeted and culturally competent outreach to promote uptake of innovative rural HIV/AIDS health care delivery systems (e.g. home health care, telehealth), particularly among underserved people in rural areas, Puerto Rico, and the U.S. Virgin Islands, as well as in Native Communities.
H-i. With the same level of attention to cultural competence as required in work with the rural and under-served communities mentioned above, extend targeted outreach to older citizen communities, using age appropriate models that make discussion of sexual health issues acceptable and de-stigmatize discussion of HIV risk, testing, and services.
3.1 Enhance client assessment tools and measurement of health outcomesNHAS states that federal agencies” in coordination with HHS OS, will work with States, localities, and CBOs to encourage the adoption of nationally accepted clinical performance measures to monitor the quality of HIV care.”I. Develop uniform gender-responsive standards of care and quality measures for the delivery of SRH and HIV care. Standards must assure equity in the levels and quality of care provided to women, men and transgender individuals.
3.2 Address policies to promote access to housing and supportive services to people living with HIVNHAS directs federal agencies to “collaborate and increase access to nonmedical supportive services (e.g. housing, food/nutrition services, transportation) as critical elements of an effective HIV care system.”J. Expand resources and programmatic support available to informal (unpaid) care givers who are providing primary, day-to-day care to people living with HIV in their family and/or community networks. Most unpaid care givers are women and girls and the provision of supportive services such as day care, transportation, food resources etc. are essential to their ability to sustain this role effectively.
3.4 Strengthen enforcement of civil rights lawsNHAS notes that the “Department of Justice and other federal agencies must enhance cooperation to facilitate enforcement of Federal antidiscrimination laws.”K. Issue a joint DOJ/DHHS statement against discriminatory practices affecting people living with HIV in the criminal justice system. Such a statement should specify the penalties and funding repercussions that will attach to such practices.
Chapter 3: Reducing HIV-Related Health Disparities
2.1 Establish pilot programs that utilize community modelsNHAS states that DHHS agencies will collaborate “to engage in policy research and evaluation activities to identify effective prevention approaches to reduce disease burden in high prevalence communities.”A. Support community-based participatory research (CBPR) to identify barriers to HIV testing and treatment in areas of high HIV prevalence and incidence in the United States. CBPR should also be funded to develop effective tools for SRH promotion and HIV prevention programming, as well as optimal methods of program integration, particularly in these regions.
NHAS directs “relevant HHS agencies to consider ways to enhance the effectiveness of prevention and care services provided for high risk communities, including services provided through the Minority AIDS Initiative.”B. Create a funded Congressional Initiative on Women and HIV that is directly analogous to the Minority AIDS Initiative.
2.3 Promote a more holistic approach to healthNHAS directs “HRSA/CDC, SAMHSA” DOJ and HUD to “include language in grant announcements requiring the integration of prevention and care services, including referrals to clinical services.”C. Issue RFAs for joint grant awards to fund demonstration projects in SRH/HIV/GBV integration. Pilot such collaborations in epidemiological “hotspots” (areas with high numbers of new HIV infections) in the United States. (This recommendation also applies to section 1.2.4 in Chapter 1 above.)
NHAD directs the HHS OS to “mine existing databases to explore associations between HIV infection and social determinants of health.”D. Feed this information into the process described above (see recommendation A of Chapter 1) in the development of mechanisms with which states and localities can collect, record and use social and structural determinants data relevant in their assessments of HIV service needs. Data should be disaggregated by sex (male, female, MTF, FTM) wherever possible.
3.1 Engage communities to affirm support for people living with HIV.NHAS directs federal agencies to “develop a joint initiative to consider ways to help individuals living with HIV access income supports, including job skills and employment.”E. Fund and support HIV service providers to train and engage qualified HIV positive women as peer health educators, primary and secondary prevention promoters, and service advocates for people living with HIV (PLWH). Assure that they are provided with regular, professional supervision and appropriate compensation.
3.2 Promote public leadership of people living with HIVNHAP states that federal agencies will “develop recommendations for strengthening the parity, inclusion and meaningful representation of people living with HIV in planning and priority-setting bodies.”F. The CDC/HRSA HIV/AIDS Advisory Committee, jointly with the DOJ, should establish a Community Advisory Board that includes formerly incarcerated women (both HIV positive and HIV negative) among its members to review the potential effectiveness and impact of all HIV and gender-related initiatives implemented in correctional facilities.
3.3 Promote public health approaches to HIV prevention and careNHAS states that the “CDC/HRSA HIV/AIDS Advisory Committee will solicit public input and make recommendations for normalizing and promoting individuals’ safe, voluntary disclosure of their HIV status.”G. Support school-based, community outreach, and social marketing campaigns that normalize HIV testing and care as a part of primary health care. This should be a part of comprehensive sexual health education (see recommendation I in Chapter 1 above).
NHAS states that DOJ and DHHS will “identify a departmental point of contact and provide technical assistance resources to States considering changes to HIV criminal statutes in order to align laws and policies with public health principles.”H. Invest in research to assess the impact that laws criminalizing HIV exposure and transmission are having on various populations’ willingness to get tested for HIV and access HIV care and services.
Important Issues Not Included in the NHAS that Related to Health Disparities
SRH and GBV integration issuesThe Implementation Plan does not address the integration of SRH and GBV services into HIV-related service provision as a way of more effectively and holistically meeting the needs in under-served communities, especially women and girls at high risk of HIV.I. During reauthorization of the Ryan White CARE Act, add SRH provision and GBV reduction language that requires grantees to indicate how these services will be linked with, and/or integrated into, the services provided by CARE Act grantees.
I-i. Ensure that the Affordable Care Act (ACA) guidance language, as it is developed, includes integration of SRH/HIV/GBV screening and treatment services by primary health care providers and provides incentives for such integration of services at the local level.
I-ii. The scope of the need for integrated services in diverse locations including rural communities, high risk urban settings, and Native Communities should be a taken firmly into account during development of ACA guidelines and delivery systems.
Criminal justiceThe value of peer health education is widely acknowledged and supported throughout the rest of the NHAS but this significant barrier to its provision in correctional institutions is not addressed.J. BOP guidance should include direction to revise “clearance procedures” that prohibit people with criminal histories from entering correctional facilities to deliver peer health education, since the provision of such information by formerly incarcerated peers has been shown to be highly effective.33, 34
Puerto Rico and the U.S. Virgin IslandsThe NHAS mentions that “Puerto Rico and the U.S. Virgin Islands, are disproportionately impacted by HIV” (see page 2) but steps assess the scope of this impact are not included in the Implementation Plan.K. Invest in more research to analyze the scope of the epidemic in the U.S. Virgin Islands and Puerto Rico, specifically with regard to incidence, structural risk factors, transmission rates, etc. Determine the impact of human trafficking (as distinct from the sale of adult, consensual of sex) on HIV transmission in the U.S. Virgin Islands
Chapter 4: Achieving a More Coordinated National Response to the HIV Epidemic in the United States
1.1 Ensure coordinated program administrationNHAS states that “OGAC will take specific action to facilitate the exchange of best practices and lessons learned between domestic and international HIV/AIDS programs funded by the U.S. government. “A. All federal funding agencies should be required to systematically document and disseminate information on “best practices” emerging from the programs they fund. A technical assistance database containing this information should be created and updated regularly to assure that it is readily available to grantees, service consumers, advocates and others. Program evaluation data contained in this database should be disaggregated by sex wherever possible.
A-i. Identify the interventions, techniques, opportunities and evaluation strategies that have successfully met the needs of women and girls in PEPFAR-funded programming abroad and assess their possible applicability in specific U.S. regions and populations.
A-ii. Similarly, identify gender-responsive strategies in the United States that have been effectively incorporated into the prevention and management of other diseases such as diabetes, cancer, hypertension, etc. Use the “best practices” database to make documented descriptions of these available for incorporation into HIV/SRH/GBV program, policy, and research as appropriate.
A-iii. Set aside resources to evaluate how such gender-responsive strategies, once adapted and incorporated into existing programs, have functioned and whether further adaptation and adoption of them is warranted.
NHAS states that “CDC, HRSA and SAMHSA will collaborate to examine the use of the same unique identifier across federal reporting to allow better coordination at the local, state and federal levels.”B. Through the Office of National Coordination of Health Information Technology (ONC), develop systems to ensure that electronic health records can be accessed regardless of health care provision site. Ensure appropriate transfer of electronic records when referrals for care and/or preventions services occur

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References and Notes 

  1. Office of National AIDS Policy, the White House. (2010). National HIV/AIDS Strategy. (page vii). Available: http://www.WhiteHouse.gov/ONAP.
  2. Office of National AIDS Policy, the White House. (2010). National HIV/AIDS Strategy: Federal Implementation Plan (page 1). Available: http://www.WhiteHouse.gov/ONAP.
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  28. Courts may, but are not required to, allow parents to participate in dependency hearings by telephone rather than in person. Failure to appear in person (or to participate by telephone, if permitted) often weighs against a person in the court’s judgement (see “Willie G. and Bonnie H. v Arizona Department of Economic Security and Nycole G. 2 CA-JV 2004-0065-2 CA-JV 2004-0066 (consolidated), 2005.” Available: http://www.apltwo.ct.state.az.us.
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  30. Carlson JR. Evaluating the effectiveness of a live-in nursery within a women’s prison. 1998. Journal of Offender Rehabilitation. 1998;27:73–85
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  34. In:  Richard R editors. Forging a future: The HIV-positive ex-offender. HRSA CARE Action Report. Washington, DC: Health Resources and Services Administration (HRSA), HIV/AIDS Bureau; 2007;Available: http://hab.hrsa.gov. This article notes that, “Peer educators can be inmates incarcerated alongside the inmates they are teaching, or they can be former inmates who have ‘been there, done that’ and have the valuable experience of life both inside and outside prison walls—and the experience of successfully remaining outside prison walls.”

 These recommendations reflect the opinions of the Forum participants and do not necessarily represent the views of the federal employees who facilitated this meeting or the federal agencies that sponsored it.

PII: S1049-3867(11)00173-3

doi:10.1016/j.whi.2011.07.009

Women's Health Issues
Volume 21, Issue 6, Supplement , Pages S227-S236, November 2011

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