The U.S. Ending the HIV Epidemic (EHE) Initiative: What You Need to Know

What is it?

The Ending the HIV Epidemic (EHE): A Plan for America is an initiative launched by the federal government with the aim of addressing the HIV epidemic in the United States. The initiative was announced by President Trump during the State of the Union address in February 2019 and aims to reduce new HIV infections by 75% in five years and by 90% in ten years by focusing first on the hardest hit areas of the country. The EHE includes four “pillars”: diagnose, treat, prevent and respond (see below).

Where are the targeted jurisdictions?

During “Phase 1,” the initiative focuses on the 48 counties that had the highest number of HIV diagnoses between 2016 and 2017, as well as San Juan, Puerto Rico, and Washington D.C. It also focuses on seven states with a substantial rural burden. More than 50% of HIV diagnoses in the US occur in these 48 counties, D.C., and San Juan. Phase 2 will reportedly have a broader reach extending to the nation as a whole.

Figure 1: Ending the Epidemic (EHE) Phase 1 Jurisdictions: 48 high burden counties, D.C., San Juan, P.R., and 7 states with a high rural burden

How is it Funded?

The commitment to “ending the HIV epidemic” has been accompanied by new federal funding, starting in FY 2019. Funding in FY 2019 consisted of a small number of grants reprogramed from the Secretary’s Minority AIDS Initiative (MAI) fund to launch the initiative prior to its formal year one start in FY 2020.

Table 1: Ending the Epidemic Funding – President’s Budget Requests (BR) FY2020 + FY2021 and Enacted Funding FY2020 (In Millions)
FY20 BR FY20 Enacted FY21 BR % Change
FY20 BR –
FY21 BR
$ Change
FY20 BR –
FY21 BR
% Change  FY20 Enacted – FY21 BR $ Change
FY20 Enacted –
FY21 BR
CDC $140 $140 $371 165% $231 165% $231
HRSA
  Ryan White $70 $70 $165 136% $95 136% $95
  Health Centers $50 $50 $137 174% $87 174% $87
IHS $25 $0 $27 8% $2 $27
NIH $6 $10 $16 167% $10 60% $10
TOTAL $291 $270 $716 146% $425 169% $450
Sources: Domestic HIV Funding in the White House FY2021 Budget Request

The MAI is a federal program supporting “innovative projects to improve HIV prevention and care in communities of color.” In his FY 2020 budget request, the President asked for $291 million in new funding for the EHE and Congress provided $271 million. This represented the first significant increases for HIV prevention at the Centers for Disease Control and Prevention (CDC) and for the Ryan White HIV/AIDS Program, the nation’s safety net program for HIV care and treatment, in many years. FY 2020 funding was also provided to National Institutes of Health (NIH)’s Office of AIDS Research (OAR) and proposed for but not allocated to the Indian Health Service (IHS). (See table 1).

The President’s FY 2021 budget request to Congress includes $716 million for the EHE, which if enacted, would represent an increase of $450 million (165%) over the FY 2020 amount. Congress has not yet finalized appropriations for FY 2021. More detail about the FY2021 request is available here.

Agency funding is distributed via grants to the targeted jurisdictions, as well as to support related efforts. For additional detail, see our EHE funding tracker.

It is important to note that while EHE funding represents a significant increase for certain agencies, it still accounts for a relatively small share of total federal HIV funding provided to state and local jurisdictions. For a fuller accounting of such funding, see our state HIV funding tracker.

What are the EHE goals? What is the plan to meet them? And can they be met?

The goal of reducing new HIV infections by 75% in five years and by 90% in ten years, if successful would, according to the federal government, avert an estimated 250,000 new infections.  

There are four “pillars” to the initiative that serve as a road map for achieving EHE goals:

  • Diagnose: Currently, 14% of people in the United States with HIV are unaware of their infection and 40% of all new HIV infections result from someone who did not know they were HIV positive. This strategy pillar seeks to diagnose all people in the US as soon as possible after infection.
  • Treat: HIV Treatment is important for optimal individual health outcomes and harnessing the benefits of “treatment as prevention”– that is when someone is virally suppressed, they cannot transmit HIV to others. This pillar aims to treat people with HIV rapidly after diagnosis to help achieve and maintain viral suppression.
  • Prevent – While the rate of new HIV infections has slowed since its peak, progress has stagnated in recent years and racial disparities persist. The prevent pillar seeks to use proven prevention interventions to stop new HIV infections from occurring with a specific focus on bolstering PrEP uptake.
  • Respond – The respond pillar is focused on rapidly responding to potential HIV outbreaks to disseminate prevention and treatment services as needed and in part relies on harnessing public health strategies, such as molecular surveillance.

The EHE goals are ambitious and the strategy to reach them is grounded in science, yet one model suggests that the goal of reducing new infections by 90% in ten years “is likely unachievable with the current intervention toolkit.” However, these researchers also note that while the goals may not be fully realized, HIV infections could be reduced by up to 67%with higher levels of engagement in care and increased PrEP uptake.

What is the process for determining local-level activities?

In Phase 1, the initiative focus is on areas where HIV transmission occurs most frequently or disproportionately. As such, the Administration is working to provide these jurisdictions with “resources, expertise, and technology to develop and implement locally tailored EHE plans.” Locally-focused plans mean that jurisdictions can adjust their efforts to meet local cultural and epidemiological needs. For example, a jurisdiction hard hit by the opioid epidemic might make addressing this a central theme in their EHE plan, but such a focus might not be appropriate in all areas. According to Administration officials, jurisdictional plans are set to be approved by CDC and HRSA later in 2020 and will be made publicly available.1

How does the EHE fit within the larger policy environment?

The EHE initiative, while grounded in science and public health principles, does not take place in a vacuum. Other policies backed by the Trump Administration, namely those that could limit health care access (e.g. work requirements in the Medicaid program, support for non-compliant health plans, efforts to repeal the ACA, etc.) and those that remove protections for LGBT people and other minority groups (e.g. proposals to remove gender identity and sexual orientation protections in the ACA, implementation of the public charge rule, etc.) could diminish its reach and success. These policies could result in loss of coverage or foster stigma that might make vulnerable groups less likely to access critical health services. Our recent analysis explores a range of contextual and structural factors that could mitigate or facilitate EHE progress across the jurisdictions in four areas: policy and legal, socioeconomic, service availability, and overlapping. We find substantial regional differences that may ultimately indicate uneven EHE implementation and progress over time.

What is the relationship between the EHE and the National HIV/AIDS Strategy (NHAS)?

The National HIV/AIDS Strategy (NHAS) was first introduced by the Obama Administration in 2010 marking the first time US government agencies came together to develop a coordinated approach to addressing the HIV epidemic. It was updated in 2015 and a third update is currently underway. The NHAS had four main goals 1) Reduce new HIV infections; 2 ) Increase access to care and optimize health outcomes for people living with HIV; 3) Reduce HIV-related health disparities and health inequities, and 4) achieve a more coordinated national response to the HIV epidemic.

While the Trump Administration has said that the two strategies will be complementary, details have not yet been provided. One notable difference between NHAS and EHE is that the NHAS was not exclusively a federal initiative, incorporating state, local, community and private partners in its approach, whereas the EHE sits more squarely in the administration’s purview.

What might the future hold for the EHE?

There are substantial unknowns around whether the EHE goals can be met and how effective the initiative will be in the short and long term. Some key questions that will be important to track include:

  • Will decisions made at local levels in Phase 1 jurisdictions result in different outcomes? As noted, there are underlying contextual and structural factors within each local jurisdictions that will facilitate or mitigate EHE success so disparate outcomes across the nation are likely.
  • How and when will Phase II be rolled out? The Phase I jurisdictions represented 59% of HIV diagnoses in 2018 so focusing efforts exclusively in these areas cannot meet the 5 or 10-year EHE goals.2 Broadening the EHE initiative beyond the hardest hit areas will be necessary to meet the EHE goals.
  • What will the impact of policies that reduce access to coverage and increase stigma be in meeting EHE goals? Can these barriers be overcome? As discussed above, some Trump Administration policies, such as those that could reduce access to coverage (e.g. efforts to repeal the ACA) and increase stigma (e.g. remove protections related to sexual orientation and gender identity), could run counter to EHE goals. Monitoring their impact will be critical.
  • 2020 is an election year- what might that mean for the EHE? If President Trump is re-elected for a second term, the administration will likely continue EHE given it has been a stated priority. However, if a new Administration gains office, it is unknown whether the EHE initiative will be kept in its current form.
  • Will current levels of funding be maintained, expanded, or decreased? The ability to meet the goals of the EHE initiative depends on funding. While the Trump Administration budgets made significant funding requests and so far, Congress has aligned appropriations with these asks, future funding levels are not guaranteed.
  • How might the COVID-19 pandemic and domestic response impact the ability to meet EHE goals? While as of April 2020, the administration had no plan to delay EHE goal deadlines given the outbreak, federal officials have recognized there will be implementation delays as the nation faces new challenges in light of the COVID-19 crisis.3 While the COVID-19 pandemic has made many aspects of daily life challenging, some barriers have been particularly acute in the world of HIV treatment and prevention. Many federal employees, local health department staff, and front-line workers focused on HIV have been redeployed as infectious disease specialists to address the emerging pandemic. In addition, not all HIV services, especially those related to HIV prevention, are as available as they were in the past. In recognition of these impacts, Congress appropriated additional funding for the Ryan White HIV/AIDS Program and the Housing Opportunities for People with AIDS (HOPWA) program, to assist grantees in preparing for, preventing, and responding to the COVID-19 pandemic.

This work was supported in part by the Elton John AIDS Foundation. We value our funders. KFF maintains full editorial control over all of its policy analysis, polling, and journalism activities.

Endnotes
  1. Phillips, Harold. Ending the HIV Epidemic Update Q1 and Q2 Presentation for the Federal AIDS Policy Partnership. 4/29/20

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  2. KFF analysis of data from CDC atlas.

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  3. Phillips, Harold. Ending the HIV Epidemic Update Q1 and Q2 Presentation for the Federal AIDS Policy Partnership. 4/29/20

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