Generating hypotheses to explain declining HIV infection in four U.S. jurisdictions

The aims of this study were (1) to generate hypotheses to explain declines in HIV incidence in Massachusetts, North Carolina, San Francisco, and Seattle, and (2) based on lessons learned from these jurisdictions, to offer recommendations for implementation elsewhere. Through in-depth interviews, we identified policies and practices that stakeholders across jurisdictions believe are important to achieving successful outcomes. The most unifying observation was that leadership within health departments is critical to achieving success. With this consideration, we developed a list of tools for public health officials to assert leadership to address challenges posed by HIV: extending access to health insurance, using an array of approaches to increase knowledge of serostatus, investing in services to retain people in care, collecting and using better data, translating data into policy change and public health practice, developing targeted programming for vulnerable populations, minimizing administrative policies that attenuate program success, and diversifying funding sources.