Problems of equity in US HIV integrated planning, 2015-2021: Enacting a bounded justice continuum

The US HIV/AIDS response is notably worse than those of other high-income countries. The country's epidemic is marked by low viral suppression rates, high incidence, lacking coordination, and entrenched disparities along lines of sexuality, race/ethnicity, gender, class, and other factors. In 2010, the National HIV/AIDS Strategy for the United States (NHAS) was launched, centering an equity-oriented vision that prioritized marginalized groups. NHAS implementation required states to create HIV integrated plans to better coordinate services and meet populations' needs. We used Carol Bacchi's "What's the Problem Represented to Be?" approach to analyze 20 jurisdictions' plans, focusing on how they incorporated equity-oriented principles articulated in NHAS's vision statement and other factors such as plans for integration across HIV care, surveillance, and prevention programs. Building on Melissa Creary's concept of "bounded justice," we show that integrated plans enacted a "bounded justice continuum," wherein some states pursued more equity-oriented strategies than others. We argue that this reflects constraints planners faced and the structure of US federalism, where implementing jurisdictions operated in variously restrictive or enabling conditions related to state-level politics, available public health infrastructure, and other factors. Our approach and the bounded justice continuum concept can be useful for scholars studying the rollout of equity-oriented policies in federal systems where local implementations will vary widely. We ultimately arrive at a positive assessment of US HIV integrated planning. However, we also advocate for more transformative reforms to ensure that people living with and affected by HIV can access universal healthcare, social services, housing, and employment.