Special Report: HIV Prevention at 25 Years: HIV prevention over past 25 years had early successes, now treads water
Special Report: HIV Prevention at 25 Years
HIV prevention over past 25 years had early successes, now treads water
Progress made fast and early on
When money and time are put into HIV prevention efforts, they can have a dramatic impact, and the United States is a good example of this. But the reverse also is true, HIV prevention experts say.
Prevention programs dropped new infections from 160,000 a year in the mid-1980s to 40,000 a year since 1990, says David Holtgrave, PhD, a professor and chair in the department of health, behavior and society in the Bloomberg School of Public Health at Johns Hopkins University in Baltimore.
A study Holtgrave co-authored estimated that without HIV prevention investments totaling more than $10.1 billion from the early 1980s to 2000, there would have been an additional 204,000 to 1.585 million HIV infections in the United States.1
That's the good news. The flip side of the coin is that the prevention work and research funded by the CDC and state and local prevention spending have not resulted in any further reduction in HIV infections nationwide in 16 years. This is despite the CDC's well-publicized prevention goal of 2001 to cut new HIV infections in half to 20,000 a year by 2005.
The nation's prevention strategy problems were highlighted last year when the U.S. failed to make progress toward the CDC's 2005 goal, says David Satcher, MD, PhD, former U.S. Surgeon General and interim president of Morehouse School of Medicine in Atlanta. Satcher spoke at a news teleconference about the state of HIV in America, held by the Open Society Institute of New York, NY. "The CDC's prevention budget has been cut since the goal was promoted in 2001," Satcher said.
"We invest not enough, but a significant amount of money to HIV in the U.S., but the outcomes are hugely disappointing," says Chris Collins, a Philadelphia consultant to the Open Society Institute. Collins authored a report called "HIV/AIDS Policy in the United States," produced by Public Health Watch and the Open Society Institute.
"Half of people needing treatment are not getting it, and the HIV infection rate is locked at 40,000, year-in, year-out," Collins says. "Our country has failed to hold itself accountable."
The CDC's failure to meet its 2005 goals and the stagnant new infection rate is a matter of dollars and cents, Holtgrave says.
"When we look at the HIV prevention budget at the CDC, adjusted for inflation, it's a mirror image of an HIV incidence curve," Holtgrave says. "As we spent more money we saw a drop in infections; when the investment leveled off, we saw a drop-off of reduction as well."
To further make a significant dent in the estimated 40,000 new infections each year, the CDC's prevention budget would need to be increased by $300 million annually, Holtgrave says.
In recent years, the CDC has shifted its focus to prevention efforts aimed at persons living with HIV infection and to identifying more people who are infected.
The CDC's Serostatus Approach to Fighting the HIV Epidemic was introduced in 2001; and in 2003, the CDC implemented the Advancing HIV Prevention (AHP) initiative.2
It's still too early to know if the CDC's increased push for HIV testing has had any impact on reducing the number of people who are unaware that they are HIV positive, says Richard Wolitski, PhD, chief of the prevention research branch of the CDC.
"Within our demonstration project that was supported through AHP, we've been looking at a variety of different strategies for improving the effectiveness and ability of HIV testing programs to identify undiagnosed HIV positives," he says.
For example, one project funded under AHP was the social network demonstration project in which the strategy was to recruit HIV positives in the community to refer the people they know who they think may be HIV positive and to bring them in for testing, Wolitski explains. "Under AHP, we funded a nine-site demonstration project that evaluated this strategy," he says.
Preliminary data published last year showed that of 814 people tested during that project, 5.7% were newly-identified HIV positive, he says. "That's a rate that is about six times higher than what we see in a regular HIV testing and counseling program," Wolitski says. "We'll present updated data this summer at the International AIDS Conference."
CDC officials are working on translating AHP knowledge into HIV prevention programs, creating materials and programs that will help health departments and community-based organizations (CBOs) implement the approach, Wolitski says.
"I think that CDC believes in and the data support the need for a three-pronged approach to HIV prevention that includes HIV counseling and testing, prevention for people who are living with HIV, and prevention for persons who are at high risk for contracting HIV," Wolitski says. "We can't leave any of those three major activities out of the equation."
However, critics say the CDC is emphasizing HIV testing and prevention for positives over traditional prevention programs designed for high risk groups, and they claim that this is contributing to the new infection rate remaining high.
Better spending would yield better results
If federal funding was used more efficiently, it could have a far greater impact, says Judy Auerbach, PhD, vice president for public policy with the American Foundation for AIDS Research (amfAR) of New York, NY. Auerbach also spoke at the Open Society Institute's teleconference on AIDS in America.
"A 2005 RAND study, for example, reviewed the cost effectiveness of various HIV prevention interventions and determined that the approximately $415 million dollars that CDC was providing in 2004 for HIV prevention activities could cut HIV infections in half, or by about 20,000 per year, if the funding were used for a mix of targeted and generalized interventions,"3 Auerbach says.
These interventions might include community mobilization for men who have sex with men, needle exchange programs in high drug use and HIV prevalence areas, notification, expanded condom availability, and mass media campaigns, she says.
"But these are not the things our government is supporting," Auerbach says. "Rather, the CDC's current prevention program emphasizes HIV testing, which, in fact, has not been shown to actually reduce HIV risk behaviors or HIV infections."
The CDC also continues to emphasize prevention of perinatal transmission, although this has practically disappeared in the United States, Auerbach says.
Prevention for positives is an important strategy, Wolitski says. "First of all, people who don't know they are HIV positive are at greatest risk of transmitting the virus to others. Those who test positive reduce risk behaviors following the diagnosis, and they are less likely to engage in risky behaviors that put other people at risk for contracting the virus."
Plus, it's incredibly important that people with an undiagnosed infection get diagnosed and treated for their infection, Wolitski adds.
"We have to be concerned about both the transmission to others and the health and well-being of people living with HIV and AIDS," Wolitski says. "We know that late diagnosis of HIV disease is a critical factor in the ongoing problem with AIDS morbidity and mortality."
A recent study in the American Journal of Public Health found evidence that federal HIV prevention spending correlates with increased HIV testing rates and awareness of mother to child transmission4, Wolitski notes.
The Open Society report also criticizes the increasing funds spent on abstinence-only education. In the past 10 years the federal government has spent nearly $1 billion on abstinence-only programs, and an estimated 35% of school districts that have a sex education program teach only abstinence until marriage and prohibit discussions of condoms for disease or pregnancy protection.3
"This approach to teaching about sexuality and HIV persists even though a wealth of studies and program evaluations have failed to find abstinence-only programs to be effective," the report says.3
While it's important to talk about abstinence with young people, it's neglectful to withhold information from them about what will help them prevent pregnancies and sexually transmitted diseases in the event they fail to abstain from sexual contact, Satcher says. "And certainly, everybody's not going to agree in terms of the values that we hold, but withholding information from people who need to be responsible to themselves and others is certainly not appropriate," Satcher says.
Likewise, the federal government has prohibited the use of federal funds for needle exchange programs despite the overwhelming scientific evidence that such programs greatly reduce HIV transmission.4
Nationally, the injection drug use (IDU) transmission rate continues to be substantial, but there has been a decrease in incidence of infections associated with IDU, Wolitski says.
"There has been a decline from 10% to 14% to less than 2% during the 1990s in HIV incidence among IDUs," Wolitski says.
The CDC has established a prevention effectiveness team to look at how CDC prevention money is spent and to assess what would be the optimal allocation for resources to different types of prevention programs, Wolitski says.
References:
- Holtgrave DR, Curran JW. What works, and what remains to be done, in HIV prevention in the United States. Annu Rev Pub Health. 2006;27:261-75.
- Evolution of HIV/AIDS prevention programs—United States, 1981-2006. MMWR Morb Mortal Wkly Rep. 2006;55(21): 597-603.
- HIV/AIDS policy in the United States. Monitoring the UNGASS Declaration of Commitment on HIV/AIDS. Public Health Watch/Open Society Institute. May, 2006:1-76.
- Linas BP, Zheng H, Losina E, et al. Assessing the impact of federal HIV prevention spending on HIV testing and awareness. Am J Pubic Health. 2006;96(6):1038-1043.
Subscribe Now for Access
You have reached your article limit for the month. We hope you found our articles both enjoyable and insightful. For information on new subscriptions, product trials, alternative billing arrangements or group and site discounts please call 800-688-2421. We look forward to having you as a long-term member of the Relias Media community.