Special Report: HIV prevention at 25 years

Prevention costs much less than treatment

Prevention programs needed to reduce infections

Each new HIV infection may reach more than $200,000 in medical costs and result in the loss of nearly 24 quality-adjusted life years, according to a new study.1

The cost of prevention efforts, by contrast, are estimated to range from $6,400 to $49,700 per HIV infection prevented.1

This is why more money directed at HIV prevention in the United States is a cost-effective strategy for dealing with the epidemic, says David Holtgrave, PhD, professor and chair of the department of health, behavior and society at the Bloomberg School of Public Health at Johns Hopkins University in Baltimore.

The CDC has focused in recent years on expanding HIV testing and prevention for positives, and these strategies make sense because studies show that 96% of people who know their status and live with HIV are not transmitting the disease to anyone, Holtgrave says.

Scientists define the HIV transmission rate as the number of new HIV infections in a year divided by the total number of persons living with HIV/AIDS in that year.1

In 1983, the HIV transmission rate was estimated to be 43%, but has fallen to about 4% in recent years.1

For those who are unaware of their HIV infection, the transmission rate is nine to 11%, Holtgrave says. And for HIV positive people who are aware of their status, but who are continuing to engage in risky behaviors, the transmission rate is 1.7% to 2.5%, he adds.

"So it's very important for people to receive counseling and testing and to be aware of their HIV status," Holtgrave says. It's also important to continue to provide risk reduction interventions to people who are at risk for HIV infection, but are seronegative, Holtgrave notes. "We need to make sure we're targeting services to African American metro-sex males, addressing their health disparities, and making sure we're studying the kind of interventions that are needed," Holtgrave says.

Other prevention interventions could be aimed at the general population as both a public health prevention strategy and also a way to improve HIV education and reduce the disease's stigma, he suggests.

"You might think it's obvious that people in the U.S. know how to protect themselves, and years ago, that might have been the case," Holtgrave says.

Former Surgeon General C. Everett Koop, who was appointed by President Reagan in 1982 and served in that role until 1989, had sent out a public health service brochure, called "Understanding AIDS," to all 107 million U.S. households in 1988.

Koop's public brochure and treatment of AIDS as a public health issue helped to educate the public about the disease and its transmission, Holtgrave says.

The public's knowledge about HIV/AIDS has deteriorated since then.

In a recent survey by the Kaiser Foundation, 43% of Americans answered at least one basic question wrong about how HIV is transmitted, Holtgrave says.

Also, nearly 45% of people surveyed didn't know there were medicines available that pregnant women could take to avoid transmitting HIV to their infants, Holtgrave says.

"The idea that there's that much misinformation in the United States is not widely discussed," he says.

If the U.S. fails to put money and effort behind further reducing new HIV infections then the public health cost will be considerable, with more than 100,000 persons becoming HIV infected by 2010, resulting in medical costs of about $18 billion.1

"This year, I have to say, I saw a ray of hope in the president's budget proposal to Congress," Holtgrave says. "There was an inclusion of $93 million in new dollars for domestic HIV prevention at the CDC, and that would reverse the trend of flat funding."

The proposed $93 million was targeted toward rapid testing and counseling services, especially for incarcerated populations, and it's debatable whether that would be the most efficient use of the additional funding, Holtgrave notes.

"But nevertheless, seeing that figure was hopeful," he says. "The overall level of resources is tremendously important. If you need to apply X number of tests or interventions, it costs so much per client to do so, and we need to get that $300 to $350 million more."

It's also important to use the prevention money for science-based strategies, he says.

Needle exchange programs and condom use to prevent HIV transmission have a good body of scientific evidence showing their efficacy, so it's disheartening to see political concerns pushing these strategies to the back shelf, Holtgrave says.

"There's a federal ban on needle exchange, and condoms information was removed from the CDC web site for a time," he says. "It's like we have a shelf in which one is putting interventions that we know will work, but we can't use them, and, unfortunately, that shelf is getting a little crowded."

Holtgrave says he's also dismayed that the CDC has decided to no longer recommend HIV counseling for everyone who is offered HIV testing.

"I'm in favor of making HIV testing more routinely available, but I'm concerned about tossing counseling away because it's perceived that clinicians are too busy to provide it," Holtgrave says. "There's good evidence to show the positive effect of providing HIV counseling and basic information to people."


  1. 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.