Millions for prevention could save billions

CDC likely to fall short of lofty goals

(Editor’s note: This fall, AIDS Alert will provide complete coverage of the biannual prevention conference sponsored by the Centers for Disease Control and Prevention and held July 27-30 in Atlanta. The study discussed in the article below preceded the conference.)

The Centers for Disease Control and Prevention of Atlanta set a national goal in 2001 of a 50% reduction in new HIV infections by 2005. If the nation succeeds in meeting this goal, there will be 130,000 fewer HIV infections, and the savings in unspent health care dollars would amount to $18.5 billion, a new study shows.1

That’s the good news. The bad news is that there are no signs that new HIV infection rates have been reduced at all in the past two years, and there is some evidence that they may be increasing.

"Of states with HIV surveillance in the last couple of years, there was an 8% increase in newly diagnosed HIV infections, so that would be an area of concern," says David Holtgrave, PhD, a professor in the Rollins School of Public Health at Emory University in Atlanta.

Achieving the goal of reducing new infections by half would require an additional $383 million per year for prevention programs. But even taking that cost into account, the savings to the nation’s health care system would be $18.5 billion by 2005, Holtgrave says.

Investigators determined the $18 billion cost based partly on estimates that lifetime treatment costs for a person living with HIV is about $154,000 in 1996 dollars. The analysis also assumes it would be possible to reduce new infection rates by half, given enough financial input

Holtgrave, a co-author of the study on economic implications of HIV infections, directed HIV/AIDS prevention for the CDC from 1997 to 2001. If the CDC ultimately fails to reduce HIV new infections by 50% or even 5%, it will essentially be a money matter, he says.

"These sorts of funding decisions aren’t made within the CDC," Holtgrave says. "A major expansion of a prevention program is something that would be made more in terms of the president’s budget and then, especially, in Congress."

Federal funding of HIV prevention programs received only inflationary increases during the 1990s. The CDC’s fiscal year 2003 budget was increased by only $9 million from the previous year, Holtgrave notes.

Two years ago, the CDC estimated that in order to reduce new HIV infections by 50% in four years, it would be necessary to increase by 30,000 each year the number of infected people who learn their serostatus and are linked to care and prevention services. Also, the CDC stated that full prevention services were necessary for all HIV-infected people, and achieving those goals would require an additional $300 million a year, according to a CDC study published in 2001 in the American Journal of Public Health.2

The $383 million figure is based on the investigators’ calculations of what it would cost to fund state-of-the-art prevention services. The success of additional prevention efforts would depend on whether the money was earmarked for scientifically effective programs or whether spending was constrained by policy barriers, Holtgrave says.

"We’ve done quite a number of studies, starting with the more specific and moving toward the national, on things like small-group behavioral intervention for women attending urban primary care clinics, specific interventions for gay men, and we’ve also looked at programs for African-American adolescents," Holtgrave explains. "In these previous studies, we looked at the interventions that have been shown to be effective and cost-effective."

For example, the CDC has expanded prevention programs through a model the CDC calls the Serostatus Approach to Fighting the Epidemic, which includes a focus on linking HIV-infected people with prevention programs created by community-based organizations and health departments, and with case management related to clinical care and social services that include risk-reduction counseling.

The key to success with prevention programs is implementing those that are effective according to scientific research, Holtgrave says.

"In some areas, if you put enough strings on money, then you might impact the program’s effectiveness," Holtgrave says. "In the U.S., it’s really important to be able to do programs found to be scientifically sound and go forward with those."

However, the potential use of additional prevention funds is a moot point because there has been no push to significantly increase the CDC’s prevention budget.

"In the United States, the public health system is not used to an incidence level that has remained flat in this way for so long," Holtgrave says. "I think HIV is an issue that people are somewhat burned out on, and it’s often taking a backseat these days, especially HIV prevention issues."

Apathy toward the epidemic could spell bad news for the public health system, as there have been clusters of increased incidences of sexually transmitted diseases, and there are other indicators that HIV infection rates could be on the rise, Holtgrave says.

One of the problems is that the CDC doesn’t have accurate HIV incidence numbers; more than half of the states have only just begun to collect HIV infection data, and it may be several years before the data can be considered useful, Holtgrave explains.

"I think it will probably take some time for the HIV incidence numbers to be available," Holtgrave says. "But it’s sorely needed, and it’s not the kind of thing that’s available in the next few months."

References

1. Holtgrave DR, Pinkerton SD. Economic implications of failure to reduce incident HIV infections by 50% by 2005 in the United States. JAIDS 2003; 33:171-174.

2. Janssen RS, Holtgrave DR, Valdiserri RO, et al. The serostatus approach to fighting the HIV epidemic: Prevention strategies for infected individuals. Am J Pub Health 2001; 91:1019-1024.