CDC deputy chief says trend very worrisome’

U.S. far from goal to cut new infections by half

[Ronald O. Valdiserri, MD, MPH, deputy director of the National Center for HIV, STD, and TB Prevention for the Centers for Disease Control and Prevention (CDC), answers AIDS Alert’s questions about how well prevention interventions have been working in the United States and whether the nation is on its way to meet the Bush administration’s goals, announced in 2001, of cutting new HIV infections in the United States by 50% from 40,000 to 20,000 in 2005. Valdiserri also discusses his speech at the 10th Conference on Retroviruses and Opportunistic Infections, held Feb. 10-14, 2003, in Boston, and addresses the use of abstinence-only prevention programs in this question-and-answer interview.]

AIDS Alert: Why are you and the CDC now targeting clinicians for improving prevention efforts?

Valdiserri: First, the CDC’s reliance on the clinical community is not new either in HIV or STD (sexually transmitted disease) efforts. We’ve always recognized that clinicians outside of our own government-funded public clinics have a really important role to play in diagnosis, treatment, and prevention of HIV, so it’s not new.

I think we’re definitely seeing a greater emphasis on it, and that’s a result of first and foremost the changes that we’re witnessing in the HIV/AIDS epidemic. We’re talking about people in our country who, because they can afford the improved treatment, are living longer. Also, the majority of these people are sexually active. The good news is that based on information that we’ve collected that condom use with negative partners is fairly high, ranging from 78% to 96%. It is somewhat lower with partners who have an unknown HIV status.

The point I’m trying to make is that because people are living longer as a result of improved treatments, we now have the largest number to date of HIV-infected people in the United States, and we have further opportunities for transmission. So it becomes very important for clinicians to provide some basic level of prevention. We’re not talking about spending hours counseling individuals. We understand that physicians are very busy and don’t have a lot of free time — but very, very basic and appropriate primary care messages: asking folks about their sexual health if they’re dealing with someone who is not in a stable, monogamous relationship; reminding individuals of the importance of reducing risk, and preventing transmission to other partners.

AIDS Alert: In the 25 states that record new HIV incidences, why are we seeing an increase in infections between 1999 and 2001?

Valdiserri: Those are not new HIV incidences; they are keeping track of HIV diagnoses. We just know these are HIV diagnoses, and we don’t know how long the person has had that infection.

From 1999 to 2001, there’s an 8% increase in the number of HIV diagnoses, and prior to that time for the past couple of years, the diagnoses were decreasing. So it is important to point out that these are not incidence data. Also, we’re talking about 25 states here — we’re not talking about every state in the union. And we are missing some of the states with bigger HIV epidemics, such as New York and California. So it’s important to put out those caveats. However, even having said that, we are concerned that between 1994 and 1999, we saw steady decreases in HIV diagnoses, and now in 2001, we’re seeing a change in direction.

It’s too soon to tell whether this represents a long-term trend. But when we look at it in light of some of the other epidemiological information we have, for instance, outbreaks of STDs, including syphilis among gay and bisexual men across the United States, reports across the United States of increases in unsafe sexual behaviors, and also being aware of the fact that other countries in the industrialized world are reporting increases in unsafe sexual behavior and STD outbreaks, it’s very worrisome.

So we can’t say definitively that this means that HIV infections are increasing for all of the reasons that I stated, but certainly we’re concerned about it. And that brings me back to the point that we’re putting a greater emphasis on working with folks who are already infected with HIV to make sure we don’t fall short on their ongoing prevention needs.

I think as a nation, we’ve done a pretty good job of providing care for people who have HIV infection, and I think what we need to do is enhance the prevention services that provide to those individuals so we interrupt transmission.

AIDS Alert: In your talk at the retroviruses conference, you cited a number of studies that showed some positive effects of prevention programs.

Valdiserri: The point I was trying to make to this audience, which was primarily an audience of clinicians who provide care to people who are living with HIV and basic scientists, is I wanted to make sure they were well aware that there is a very strong and sound scientific basis for behavioral interventions that can reduce the risk of transmission. First of all, make the case that in two-plus decades of working to reduce HIV infection, we do have some irrefutable and randomized-control strong evidence that shows that if behavioral interventions are put together the right way and delivered at an appropriate level then they can reduce risk behavior. So I was trying to make that point about why it’s important to understand that people can change their behaviors, and we can work with individuals who are effective with HIV and encourage them to continue to maintain safe behavior so they don’t spread the infection. It’s the same way we work with people who are at high risk for infection, trying to get them to understand what they can do to prevent the infection, and if that’s not possible, then to work with them to reduce their risk of acquiring infection.

AIDS Alert: Among the studies that you have personally reviewed, have there been any studies that have shown that a program that only promotes abstinence from sex to an HIV-infected or at-risk audience has any effectiveness?

Valdiserri: You probably know that’s a topic of very intense discussion. I did not personally review the scientific literature on abstinence, and I think we’re all very anxious to learn the outcomes of a number of federally funded evaluations taking place that are going to be looking at the outcomes of abstinence approaches.

Let me say that based on what I know about the scientific literature on abstinence in that area and also consistent with CDC policies that we do embrace delay of sexual intercourse as an important intervention to reduce HIV infection.

It’s not the only intervention we embrace, however, but we do recognize — particularly for young people — that delaying sexual intercourse has a number of benefits, not just in terms of preventing HIV and STDs, but also obviously in terms of unplanned pregnancy and emotional health issues. So the agency clearly is on record that abstinence and interventions that delay sexual intercourse should be part of a comprehensive approach to ending the spread of HIV. Also, for sexually active people and for people for whom that message is not going to work, then we have to come up with other approaches and other options.

AIDS Alert: How are we doing with regard to the Bush administration’s and the CDC’s five-year prevention goals that were released in 2001?

Valdiserri: Those goals were developed by the CDC in collaboration with a number of different partners from all different segments, including the academic community, the provider community, nongovernmental organizations, research scientists, etc. It was part of a five-year strategic plan that looked very carefully at the issue of how we can decrease the number of infections we’re having in the United States.

We’ve been at a seeming plateau for the past several years that we estimate about 40,000 new infections every year. Some of the trends that we’re seeing, including trends in HIV diagnoses and STD outbreaks, give us pause, give us reason for concern, but based on the best available information we have, we think it’s been relatively stable, and that’s not good enough.

The whole purpose behind this five-year strategic plan was to try to get as many players as we could with good insight into all of the various dimensions of HIV prevention, ranging from the scientist to the care provider, and to think how we could reduce the number of new infections.

Yes, we did set a very ambitious goal, and we said if we were able and given adequate resources we thought it was possible to reduce new infections by half. Have we met that goal? Here’s what I can tell you: One of the important outcomes of that activity has been a much stronger support for the development of a surveillance system that could more accurately estimate the number of new infections occurring in the United States. And we had funded a year ago, or more than a year ago a number of health department demonstration sites to use the de-tuned assay, the test that enables us to distinguish a recent HIV infection from remote HIV infection and use that to give us a much better measure of incidence. We have those pilot studies under way, and we’ve expanded the number of sites that are conducting that work. We expect to have some preliminary data on a much better estimate by 2004. That’s a direct outcome of this push to get the number of infections down.

We have a stronger emphasis on prevention for positives and a stronger emphasis on testing for the estimated 180,000 to 280,000 people in the United States who are infected with HIV and don’t know it. We have definitely made a stronger push in that direction.

We work with the Infectious Disease Society of America and federal agencies, including the National Institutes of Health and the U.S. Health Resources and Services Administration to develop guidelines that can be used in practice care settings to deliver prevention messages. Definitely, we’ve had a lot of positive movement. Have we reached the 20,000 goal? Probably not, but we are continuing to make progress in the right direction, and it’s an important goal to work toward. There definitely have been substantial advances that we can point to in surveillance and that will ultimately result in fewer infections, so we’ll need to keep striving to achieve that.

AIDS Alert: What can clinicians do in their practices to improve HIV prevention efforts?

Valdiserri: I think two things: If we’re talking about clinicians in a general practice who are not just seeing HIV-infected individuals, I would say that we really do think that it’s important for people to learn their serostatus and to make HIV testing more of a routine part of medical care for adult patients. For clinicians who are serving HIV-infected individuals, I think we need to remind them that prevention needs to be part of the primary care agenda. Again, we’re not talking so much about an HIV-infected person who is married or who has a single sexual partner who is monogamous, as those individuals who are HIV infected and have multiple sexual partners. And we do want to make sure the physician gets the point across that this still is a very serious infection and folks need to take steps to make certain they don’t spread it to others. That’s a very important message that care providers can give in a nonjudgmental way.