CDC’s 5-year prevention plan: Ambitious but feasible
CDC’s 5-year prevention plan: Ambitious but feasible
Plan calls for new SAFE action
(Editor’s note: This is the second part of a two-part series on the CDC’s launch of new prevention efforts tied to the 20th anniversary of the discovery of AIDS. The July issue of AIDS Alert reported the CDC’s findings that HIV risk has increased among young black gay and bisexual men.)
AIDS groups applaud the five-year prevention strategy plan developed by the Centers for Disease Control and Prevention in Atlanta, saying the plan’s goals are ambitious and might even be achieved, provided domestic HIV funding continues to increase. "The CDC goal is admirable, and I think it can be achieved," says Scott Brawley, MSW, policy and program analyst for AIDS Action of Washington, DC. "But you can’t have prevention efforts as one of your goals and not fund it adequately."
Brawley refers to the Bush administration’s flat funding of domestic HIV care and prevention services in the proposed FY 2002 budget. As of the end of June, Congress had taken no action to increase HIV funding in the proposed budget for next year.
The CDC’s five-year prevention goals are as follows:
• Increase voluntary counseling and testing from the current 70% of HIV-infected people to 95%.
• Increase the proportion of HIV-infected people who are receiving treatment and care from the current 50% to 80%.
• Decrease the number of people at risk for acquiring HIV infection by 50%.
To achieve these goals, the CDC has targeted programs for those populations at greatest risk of becoming infected. These include minority men and women and young gay men, especially those of color. "We really have dramatically expanded our efforts in working with communities at greatest risk, and we will provide $400 million to state prevention programs targeting high-risk individuals, among which gay men are among the highest- priority category," says Helene D. Gayle, MD, MPH, director of the CDC’s National Center for HIV, STD, and TB Prevention. Gayle spoke at a special teleconference in June 2001 about the CDC’s prevention plan.
"We owe it to the people who have been part of the HIV epidemic for the last 20 years to really invest ourselves and make the impact that we know we can and that we have to make to meet the epidemic in this country and further reduce the spread of HIV to all," Gayle adds.
The most important part of the CDC’s prevention goals is to reduce new HIV infections, and the nation is well on its way to achieving that goal, says Nancy Palmer, PhD, director of education and prevention for AIDS Action Committee of Massachusetts in Boston. "In terms of prevention, we’re at a point where we’re offering pretty intensive, enhanced prevention interventions which are reaching those at highest risk of acquiring or transmitting the virus," Palmer says.
Recent CDC reports about the rising rates of HIV infection and sexually transmitted disease (STD) infection among young gay and bisexual men, particularly those who are African-American or Hispanic, have served as a call to action that has jolted the public out of its complacency about the disease. These reports also underline the importance of targeting prevention and testing/counseling campaigns to those populations at greatest risk of infection.
"I think this is going to call for states to focus more on this population and look for ways to target resources to the [minority men who have sex with men] population," says Leo Rennie, associate director of prevention programs for the National Alliance of State and Territorial AIDS Directors in Washington, DC. "We’re hoping to work closely with the CDC at the national HIV prevention conference in August, and we’re looking toward identifying gaps in behavioral research and developing effective interventions for men who have sex with men," Rennie adds.
One of the successful changes made by the CDC and others focusing on prevention campaigns has been the increased emphasis on targeting HIV-positive people. The CDC plan calls for a new prevention program that does just this. The program, called Serostatus Approach to Fighting the HIV Epidemic (SAFE), will attempt to significantly increase voluntary testing to identify HIV-positive individuals and link these people with prevention services, treatment, and care.
The SAFE program has these goals:
• Make anonymous and confidential HIV testing widely available in all public and private health care settings, including emergency rooms, STD clinics, and community health centers.
• Evaluate and adopt rapid testing technologies to be used in street outreach programs and other nontraditional sites.
• Work with national, state, and local partners to develop additional educational, testing, and partner referral programs.
Some states and AIDS service organizations have followed the CDC’s recent example and also have instituted prevention messages that target those who are already infected. "For instance, in New England we had our first ever positive prevention conference this year," Palmer says. "That’s an important shift, and it will enable us to realize the goals of the CDC plan."
While it seems logical to target HIV-positive people in prevention campaigns, this was considered less necessary a decade ago when the life expectancy of HIV-positive people was lower. Services directed toward HIV-positive people tended to focus on preparing for illness and death. "People are living longer now, so they have a longer period of time in which to keep negotiating their sexual decisions and choices," Palmer explains.
Prevention messages that target at-risk populations also need a higher level of sophistication, because some cultural issues make traditional appeals ineffective, Brawley says. For example, it won’t work to simply send urban African-American women the message they should always have their partners use a condom, because in some African-American communities a woman may demonstrate her love and trust for a man by allowing him not to use a condom, he says.
"So you need to show women how to protect themselves and still express their love," he adds. "Using a condom for a man is a simple decision of you either use or you don’t, but for a woman there are emotional aspects, such as if you ask a partner to use a condom do you risk being struck or being subject to physical abuse."
The CDC’s other strategic goals will need some careful consideration in order to be achieved, Brawley says. The goal to increase HIV testing and counseling to reach 95% of those who are infected is certainly possible, but it may not occur as long as youths under age 25, who account for about half of all new infections, fear parental notification, partner notification, or name-based reporting, he notes. Also, there should be a greater emphasis on mobile vans to provide rapid HIV tests, he adds. Mobile vans are useful because a person can sit in the van for 20 minutes reviewing HIV educational material while waiting for test results.
Government bureaucracy also hinders counseling and testing services through complicated policies and funding mechanisms, Palmer says. However, increasing HIV patient referrals to care and services is quite feasible once HIV testing becomes routine for at-risk populations, Palmer says. "In the past 20 years, we’ve really been able to be strong in getting folks who are positive linked right into care and services," Palmer adds. "I think we can just continue that process, and that’s something we can do real well."
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