CDC renews plan to reduce new HIV infections, but with more modest goals

It's 5 percent per year instead of 10 percent

The national five-year HIV strategic prevention plan, launched in 2001, was a failure. Everyone agrees with this assessment, including the agency that created it: the Centers for Disease Control and Prevention (CDC) of Atlanta, GA.1,2

The original plan, titled, HIV Prevention Strategic Plan Through 2005 (2001 Plan), had the admirable ambition of reducing new HIV infections by 50 percent over five years. It called for cutting the 40,000 annual new HIV infection rate in half by 2005. Instead, the CDC continues to estimate that we have 40,000 new HIV infections each year.

The CDC discusses the original plan's failure, as well as revised and more modest national goals in a new report that outlines an extension of the original 2001 plan. It's called the CDC HIV Prevention Strategic Plan: Extended Through 2010 (Extended Plan).

The main reason why the prevention goals weren't met is a lack of resources and funding, according to the CDC's new HIV prevention report. It would have taken a significantly expanded investment in HIV prevention to make progress toward these original goals, the CDC states in the report, which was announced and made available online in January, 2008.

"I think that the original plan was predicated on full implementation and resources," says Robert Janssen, MD, director of the division of HIV/AIDS prevention at the CDC.

"Even now though, I think we do see these as achievable, but still a challenge," Janssen says.

The overarching goal in 2001 of reducing new HIV infections by 50 percent in five years was a vision that might be compared with the national "Healthy People" goals for the nation, Janssen says.

"It outlines the ideal," he says.

Members of the CDC/HRSA Advisory Committee on HIV & STD Prevention and Treatment (CHAC) recommended that the CDC extend the 2001 plan through 2010. CHAC also provided specific recommendations for objectives to be included in the extended plan.

CHAC first discussed extending the plan in 2005, and questioned the CDC about why the original goals were not met, says Jesse Milan, Jr., JD, the immediate past co-chair of CHAC. Milan served as co-chair during the five-year plan period.

"We agreed that a workgroup of CHAC and CDC should be created to extend the plan for three years and to update the goals and objectives," Milan recalls.

"By the time we got to the fall meeting of CHAC in 2006 it was clear that the work of the workgroup was finished, and they asked CDC to come back to CHAC with revised goal statements and objectives, based on the work of the workgroup," Milan says.

It was May 2007, before the CDC provided specific numerical target goals, and these were to reduce infections by 5 percent by 2010, Milan says.

"We were aghast because how do you explain to the world that you have gone from a strategic plan that said to reduce new infections by 50 percent over five years to now a 5 percent reduction," Milan says.

CDC officials told CHAC that the new, considerably more modest goal was pragmatic given the current environment, Milan recalls.

After further discussion and debate, the CDC revised the plan to call for a 5 percent per year reduction, with no less than a 10 percent reduction by the end of 2010, he says.

"And so CHAC unanimously endorsed that as the new plan for extension," he says. "The old plan was based on new resources, so this might be the most anybody can expect, but it's certainly less than what we should hope for."

Another way to look at the extended plan is to think of it as a reality check, says Edward Hook, III, MD, a new co-chair of CHAC. Hook also is a professor of medicine at the University of Alabama at Birmingham (UAB).

For one thing, 2010 is less than two years away, Hook notes.

"If over the next two years we could decrease the number of people acquiring HIV in this country by 10 percent, CHAC would have such great cause for celebration," Hook says. "This epidemic is like a supertanker, and it has its own momentum; the effects of change in direction take a while to become apparent."

The 2001 strategic plan failed because it was too ambitious and there was inadequate funding and support, says Donna E. Sweet, MD, MACP, professor of medicine at the University of Kansas School of Medicine in Wichita, KS. Sweet is a new co-chair of CHAC.

Also, the initial plan did not have an overall strategy for implementation, Sweet says.

"The overall recommendation that the CHAC made is that whatever the goal, that there is enough planning and resources dedicated to make it feasible and doable so that it is not destined to fail," Sweet says. "We do hope for adequate, which means by definition, more funding for this federal plan."

Politics also played a role in the plan's failure. Due to political concerns, a variety of policy barriers exist, including a federal prohibition on funding needle exchange programs, which have been proven scientifically to reduce HIV transmission among injection drug users (IDUs).1

Another reason why the 2001 plan was unable to meet its goals was because of the HIV prevention successes of the 1980s and 1990s, Hook says.

During the first 15 years of the epidemic, public HIV prevention campaigns and the introduction of highly-active antiretroviral therapy (HAART) helped to reduce new HIV infections to 40,000 per year from the late 1980s high of an estimated 160,000 per year.

"We've taken the low-hanging fruit, and now it's the hard work, the heavy lifting," he explains. "I think these are appropriate goals and targets for us, but making them is going to be a push."

The key will be to target prevention efforts on people who already are infected because this is the most efficient use of prevention resources, Hook says.

Targeting prevention messages to HIV positive people also might be the only method that will work over the long run, says Michael S. Saag, MD, professor of medicine at the University of Alabama at Birmingham and the director of the UAB Center for AIDS Research.

"I'll take a radical view and say that I can't imagine that any primary care prevention programs for sero-negatives will have any chance of working," Saag says. "The reason I'm saying that is we've had 20-some odd years of the epidemic, and we haven't made a dent."

The strategic plan did result in some very positive new initiatives and programs, Janssen notes.

There have been some prevention successes in recent years, including the dramatic decline in mother-to-child (MTC) HIV transmission, according to the extended plan.

In 1991, there were 1,650 documented cases of mothers transmitting HIV to their children. Now there are an estimated 150 cases of MTC transmission per year.2

Also, there were declines in the proportion of youth reporting engaging in sexual intercourse between 1991 and 2005.2

The CDC has trained several thousand prevention providers to use effective prevention interventions, Janssen says.

"I think one of the things we've done a good job on is expanding HIV prevention to include prevention for people living with HIV," Janssen says. "That continues to be an important gap for us, getting medical providers to increase prevention services when taking care of people with HIV."

Also, the agency has awarded $35 million to state and local health departments to implement testing guidelines, particularly in areas where there's a high HIV prevalence, Janssen says.

"We continue to be challenged by [the lack of] reimbursement for HIV testing and screening," Janssen says.

Even Medicaid does not reimburse providers for HIV screening, except among pregnant women, he adds.

The CDC will continue to push for routine testing, however, he says, "We've been working very hard to implement the 2006 recommendations for routine screening in health care settings," Janssen says. "We have had workshops with emergency room providers across the country, particularly in high-HIV prevalence areas."

References

  1. Holtgrave DR, et al. The magnitude of key HIV prevention challenges in the United States: implications for a new national HIV prevention plan. Am J Pub Heal. 2007;97:1163-1167.
  2. HIV prevention strategic plan: extended through 2010 (extended plan). Centers for Disease Control and Prevention. October, 2007; available at http://www.cdc.gov.