CDC issues ambitious goals for reducing HIV infections
Draft plan draws both praise and criticism
The Centers for Disease Control and Prevention in Atlanta placed its formidable goals for preventing new HIV infection in the national political arena this fall, and already the draft document has created a stir among Congress, supporters, and critics. The CDC’s goal to reduce new HIV infections in the United States from an estimated 40,000 per year to 20,000 could cost as much as $1 billion annually, according to scientific reports quoted in the CDC’s draft plan. The CDC’s prevention budget for fiscal year 1999 was $637 million.
Research presented at the International AIDS Conference held in Durban, South Africa, in July 2000 estimated that just to provide prevention services to at-risk injection drug users in the United States would cost $423 million a year.
"We at the CDC recognize that these are ambitious goals, and they won’t be easily obtained, but we do think it’s possible with appropriate focus and resources to reduce new infections in this country by half," says Ron Valdiserri, MD, MPH, deputy director of the National Center for HIV/STD/TB Prevention at the CDC.
Even this ambition does not go far enough, some critics charge. "It talks about reducing new infections, but not eliminating them," says George Bellinger Jr., program director for the Harlem Directors Group in New York City. "My overall opinion is that the CDC’s plan looks like a very good HIV care document because it focuses more on people already living with HIV rather than preventing HIV," Bellinger says.
For instance, the CDC’s third goal is to increase the proportion of HIV-infected people in the U.S. who are linked to appropriate care. "That’s fine," Bellinger says of this goal. "However, if the CDC spends its money on locating and educating HIV-positive individuals about AIDS, that’s what the Ryan White funding is for."
Bellinger suggests a better prevention goal would be to increase the number of HIV-positive people involved in the implementation of prevention strategies. "This is so people who are positive will be involved with prevention strategies to educate other people about the risk of transmitting HIV," he says.
Others say the plan is laudable simply because it gives politicians and others a concrete plan for reining in the epidemic. "It’s going to be a very useful tool with Congress in the sense that it finally puts a tangible goal out there," says Julio Abreu, deputy director of government affairs for AIDS Action, an AIDS advocacy group in Washington, DC.
In fact, Congress already has taken note of the plan, says Steve Morin, PhD, an associate professor of medicine at the University of California-San Francisco. Morin was one of the more than 100 experts who helped write the five-year strategic plan. "This is exactly the kind of tool that is needed to build confidence that if you invest more money in prevention, it will be spent wisely with measurable outcomes and performance indicators," Morin says.
Capitol Hill briefings have already made mention of the CDC’s plan, he says. "And the labor, health, and education bill may include a significant increase to respond to this plan, so it’s made a difference already."
CDC officials are revising the plan, taking into consideration comments made by HIV service organizations, clinicians, and others, and the final plan is expected to be released in January. AIDS service organizations and others will look at the comments the CDC receives on the plan and how these are incorporated into the final document.
"We want to see if these comments make sense and if we can strengthen the document," says A. Cornelius Baker, executive director of the Whitman-Walker Clinic in Washington, DC. "I think the document is clearly written and the plan is heading in a good direction, but I think we all want to make sure it’s not just a good, well-written document that’s not used."
Plan addresses needle-exchange programs
For instance, the CDC’s draft plan includes a priority objective of increasing the proportion of injection drug users (IDUs) who abstain from drug use or who use harm-reduction strategies to reduce their risk of HIV transmission or acquisition. One of the selected strategies listed under that objective reads, "Continue to disseminate scientific evidence that needle-exchange programs are effective at reducing HIV infection while not increasing drug use."
That’s fine, but it doesn’t solve the problem that the federal government has been actively opposed to needle-exchange programs, Baker says. "This plan is going to require bold leadership, because there are areas where we need to be clear that this plan will not succeed if we don’t have more enlightened policies on AIDS," Baker adds. "To the extent that the government is not willing to support needle-exchange plans across the country, our ability to impact the HIV infection rate among injection drug users is fairly limited."
At least the plan makes it clear that targeting IDUs is a priority. Some at-risk populations, however, are not even mentioned in the draft plan. For instance, Bellinger questions why the CDC plan fails to identify strategies that target the high-risk transgendered population.
"The plan does not mention transgender individuals at all, and that’s important when dealing with men who don’t identify as gay or bisexual who may be having sex with men and post-op transsexuals," Bellinger says. "The CDC should mention this issue, bring it out of the closet, and identify resources to address transgender communities."
Despite flaws, some of which may be ironed out in the final plan, the document is likely to serve as a catalyst for increasing funding for HIV prevention, and that’s a very positive first step, Abreu and Morin say.
"We’ve always had difficulty getting adequate funding for CDC prevention efforts," says Morin, who worked for the U.S. House of Representatives’ appropriations committee for six years and is very familiar with the CDC’s budget. "A lot of external groups have been critical of the CDC’s priorities and programs," he adds.
To answer the criticism, an external budget review group that included Morin met several times last year to analyze how the CDC was spending HIV prevention and surveillance funds. "The group concluded that it was difficult to know whether the CDC’s spending was the best allocation of resources unless you could match it against a strategic plan," Morin says.
There has never been a strategic plan directly linked to a budget, he adds. "So that’s what the external budget review group recommended, is that the CDC develop this national plan and try to see how the budget reflected the priorities in the plan."
The CDC enlisted help from more than 100 people, including government employees, community providers, academicians, activists, researchers, and others, to help draft the plan. The large group was divided into four working groups, each of which worked on one of the four goals. The groups identified objectives and strategies that would be necessary to achieve the goals within a five-year time frame, Valdiserri says.
"We will take a close look at our budget to make sure we direct those priorities," Valdiserri says. "We hope to be able to more completely describe to policy-makers what some of the unmet needs are."
Valdiserri says the plan’s top priorities are listed first. Under the first goal to reduce the new HIV infection rate, the objectives put programs targeting men who have sex with men and programs directed toward adolescents near the top of the list. This is because the CDC’s most recent data show that men who have sex with men still account for the greatest proportion of new HIV infections.
Likewise, the CDC estimates that more than half of all new HIV infections are among people under age 25, and the majority of these people have become infected through sexual activity. The CDC, with help from providers, Congress, and U.S. citizens, should be able to make the prevention plan a reality, Valdiserri says.
"We have the science to achieve these goals," he adds. "If we have the national will and adequate resources, we can achieve them, and that’s an issue that all of America needs to address because it’s not just a CDC issue."
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Goal No. 3 of the CDC’s Draft HIV Prevention Plan |
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| Priority Objectives | Selected Strategies |
| Work with public health, the private medical sector, the Health Resources and Services Administration (HRSA), and other partners to reduce the disparities in access to prevention and care services that are experienced by communities of color and by women. |
1. Collaborate with HRSA, the National Institutes of Health, the affected communities, and other partners to develop and implement a comprehensive research agenda that identifies and addresses barriers to prevention services and access to care. 2. Promote cultural and linguistic competence in CDC-funded programs. |
| Work with public health, the private medical sector, and other partners (e.g., the Substance Abuse and Mental Health Services Administration, HRSA) to increase the percentage of people diagnosed with HIV who are successfully linked to culturally competent, science-based behavioral prevention services. | 1. Assure that HIV-infected people tested in
CDC-funded sites obtain a comprehensive prevention assessment and appropriate referral to prevention case management
(PCM) within 3 months of learning their HIV status. 2. Collaborate with HRSA to encourage the establishment and maintenance of behavioral prevention services in public HIV/AIDS outpatient clinics. 3. Increase the capacity of health care providers to provide behavioral prevention counseling. 4. Develop a system to monitor HIV-infected patients’ linkage to prevention services. |
| Work with public health, the private medical sector, HRSA, and other partners to increase the percentage of people diagnosed with HIV who are successfully linked to care within 3 months of learning their HIV status or of being re-identified as being HIV-infected but out of care. | 1. Publish guidelines for best practices for linkage from post-test counseling to medical evaluation. 2. Conduct research to determine why previously diagnosed but currently out-of-care people didn’t initially access or remain in medical care and develop interventions to enhance care utilization. |
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Source: CDC’s prevention plan, September 2000 draft. |
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