Big question for 2005: What happened to CDC’s HIV prevention plan?
Experts say U.S. is long way from meeting goals
HIV/AIDS clinicians, researchers, and activists praised and applauded the Centers for Disease Control and Prevention (CDC) in January 2001 for the bold public plan to cut new HIV infections in half by 2005. Now, nearly halfway through 2005, the enthusiasm has turned into dismay and resignation for the status quo as the goals remain about as unattainable now as they were then.
The CDC had unrolled its HIV Prevention Strategic Plan Through 2005 to positive fanfare and raised hopes that the nation would see a major transformation in HIV prevention success, just as was seen in the treatment and care arena where illnesses and deaths were decreased dramatically because of the antiretroviral drug regimens.
The estimate of 40,000 new infections per year had been stable since the early 1990s and, while that in itself was a great public health achievement, far better than the estimated 150,000-plus new HIV cases during the epidemic’s peak years, the CDC’s strategic plan called for cutting the new infection rate in half by 2005. (See chart of CDC strategic plan, below.)
| CDC’s Prevention Goals January 2001-2005
Overarching National Goal:
International Goal:
Source: Centers for Disease Control and Prevention’s |
The problem with the goals cited in the strategic plan is that Congress and President Bush’s administration provided no additional funding for scientific-based prevention efforts during the past four years. And just as was predicted by published studies that analyzed prevention spending and needs, there have been no prevention improvements without the additional money.
CDC data estimate no change in the new infection rate in 2005, and some experts contend it has probably crept up in the past couple of years.
"Since we don’t have good HIV incidence numbers in the United States, the next best proxy is HIV diagnoses from 30 states," says David Holtgrave, PHD, professor in the departments of behavioral science and health education and health policy and management at the Rollins School of Public Health in Atlanta.
"HIV numbers seem to be ever so slightly going up in diagnoses," he says.
The HIV epidemic in the United States appears to be stable, with variations among specific populations, such as statistically significant declines in new diagnoses among women, which are balanced by increases in HIV diagnoses among men who have sex with men (MSM), says Ronald Valdiserri, MD, MPH, deputy director of the CDC’s National Center for HIV, STD, and TB Prevention.
He says the CDC plans to work with public health and community partners to determine its next step, but there are no immediate plans to develop a new strategic plan or put a new date on the 2001 plan.
Holtgrave has published numerous studies analyzing the country’s prevention spending and achievements, and estimated as early as 2001 that it would require at least $300 million additional prevention money per year to achieve the CDC’s goal of cutting new infections in half.1
Without a substantial increase in prevention spending, there likely would be no decrease in new infections, he concludes from his research.
"I wanted desperately to be very, very wrong about this, but it doesn’t seem like it’s turning out this way," Holtgrave says.
His latest research estimates that unless the nation can reduce the new HIV infection rate from its estimated 40,000, by the year 2010, there will be an additional 130,000 new HIV infections that will cost the health care network more than $18 billion over the same period.1
Another study shows that the HIV transmission rate for people who are unaware of their HIV serostatus is 10.79%, compared with a 1.73% HIV transmission rate for people who are aware of their HIV status, and a near-zero percentage rate for people who receive effective HIV testing and counseling.2
This research further highlights the need for well-funded, scientifically based prevention programs aimed at reducing the nation’s HIV new infection rate as quickly as possible, Holtgrave says.
"We need an additional $300 million per year for four years in order to really address the HIV prevention needs in the U.S.," he adds. "If we get the infections down to half by that investment, then we might be able to scale back that investment."
The nation has fallen short of achieving the other CDC prevention goals for 2005, as well, experts say.
The CDC still estimates the number of people living with HIV/AIDS who do not know their HIV status to be from one-third to one-quarter of the total number of people infected, and that was the same in 2001, says Paul Feldman, public affairs director for the National Association of People With AIDS in Silver Spring, MD.
And since the proportion of people who know their HIV status hasn’t improved, neither has there been an increase in the proportion of HIV-infected people who are linked to appropriate care and treatment, he notes.
"There are on order one-quarter of a million Americans who need HIV care and who aren’t getting it for a variety of reasons," Feldman says. "These are everything from waiting lists on AIDS Drug Assistance Programs to an unwillingness to approach the system to not being linked up with available services where Medicaid doesn’t cover enough of the services," he adds.
Likewise, Feldman says he’s unimpressed with the CDC’s monitoring and capacity building efforts because they are burdensome and some require the reporting of client-level information that makes some HIV clients unwilling to receive services, he says.
Prevention experts reserve their biggest criticism for the political atmosphere, fostered by the Bush administration, in which additional funding for effective HIV prevention interventions is short-changed in favor of increased funding for unscientifically proven abstinence-only programs.
"In the last few years, we’ve become squeamish about talking about sexuality, and in fact, in many ways, we have put our heads in the sand," says Georges C. Benjamin, MD, executive director of the American Public Health Association of Washington, DC.
"That certainly doesn’t help if you want people to know they’re at risk for HIV infection," he says. "This is a disease that should have our full attention."
CDC officials may have had the best of intentions in setting the prevention goals, but their efforts were unlikely to succeed without financial and political capital behind them, says Howard Grossman, MD, executive director of the American Academy of HIV Medicine in Washington, DC.
"The basic problem is that the people at the CDC are trying very hard and working very hard, but they’re completely hamstrung by a government that instead of putting out good prevention messages puts out lies and a resistance to science," he explains.
"Abstinence-only campaigns are receiving up to $300 million in the new budget, and everything else has been cut," Grossman says.
"Research clearly shows that abstinence-only programs don’t work. The latest data show that not only do kids who take abstinence pledges have the same number of sexually transmitted diseases as those who don’t take the pledge, but they are six times more likely to have anal intercourse and more likely to have oral intercourse," he notes.
Grossman says his criticism is not intended for the people working at the CDC. "I have nothing but respect for people at the CDC and what they’d like to do, but I think they’re stymied at every turn."
The CDC’s goals were ambitious, but they were appropriate, particularly the overarching goal of eliminating racial and ethnic disparities in new HIV infections, Benjamin says. "We need different prevention messages for different populations."
For example, prevention messages for the African American community could rely a lot more on radio advertisements, Benjamin says.
Also, prevention messages need to be translated into the languages of the various ethnic communities, both in the literal and figurative sense, he notes.
"We need to communicate to people in languages they understand, not just the language, but by using the words they understand," adds Benjamin.
References
- Holtgrave DR. A proposed format for tracking the Centers for Disease Control and Prevention’s national HIV prevention goal. J Public Health Man Prac 2005; 11(1):4-6.
- Holtgrave DR, Anderson T. Utilizing HIV transmission rates to assist in prioritizing HIV prevention services. Int J STD & AIDS 2004; 15:789-792.
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