CDC plans to persevere with prevention efforts
(Editor’s note: In this Q&A, AIDS Alert interviews Ronald Valdiserri, MD, MPH, deputy director of the National Center for HIV, STD, and TB Prevention at the Centers for Disease Control and Prevention. Valdiserri discusses what has been achieved with regard to the HIV Prevention Strategic Plan Through 2005, and what more needs to be accomplished.)
AIDS Alert: The first goal stated in the CDC’s five-year prevention plan was to decrease by at least 50% the number of people in the United State at high risk of acquiring or transmitting HIV infection. Why has it been so difficult to accomplish this goal?
Valdiserri: That estimate [40,000] remains in place. I think one of the issues we’ve been grappling with is the fact that coming up with the 40,000 estimate in today’s environment is a lot more complex.
Now the good news is that we have made significant progress in improving our ability to monitor the epidemic, which was, of course, one of the major domestic goals in the plan. We are very far along in the implementation of a national HIV incidence system, which has been expanded from five sites in 2001 to 35 sites today, and we anticipate in 2006 actually having new population-based estimates on the incidence of HIV infection.
So we haven’t updated the 40,000 [figure], but we anticipate with the national incidence system in 2006 we will have an updated, accurate estimate of HIV incidence.
Granted the goals were very ambitious, which is not unusual when folks get together and set goals for public health problems. But the fact that we haven’t observed substantial increases in HIV incidence is significant. Many epidemiologists and modelers predicted that as treatment was made widely available and people lived longer with HIV, then we would have an increase in new infections because of increased opportunities to transmit. So I think that the fact that we haven’t seen that increase is positive news, but it is true that we did not make the kind of progress that we initially had hoped to make.
AIDS Alert: In the MMWR Dec. 3, 2004, issue, a surveillance report says that the CDC estimates 180,000-280,000 people are infected with HIV and do not know it. Why has the goal of increasing the proportion of people who know they are infected to 95% been difficult to achieve, and will the new rapid HIV testing program help close the gap?
Valdiserri: We are seeing focal differences. As an example of that, with the availability of the licensure of the rapid HIV test in the United States, one of the ways the public health community responded to that was trying to push to make that technology more widely available and to reach out to people who might be infected and wouldn’t otherwise be tested. And we invested in a number of demonstration projects, which are coming to completion.
Several of those demonstration projects have shown very promising results in terms of the number of people who are tested and the number of people who are found to be positive, especially when we compare them to some of the more traditional, clinic-based approaches.
Now we have to scale up that effort to make sure effective models are put into place. We have plans under way to work with funded partners, particularly with health departments and community-based organizations, to scale up the findings from the demonstration projects to be able to make a substantial impact on the percentage of people who are infected but don’t know it.
It’s not going to be easy, and it’s not going to happen quickly because we’re talking about a whole national system here, but we can definitely bring that number down.
AIDS Alert:Has the United States had any improvement in the proportion of HIV-infected people who are linked to appropriate prevention, care, and treatment services?
Valdiserri: A CDC researcher has determined from a modeling exercise that about two-thirds of the people who are eligible for antiretroviral treatment and are not receiving it were not receiving it because they are undiagnosed.
There are some others issues about once people are diagnosed, but I think it goes back to the fact about how important it is to get people diagnosed early so they can get into care and also because we know that the majority of people when they find out they’re infected with HIV definitely take positive steps to reduce transmission to their partners.
AIDS Alert: Have you made improvements in linking people to care who know they are infected?
Valdiserri: Anytime we’re talking about crossing care systems, in HIV or any other kind of complex illness, we have to continue to work to improve referral systems and mechanisms to ensure effective referral, so I don’t want to declare victory there. What I’m trying to say is if we can continue to get people diagnosed as early as possible that we’re also going to make some great strides in that arena.
AIDS Alert: The fourth goal discusses strengthening the capacity nationwide to monitor the epidemic, develop and implement effective HIV prevention interventions, and evaluate prevention programs. What has the CDC done to improve in those areas?
Valdiserri:There arethree major and substantial successes there: First, we are very close — we’re not there yet, but we’re very close to having a new estimate of HIV incidence based on a national incidence surveillance system; we’ve made substantial progress in implementing that activity.
Secondly, we have invested in behavioral surveillance for two high-risk groups: men who have sex with men and injection drug users.
And third, I think the one point I didn’t mention before that is important to point out is we have substantially improved our program evaluation activities for CDC grantees. We’ve always had requirements that CDC grantees, whether they’re health departments or community-based organizations. For example, they are required to monitor their work and report on their efforts, but we have substantially improved the measures that will now be reported back to CDC that will help individual programs see how well they’re doing to improve programmatic goals. These also will help the CDC in terms of targeting resources. So that Program Evaluation and Monitoring System has been substantially improved, and that’s under way as well.
AIDS Alert: The overarching national goal included a focus on eliminating racial and ethnic disparities in new HIV infections. Comparisons of the MMWR reports from Nov. 28, 2003, and Dec. 3, 2004, suggest some improvements in the percentages of black men and women who had new HIV diagnoses between the periods 1999-2002 and 2000-2003, but the percentages of Hispanic men and women has risen. Do the data suggest any improvements as a result of targeted HIV prevention programs for African Americans, and what more can be done? Also, what can be and is being done to address the growing problem in the Hispanic population?
Valdiserri:It’s a mixed picture. Again when we look at trends in rates of HIV diagnoses in terms of gender and race ethnicity, we have seen declines among African American females. But we have seen increases among men who have sex with men, many of whom are men of color. So I think that we’ve certainly had some successes, and there are a number of positives we can point to, but we need to continue to work in that regard.
That, too, is a very complex issue, that cuts across many different lines, and it’s not just a matter of how good are our HIV prevention programs. It also has to do with socioeconomic status, issues of ongoing racism, and issues of unequal access to care.
If you look at many of the organizations that the CDC funds directly, the majority of those organizations are serving racial and ethnic minority communities.
We’re also really putting emphasis on trying to disseminate effective behavioral interventions to reduce risk of infection, to encourage early diagnosis, especially if these are efforts that target African Americans and other ethnic and racial minorities.
So again, I think we can point to some focal successes, but we still have a long way to go as a nation.
It’s so important to look at the strategic plan for what it is, and that’s a way to strengthen our collective resolve to address this ongoing, extremely important health problem that continues to trouble our nation. That’s why it’s important to have goals, even if they are ambitious goals, because we have something to work toward, and we can work with all of our partners.
AIDS Alert: The first goal stated in the CDCs five-year prevention plan was to decrease by at least 50% the number of people in the United State at high risk of acquiring or transmitting HIV infection. Why has it been so difficult to accomplish this goal?You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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