have to set a goal. . . We have to reduce the number of new infections
each and every year until there are no more new infections."
Clinton, December 5, 1995
The White House Conference
on HIV and AIDS
the epidemic began, there has been important progress in preventing HIV infection.
Early in the epidemic, CDC estimated that more than
100,000 Americans were becoming infected with HIV each year; today, that total
is estimated to be approximately 40,000 to 60,000 people each year. A great
deal of credit for this reduction must go to the affected communities. Community-based
efforts to educate people about HIV transmission and prevention provided important
leadership, especially in the early years of the epidemic.
accomplishments in prevention of HIV include:
in the Morbidity and Mortality Weekly Report by the Centers for Disease
Control and Prevention (CDC) in 1981 of the first AIDS cases;
in 1982 by the Centers for Disease Control and Prevention (CDC) of the major
risk factors associated with HIV infection;
- Due to
NIH-sponsored research, demonstration that administration of AZT can prevent
transmission of HIV from an infected mother to her newborn; and
- Due in
part to successful implementation of CDC-sponsored prevention strategies,
a slowing in the growth of the epidemic.
President Clinton took office, Federal efforts in HIV prevention have been accelerated.
funding for AIDS prevention at CDC by 24 percent;
the AIDS prevention community planning partnership -- empowering local communities
to target resources toward innovative prevention efforts;
the Prevention Marketing Initiative, focusing on young adults (18 to 25)
with frank public service announcements advocating sexual abstinence and,
for the first time, the correct and consistent use of latex condoms;
workplace education through the Federal Workplace AIDS Education Initiative
and the Business and Labor Responds to AIDS programs;
AIDS prevention efforts at the CDC to foster greater
coordination of efforts to reduce sexually transmitted diseases and tuberculosis;
- As a result
of PHS guidelines recommending the use of AZT by HIV-positive pregnant women
and their newborns, the number of infants with perinatally-acquired HIV
infection dropped 17 percent form 1994 to 1995
agencies have been instrumental in expanding our knowledge base about HIV prevention
(see Appendix A). CDC, the agency with primary Federal
HIV surveillance and prevention responsibilities, has been pivotal in identifying
risk factors associated with HIV transmission, seroprevalence of HIV in society,
and trends in HIV infection and AIDS.
efforts have shown that HIV prevention programs can be effective. CDC's prevention
projects, many in partnership with states, local governments, schools, and community-based
organizations, have demonstrated that prevention programs are most effective
when designed and implemented in partnership with communities to which they
are targeted. Biomedical, behavioral, and social science prevention research,
including epidemiological and natural history studies, conducted and supported
by the National Institutes of Health (NIH) and CDC,
has expanded and will continue to expand our understanding of HIV transmission
and the determinants of HIV-related risk behavior.
Nation also has combatted the dual epidemics of HIV and drug abuse. The National
Institute on Drug Abuse (NIDA), the Substance Abuse and Mental Health Services
Administration (SAMHSA), and CDC support efforts
to prevent HIV infection among drug users and their sexual partners. The White
House Office of National Drug Control Policy (ONDCP)
has pursued and coordinated efforts to combat the problem of substance abuse
and its devastating consequences.
stigma that has been attached to HIV disease has hampered prevention efforts.
Sadly, the HIV epidemic has been accompanied by a great deal of misinformation
and discrimination. Early in the epidemic, people living with HIV or AIDS often
were the victims of discrimination in housing, employment, and public accommodations.
Fear of discrimination and stigma causes many people not to seek testing for
HIV; thus many remain unaware of their HIV status and may unknowingly infect
others. The stigma attached to HIV remains a co-factor in HIV infection.
have been advances in integrating primary prevention into health care service
systems. The Health Resources and Services Administration (HRSA)
and the Department of Veterans Affairs (VA)
have encouraged broader access to HIV prevention information through the integration
of prevention interventions into primary health care services and through support
of early intervention services. HRSA and HCFA
have also undertaken special initiatives designed to reduce perinatal transmission
of HIV. HRSA has promoted primary prevention through the training of health
professionals in the AIDS
Education and Training Centers program.
Opportunities for Progress
achieve the national goal of no new infections requires efforts in the prevention
area on six fronts:
of Trends in the Epidemic
who is becoming infected and through what behaviors is critical to designing
effective HIV prevention interventions, as well as for targeting appropriate
service resources. As discussed in the introduction, the demographics
of the epidemic are evolving, and effective prevention depends on rapidly
understanding these shifts and responding to them.
AIDS case and case death reporting
system provides important data for assessing AIDS prevalence and mortality
by gender, race/ethnicity, age, and mode of exposure. However, this approach
does not capture sufficient "front-end" information on the incidence
and prevalence of HIV prior to an AIDS diagnosis. Therefore, we miss critical
warning signs about new trends in affected populations and increasing
this concern, CDC will work to improve its surveillance of HIV infection
and related diseases and surveillance of HIV behavioral risk factors both
to better monitor the course of the epidemic and to provide guidance to
community planners for targeting prevention and service dollars. This
can and will be undertaken without compromising the confidentiality of
on Effective Prevention
interventions must be based on sound research findings and evaluations.
In response to the recommendations from the Report of the NIH
AIDS Research Program Evaluation Task Force, NIH is developing a comprehensive
HIV prevention science agenda. NIH and CDC are
committed to increasing future support for basic research on behavior,
interventions, social marketing, and program evaluation.
research answers key questions about the determinants of HIV-associated
sexual and drug-using behaviors. We still lack critical knowledge in this
area, which is central to developing effective interventions.
research focuses on individual and community-level interventions that
result in modified sexual and drug-using behaviors and, as a consequence,
reduced HIV transmission. There have been significant accomplishments
in this area, but, as this portfolio expands, it will be critical to assess
interventions in the context of community cultures and social networks
that are relevant to the growing number of populations that must be reached
by HIV prevention programs. This research should be designed by a broad
range of scientists, public health, and community experts to assure its
of social marketing techniques is a relatively new approach to HIV prevention.
This promising area should be based on basic behavioral and intervention
research, as well as on careful design and evaluation of social marketing
that prevention programs actually are working -- and to ensure that scarce
resources are spent on the most effective interventions -- all Federally-funded
prevention activities routinely will include evaluation components. Funding
agencies will share widely the knowledge gained about what works and what
does not work to ensure promotion of innovation and best practices in
the field. In addition, as part of the Federal government's compliance
with the Government Performance and Results Act, CDC
and SAMHSA will continue to work with their
grantees to develop appropriate performance measures for HIV prevention
programs, including those developed under the community planning process.
prevention planning is one of the key innovations in CDC's
prevention programming over the last several years. This public-private
partnership puts Federal funds to work based on locally-designed priorities.
This three-year-old initiative is at a crucial stage of development, and
ensuring its continued success is the third key element of this Strategy's
planning requires ongoing leadership from CDC and its partners as well
as the resources to provide the technical assistance the community planning
process needs to flourish. Successful HIV prevention often depends on
small, new, community-based organizations, many serving minority populations.
These organizations need assistance not only on how to plan and compete
successfully for available resources but also on how to appropriately
incorporate epidemiological and research information into community prevention
Integration and Collaboration
component of the prevention agenda is improving the integration of HIV
prevention into other program areas that reach individuals at risk for
HIV. HIV prevention programs cannot stand apart from other related public
with communities and schools is a critical factor in communicating HIV
prevention messages to our youth. The Centers for Disease Control and
for Effective School Health Programs to Prevent the Spread of AIDS
helps assure that young people understand the nature of HIV transmission
and the specific actions they can take to prevent HIV infection. Support
for these programs should and will continue.
is closely related to substance abuse, through needle-sharing behaviors,
as sex is traded for drugs, and as drug and alcohol use impairs judgment
and increases risk-taking behaviors. Breaking these linkages will require:
HIV prevention into substance abuse treatment and prevention programs.
In August 1996, at the request of President Clinton, the Public Health
agencies jointly co-sponsored a national meeting of State and local
officials, researchers, and community experts from the fields of HIV
and substance abuse to develop an action plan to more effectively integrate
HIV and substance abuse prevention efforts. PHS Agencies are committed
to implementing this strategy in the year ahead.
substance abusers into drug treatment. Substance abuse treatment
is a major form of HIV prevention. This Administration will continue
to support funding for substance abuse treatment. Further, through outreach,
research, and demonstration programs, SAMHSA, NIH, and CDC will work
to enroll more people in treatment and to find more successful interventions
to accomplish this end.
the availability of illegal drugs. The White House Office of National
Drug Control Policy (ONDCP) is leading this fight on two fronts: reducing
demand for drugs through treatment and prevention programs and reducing
the availability of drugs through supply reduction programs.
HIV transmission from the use of contaminated injection equipment. The
sharing of needles and syringes among injecting drug users is a major
means of HIV transmission in the drug-injecting population. Abstinence
from drug use is always the preferred means of HIV prevention. The CDC
recommends using sterile or never-used injection equipment. CDC-supported
research has indicated that removal of restrictions on over-the-counter
sale of syringes resulted in decreased reported needle sharing. Current
Federal law restricts the use of Federal funds for syringe exchange
programs; however, a number of communities across the country have undertaken
these programs with local resources. NIH-supported research on existing
needle exchange programs is identifying the characteristics that influence
program success as an HIV prevention strategy.
needs to be better integrated into primary health care. New and promising
medical interventions make it critical to improve our approach to HIV
counseling and testing -- creating a critical bridge between prevention
and primary care. CDC is committed to improving
the follow-up services for those counseled and tested at publicly-funded
sites including the quality of referral to services for those who test
must also go in the opposite direction: from primary care to prevention.
Primary care providers must learn to incorporate a person's sexual and
drug-using history when a medical history is taken, offering HIV-related
counseling and voluntary testing, and providing prevention education to
HIV-positive individuals as part of the provider-patient relationship.
AIDS Education and Training Centers (AETCs)
have played a crucial role in giving health care professionals the information
and skills they need. The Administration supports the AETC program and
will give it a renewed focus to support this goal.
care is a direct form of HIV prevention. The NIH-supported
research that showed AZT reduces perinatal transmission of HIV was a tremendous
medical breakthrough. Realizing the promise of this advance requires a
commitment to assuring that all pregnant women are counseled and offered
HIV testing -- and that AZT treatment is available for all who desire
it. All Federally-funded programs reaching pregnant women -- from Medicaid
to Ryan White CARE Act grantees to community
and migrant health centers -- should take part in this effort. Strong
support for outreach is important for assuring appropriate care to further
reduce perinatal transmission.
STDs and TB
research has confirmed that treatment of sexually transmitted diseases
(STDs) other than HIV can reduce the likelihood of HIV transmission --
making the need for collaboration between HIV and STD prevention efforts
even more important. In addition, people living with HIV are at very high
risk for developing active tuberculosis. Studies suggest that the risk
of developing active tuberculosis (TB) is 7 to 10 percent per year for
persons who are infected with both TB and HIV, as opposed to a 10 percent
lifetime risk for persons not infected with HIV.
the need to integrate work on these interrelated epidemics, CDC organized
the new National
Center for HIV, STD and TB Prevention. CDC has initiated -- and will
aggressively pursue -- efforts to increase collaboration among these programs.
epidemic continues to have a disproportionate impact on certain populations
where infection rates are rising at a rapid pace. A fifth and final challenge
for prevention programming is to pay particular attention to groups that
traditionally receive fewer services, but where the risk of infection
is greatest. These include adolescents (especially young gay men), women,
minorities, gay men of color, substance abusers, and prisoners. Many Federally-funded
HIV prevention activities already target these populations. The additional
$32 million appropriated in FY 1997 for the CDC
will provide new funds specifically intended for programs and research
targeting adolescents, women, and substance abusers. To ensure that prevention
programs, including community planning efforts, are as effective as possible
all Federally-funded prevention activities routinely will include monitoring
and evaluation components.
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