Prevention

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T H E W H I T E H O U S E

Overview: Prevention

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"We 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."

President Clinton, December 5, 1995
The White House Conference
on HIV and AIDS

Record of Accomplishment

Since 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.

Sentinel accomplishments in prevention of HIV include:

Publication in the Morbidity and Mortality Weekly Report by the Centers for Disease Control and Prevention (CDC) in 1981 of the first AIDS cases;
Identification 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.

Since President Clinton took office, Federal efforts in HIV prevention have been accelerated. Actions include:

Increasing funding for AIDS prevention at CDC by 24 percent;
Launching the AIDS prevention community planning partnership -- empowering local communities to target resources toward innovative prevention efforts;
Launching 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;
Promoting workplace education through the Federal Workplace AIDS Education Initiative and the Business and Labor Responds to AIDS programs;
Reorganizing AIDS prevention efforts at the CDC to foster greater coordination of efforts to reduce sexually transmitted diseases and tuberculosis; and
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

Federal 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.

Federal 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.

The 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.

The 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.

There 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.

Future Opportunities for Progress

To achieve the national goal of no new infections requires efforts in the prevention area on six fronts:

Improving understanding of trends in HIV transmission, seroprevalence, and risk behaviors;
Improving scientific knowledge about effective prevention models and strategies;
Strengthening community-based programs;
Improving integration of prevention into primary care and improving linkages between counseling and testing and primary care; and
Targeting vulnerable populations.

Improving Understanding of Trends in the Epidemic	Understanding 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. CDC's 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 risky behaviors. To address 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 those involved.
Research on Effective Prevention Strategies	Effective 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.
Behavioral Research	Basic behavioral 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.
Intervention Research	Intervention 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 relevance.
Social Marketing Research	The use 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 efforts.
Evaluation and Dissemination	To ensure 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.
Strengthening Community-Based Programs	Community 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 prevention agenda. Community 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 programs.
Program Integration and Collaboration	The fourth 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 health efforts.
Prevention Education	Collaboration with communities and schools is a critical factor in communicating HIV prevention messages to our youth. The Centers for Disease Control and Prevention's Guidelines 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.
Substance Abuse	HIV transmission 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: Integrating HIV prevention into substance abuse treatment and prevention programs. In August 1996, at the request of President Clinton, the Public Health Service (PHS) 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. Enrolling 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. Reducing 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. Preventing 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.
Primary Care	HIV prevention 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 HIV-positive. The linkage 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. HRSA's 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. Often primary 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.
Other STDs and TB	Recent 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. To address 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.[4]
Targeting Vulnerable Populations	The HIV 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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