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July 2007, Vol 97, No. 7 | American Journal of Public Health 1163-1167
© 2007 American Public Health Association
DOI: 10.2105/AJPH.2006.095182

COMMENTARY

The Magnitude of Key HIV Prevention Challenges in the United States: Implications for a New National HIV Prevention Plan

David R. Holtgrave, PhD, Jean Flatley McGuire, PhD and Jesse Milan, Jr, JD

David R. Holtgrave is with the Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, Md. Jean Flatley McGuire is with the Institute on Urban Health Research, Bouvé College of Health Sciences, Northeastern University, Boston, Mass. Jesse Milan Jr is with the Center for Global Health Convergence, Constella Group, LLC, Washington, DC.

Correspondence: Requests for reprints should be sent to David R. Holtgrave, PhD, Department of Health, Behavior & Society, Johns Hopkins Bloomberg School of Public Health, 624 N Broadway, Baltimore, MD 21205 (e-mail: dholtgrave{at}jhsph.edu).


   ABSTRACT
TOP
 ABSTRACT
INTRODUCTION
 POSSIBLE NEW OVERARCHING GOAL
 POSSIBLE NEW SUBGOALS
 COMPARISON TO THE ADVANCING...
 LIMITATIONS AND CONCLUSIONS
 References
 

The Centers for Disease Control and Prevention has undertaken an advisory process to update its national HIV prevention plan. We offer observations on the magnitude of HIV prevention challenges in the United States and reflect on how these challenges might influence the structure of a new HIV prevention plan.

We recommend a plan structure that (1) is based on fundamental principles of prevention, (2) enables accountability and mid-course correction, and (3) if achieved, would result in historic changes in the US HIV epidemic.

The recommended plan structure would differentially prioritize serostatus determination and prevention and care interventions for people living with HIV while retaining goals directed at high-risk HIV-negative and general population members.


   INTRODUCTION
TOP
 ABSTRACT
 INTRODUCTION
POSSIBLE NEW OVERARCHING GOAL
 POSSIBLE NEW SUBGOALS
 COMPARISON TO THE ADVANCING...
 LIMITATIONS AND CONCLUSIONS
 References
 
IN JANUARY 2001, THE Centers for Disease Control and Prevention (CDC) issued a national HIV prevention strategic plan. It called for a reduction from 40 000 new HIV infections per year in the United States to 20 000 in 2005 with an emphasis on reducing racial/ethnic disparities in infection rates.1 The plan had 4 major domestic subgoals, dozens of strategies, and hundreds of action steps. The goal of a 50% reduction in incidence was not achieved; in fact, between 2001 and 2005, little progress was made in lowering the number of new infections, and racial/ethnic disparities continue.2,3 The CDC has embarked on a consultation process designed to gain input to help update the national plan. The CDC/Health Resources and Services Administration Advisory Committee on HIV and STD Prevention and Treatment is providing input to and working collaboratively with the CDC on this planning process. The move to update the plan coincides with the release of a report by the Presidential Advisory Council on HIV/AIDS4 and the new HIV prevention initiative focusing on HIV testing included in the president’s budget proposal for fiscal year 2007.5

We discuss the magnitude of HIV prevention challenges in the United States and reflect on how these challenges should influence the structure of the new HIV prevention plan. The plan structure we suggest is based on 3 fundamental tenets : (1) sound principles of prevention, (2) accountability and midcourse correction, and (3) goals that, if achieved, would result in historic changes in the US HIV epidemic. Further, the plan would comprehensively include the following services: (1) serostatus determination, (2) prevention and care for persons living with HIV, (3) prevention for high-risk HIV-negative persons, and (4) programs for the general population designed to increase HIV-related knowledge and reduce stigma toward persons living with HIV. Additionally, it would explicitly address the full range of federal health policy and funding authority (not just CDC policy and funding).


   POSSIBLE NEW OVERARCHING GOAL
TOP
 ABSTRACT
 INTRODUCTION
 POSSIBLE NEW OVERARCHING GOAL
POSSIBLE NEW SUBGOALS
 COMPARISON TO THE ADVANCING...
 LIMITATIONS AND CONCLUSIONS
 References
 
In an era of flat federal funding for HIV prevention efforts in the United States, one might argue that a reasonable national goal would be to continue to hold HIV incidence at the current rate of 40 000 new infections per year. Without the current prevention efforts in place, new infections would likely number more than 40 000 per year.6

However, the goal that might be achievable should not be determined on the basis of a presumed funding level. Rather, the necessary public health goals should be determined, the necessary public health services to reach the goals identified, the cost of needed services estimated, the efficiency of the necessary investment calculated; and a necessary funding level to achieve the goals recommended. We explore the first step of this chain.

Given the health and socioeconomic impact of HIV on individuals and communities, it is necessary to accelerate efforts to decrease new HIV infections in the United States to levels far below 40 000 per year. Such a goal is achievable if policymakers refocus the relative prioritization of the multiple components (subgoals, objectives, and strategies) of the existing national plan, expand certain segments, and remedy the documented underfunding of HIV prevention in the United States. Of course, the ideal number of new infections is 0, but it may take an extended time to go from 40 000 to 0 infections per year even with substantial new resources.7 Further, any overarching goal should address the continuing issue of racial/ethnic health disparities.

One possible goal is for the annual number of new HIV infections to be reduced from 40 000 to 20 000 or fewer after 3 years, with a particular focus on significantly reducing racial/ ethnic disparities. We believe that the new plan should be more aggressive than the old 5-year plan and that a period of 3 to 4 years is appropriate.

To measure this goal, the CDC would need to produce annual, national estimates of HIV incidence with a breakdown by race/ethnicity.8 New CDC studies focused on estimating HIV incidence should be available in the near future (at this time neither data nor practical information about the sustainability of such a measurement system are available). HIV diagnosis information available from most states can serve as a temporary proxy measure until new incidence information is available3; however, it is important to note that HIV case diagnosis data are not the same as HIV incidence data.8

To make midcourse corrections during a program’s implementation, it is necessary to monitor the annual investment in prevention services and to monitor key short-term measures of service delivery.8 Annual analyses should determine if sufficient resources are provided, not only in aggregate but also by population in need of services. For instance, if racial/ethnic health disparities are to be reduced, intensive initiatives must focus on communities of color.7,8


   POSSIBLE NEW SUBGOALS
TOP
 ABSTRACT
 INTRODUCTION
 POSSIBLE NEW OVERARCHING GOAL
 POSSIBLE NEW SUBGOALS
COMPARISON TO THE ADVANCING...
 LIMITATIONS AND CONCLUSIONS
 References
 
Fundamentally, HIV prevention efforts must reduce risk behaviors among HIV-positive persons that could result in transmission to HIV-negative partners, reduce risky behaviors among HIV-negative persons that put them at risk of infection, and maintain low-risk HIV-negative and HIV-positive persons at low (or no) risk of acquisition or transmission.7,9,10 Therefore, when customizing HIV prevention services to meet client needs, 2 key factors to be considered are the client’s HIV serostatus and that client’s level of HIV-related risk behavior.

Figure 1Go shows several key populations relevant to HIV prevention. Within the general population of the United States (approximately 298 million people),11 there is a population of HIV-negative persons at heightened behavioral risk of infection. The at-risk HIV-negative community is estimated to be between 5 and 26.3 million persons, depending on the definition of risk employed. One study defined sexual risk as 6 or more partners per year and estimated approximately 4 million persons at sexual risk of infection and another 1 million at risk of infection through drug injection.12 The 2002 National Survey of Family Growth estimated that 11.7% of the general population aged 15 to 44 years engaged in risky behavior; this translates to more than 14 million persons at risk of infection.13 Assuming that 11.7% of the population aged 15 years and older is at risk and that this level of risk continues until the end of life expectancy, then the number of persons at risk of infection in the United States climbs to 26.3 million (excluding persons already living with HIV).


Figure 1
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  		FIGURE 1—— Key populations for HIV prevention in the United States.

 
In 2005, the CDC increased its estimate of persons living with HIV in the United States to 1.1 million.14 The CDC estimated that 25% (275 000) of Americans who were HIV positive were unaware of their serostatus,14,15 implying that roughly 825 000 persons living with HIV were aware of their HIV seropositivity.

We estimated that approximately 16% (132 000) of the 825 000 persons aware of their HIV seropositivity engage in behaviors that could transmit HIV to others. We examined the work of Marks et al., who conducted a meta-analysis of the effect of awareness of HIV seropositivity on risk behavior; we found a value of 16% by taking the representative result for research conducted in the 1990s and later.16 (It is important to note that even if the risk behavior level is 16%, other studies have estimated that the actual annual transmission rate from HIV-positive persons aware of their serostatus to HIV-negative partners is roughly 2%.17) We estimate that approximately 693 000 persons living with HIV are aware of their serostatus and engage in no risk behaviors.

Figure 2Go shows how identifying these key subpopulations can suggest important plan subgoals on the basis of sound principles of public health practice and infectious disease control.18–20 A first subgoal should be to increase the percentage of persons who are aware of their HIV-positive status, with a special emphasis on providing counseling, testing, and other prevention services. Previously published studies have demonstrated that, as persons become aware of their HIV-positive status, they substantially decrease risk behavior and transmission rates.16,17


Figure 2
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  		FIGURE 2—— Desirable movement among subpopulations and directions for HIV prevention services in the United States.

Note. The arrows show desired directions of population change, and the cross-shaped symbol indicates that all persons living with HIV need to learn of their HIV serostatus and have access to high-quality HIV-related care. The twisted arrow indicates that very low risk levels and non-stigmatizing attitudes should be maintained.

 
A second subgoal should be to decrease the already low percentage of persons aware of their HIV positivity who engage in transmission risk behavior. Some behavioral interventions have been successful in reducing HIV-related risk behaviors among persons who are HIV positive.16,21,22 However, relatively few studies focus exclusively on persons living with HIV who continue to engage in high levels of transmission-related risk behaviors because of substance use, mental illness, lack of regular access to health care, and so on; this body of research must grow quickly.

A third subgoal should be to increase the percentage of persons living with HIV who access appropriate HIV care and treatment. An Institute of Medicine committee found that a comprehensive package of care, treatment, and related services for persons who are HIV positive was effective and efficient at improving mortality and morbidity. In fact, this committee recommended that such a bundle of services be a federal entitlement program for persons who are HIV positive and earn less than 250% of the federal poverty level.23 Aside from care being a pathway to transmission prevention services for persons living with HIV, it is theoretically possible that HIV treatment itself may reduce infectivity, at least at the individual level. However, what is possible at the individual level may not be possible at the community level.24,25

A fourth subgoal should focus on reducing the number of persons at behavioral risk of HIV infection. A large literature demonstrates that, for persons who are HIV negative or of unknown serostatus, prevention interventions can be both effective and efficient for modifying HIV-related risk behaviors.7,26–29 These prevention services, including individual, small group, and community-level interventions, seem most effective when delivered by opinion leaders (influential persons in the community) in peer groups and targeted to communities at behavioral risk.7,26–28

Two other subgoals should focus on the general population. These goals would shift broader cultural norms that promote greater risk of HIV transmission by fostering basic HIV-related knowledge (basic HIV information is insufficient but necessary for HIV prevention) and reducing HIV-related stigma (aside from being morally objectionable, stigmatization of persons living with HIV and of HIV/ AIDS services creates an environment that fosters avoidance of HIV-related services). Approximately 40% of the general population incorrectly answers at least 1 HIV knowledge question on a basic quiz.30–33 Furthermore, roughly 20% of the population believes that persons who are HIV-positive deserved to become infected.30,33 Such beliefs create a national backdrop that inhibits candid, necessary, and influential prevention services. Indeed, one could conceive a "risk environment" in which stigma, discrimination, income inequality, lack of social capital, and other societal conditions set the stage for, and may even produce, HIV-related risk behaviors.34,35 Changing such conditions may require broad structural interventions that include modifying laws, policies, regulations, and societal norms.36,37


   COMPARISON TO THE ADVANCING HIV PREVENTION INITIATIVE
TOP
 ABSTRACT
 INTRODUCTION
 POSSIBLE NEW OVERARCHING GOAL
 POSSIBLE NEW SUBGOALS
 COMPARISON TO THE ADVANCING...
LIMITATIONS AND CONCLUSIONS
 References
 
In 2003, the CDC launched its 4-pronged Advancing HIV Prevention (AHP) initiative in which the goals are (1) increasing awareness of HIV serostatus through testing (perhaps without counseling) in traditional medical settings, (2) developing new models for diagnosing HIV infection outside of traditional medical settings (emphasizing rapid HIV testing), (3) providing prevention services for persons living with HIV to avoid further transmission, and (4) further lowering mother-to-child HIV transmission.10 Our proposed plan incorporates many of the AHP activities as special cases, but our plan framework is much more comprehensive. In fact, our proposal bears more resemblance to the CDC’s earlier Serostatus Approach to Fighting the Epidemic initiative, which emphasized consideration of serostatus when customizing HIV prevention services for clients but, unlike AHP, did not focus narrowly on HIV testing and prevention services for HIV-positive persons to avoid further transmission.9


   LIMITATIONS AND CONCLUSIONS
TOP
 ABSTRACT
 INTRODUCTION
 POSSIBLE NEW OVERARCHING GOAL
 POSSIBLE NEW SUBGOALS
 COMPARISON TO THE ADVANCING...
 LIMITATIONS AND CONCLUSIONS
References
 
It is beyond the scope of this article to provide annual quantitative targets for each of the subgoals; rather, we focused on the types of subgoals required. Additional modeling analyses must be done to determine how much progress is needed in each subgoal to reduce new infections by 50% in 3 years (while also reducing racial/ethnic health disparities). Further, this work must identify objectives for each subgoal by target population (defined broadly).

Another limitation is that we focused on the magnitude of prevention challenges defined by HIV serostatus. We hasten to add that racial/ethnic health disparities must be urgently remedied because HIV dramatically disproportionately affects communities of color, most notably African American communities. Further, there are key priorities for populations defined by the intersection of race/ethnicity, risk behavior, and serostatus. The CDC recently released behavioral surveillance data from Baltimore, Md; New York, NY; Miami, Fla; and San Francisco and Los Angeles, Calif, that found that 46% of African American men frequenting gay venues were HIV infected, but less than half of these men knew their serostatus.38

All of the services described here merit federal investment and are needed to sustain a comprehensive, effective national HIV prevention program, but we do not argue for equal investment in all of these service categories. Rather, we call for additional economic optimization analysis to help determine the most influential level of investment in each type of services39,40 and for analyses of the costs of unmet needs to determine the total budget to provide necessary, evidence-based HIV prevention services to all those in need.41

Another limitation is that we focused on the structural framework of the plan and called for evidence-based interventions but did not provide a comprehensive review of the evidence for each and every type of intervention that might be employed to reach each subgoal. Nevertheless, quite a number of recent articles examine the efficacy and effectiveness evidence for HIV prevention interventions.7,21,22,26–28,42–44

There are multiple root causes of why HIV incidence was not reduced by 50% from 2001 to 2005. These reasons include lack of necessary investment to meet HIV prevention needs, and policy barriers that limited the optimal use of HIV prevention science. Scientific evidence has taken a backseat to politics at several points in the HIV epidemic. In the 1980s, a president would not utter the word "AIDS"; in the 1990s, effective needle and syringe exchange programs were consciously passed over for federal funding; and in recent years, basic information about HIV prevention was removed (at least for a time) from the CDC’s Web site.7 If we are to reduce the rates of HIV infection, scientific evidence must guide our HIV prevention programs and policies.

Further, the CDC’s original plan was implemented as a CDC-specific plan, not as a comprehensive national plan. We reiterate that it is critical for the United States to have a truly national plan, one that includes the CDC and all relevant public- and private-sector HIV prevention partners. The Open Society Institute recently released a report comparing the HIV prevention efforts in the United States with the criteria for HIV prevention programs issued in 2001 in the United Nations General Assembly Special Session Declaration of Commitment on HIV/AIDS. A central criticism is that the United States does not meet the requirement of one comprehensive national HIV plan.45

A new and truly comprehensive national plan is needed to reduce new infections by at least 50% in 3 years and to reduce racial/ethnic health disparities. The plan’s subgoals should be based on sound principles of public health practice and the evidence of unmet needs, and should include effective interventions to meet those needs. The goal and subgoals will not be achieved, however, without a national commitment of the necessary resources to substantially reduce unmet HIV prevention needs and a willingness to target prevention services to the communities most in need.


   Footnotes
 
Peer Reviewed

Contributors
All authors worked collaboratively on the HIV prevention framework described in this article and participated in the review of the literature. D. R. Holtgrave conducted the quantitative analyses, wrote a rough first draft, and participated in the editing of the article. J. F. McGuire drafted selected paragraphs, reviewed the analyses, and heavily edited the article. J. Milan Jr drafted selected paragraphs, edited heavily, and led the article’s coverage of health disparities.

Accepted for publication September 1, 2006.


   References
TOP
 ABSTRACT
 INTRODUCTION
 POSSIBLE NEW OVERARCHING GOAL
 POSSIBLE NEW SUBGOALS
 COMPARISON TO THE ADVANCING...
 LIMITATIONS AND CONCLUSIONS
 References
 
1. HIV Prevention Strategic Plan Through 2005. Atlanta, Ga: Centers for Disease Control and Prevention; 2001.

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3. Centers for Disease Control and Prevention. A glance at the HIV/AIDS epidemic, April 2006. Available at: http://www.cdc.gov/hiv/resources/factsheets/At-A-Glance.htm. Accessed May 26, 2006.

4. President’s Advisory Council on HIV/AIDS. Achieving an HIV-free generation: recommendations for a new American HIV strategy. Available at: http://www.pacha.gov/plan.html. Accessed May 26, 2006.

5. Kaiser Family Foundation. U.S. federal funding for HIV/AIDS: the FY2007 budget request. Available at: http://www.kff.org/hivaids/7029.cfm. Accessed April 16, 2007.

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12. Anderson JE, Wilson RW, Barker P, Doll L, Jones TS, Holtgrave D. Prevalence of sexual and drug-related HIV risk behaviors in the U.S. adult population: results of the 1996 National Household Survey on Drug Abuse. J Acquir Immune Defic Syndr. 1999;21: 148–156.[Web of Science][Medline]

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16. Marks G, Crepaz N, Senterfitt JW, Janssen RS. Meta-analysis of high-risk sexual behavior in persons aware and unaware they are infected with HIV in the United States: implications for HIV prevention programs. J Acquir Immune Defic Syndr. 2005;39:446–453.[CrossRef][Web of Science][Medline]

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29. Pinkerton SD, Johnson-Masotti AP, Holtgrave DR, Farnham PG. Using cost-effectiveness league tables to compare interventions to prevent sexual transmission of HIV. AIDS. 2001;15:917–928.[CrossRef][Web of Science][Medline]

30. Centers for Disease Control and Prevention. HIV-related knowledge and stigma—United States, 2000. MMWR Morb Mortal Wkly Rep. 2000;49(47): 1062–1064.[Medline]

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33. Herek GM, Capitanio JP, Widaman KF. HIV-related stigma and knowledge in the United States: prevalence and trends, 1991–1999. Am J Public Health. 2002;92:371–377.[Abstract/Free Full Text]

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35. Rhodes T, Simic M. Transition and the HIV risk environment. BMJ. 2005; 331:220–223.[Free Full Text]

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43. Albarracin D, Gillette JC, Earl AN, Glasman LR, Durantini MR, Ho MH. A test of major assumptions about behavior change: a comprehensive look at the effects of passive and active HIV-prevention interventions since the beginning of the epidemic. Psychol Bull. 2005;131:856–897.[CrossRef][Web of Science][Medline]

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