Domestic HIV prevention efforts in the United States can claim important successes over the last 2 decades. HIV incidence has plummeted from its height in the mid 1980s, and the HIV transmission rate has fallen over the years.1 An evidence base of effective prevention interventions has been established, and it has been estimated that HIV prevention programs averted more than 350,000 new infections between 1991 and 2006.2
Yet although delivery of HIV prevention services has helped limit HIV incidence, it has not prevented HIV from becoming a devastating epidemic in the communities most affected. Progress in reducing incidence has stalled for more than a decade, with an estimated 56,000 new infections each year.3 Wafaa El-Sadr et al4 point out that the US domestic epidemic is characterized by “low prevalence in the general population, high prevalence among the disenfranchised and socially marginalized, with a concentration in geographic hotspots.” In many important ways, America's prevention response is not designed to address this kind of epidemic. A more effective and strategic effort would be tailored to the dynamics of local epidemics, would target resources more effectively, and would deliver services appropriate to communities facing a range of health and other challenges.
The National HIV/AIDS Strategy, issued by the White House Office of National AIDS Policy in July 2010, provides a critical opportunity to reform domestic HIV prevention efforts and, ultimately, to begin to lessen HIV incidence over time. The strategy calls for targeting prevention resources where the epidemic is most acute, relying on evidence-based approaches and improving coordination between public and private providers.
Will the national strategy lead to concrete reforms in HIV prevention policy and programing that can accomplish President Obama's goal of a 25% reduction in HIV incidence by 2015?5 At least 4 elements are essential to improving outcomes on HIV incidence and realizing the president's goal, including the following: improved transparency and accountability, scaling up programming for those most at risk, fostering indigenous efforts, and looking beyond individual behavior change interventions.
ADVANCING PREVENTION ACCOUNTABILITY
Accountability for federal HIV program funds is often conceptualized in terms of prudent administration of resources. It is time to expand our notion of accountability to include strategic use of funding to reduce HIV infection rates. Primary questions include whether local epidemic profiles closely inform the targeting of resources; whether local prevention plans are designed with the clear aim of reducing incidence; and whether outcomes are tracked and reported regularly. Evidence to date suggests that use of federal HIV prevention funds by state and local entities is not well matched to the epidemic profile in many jurisdictions.6
Some examples of how prevention accountability could be advanced 7 include:
- Having Centers for Disease Control and Prevention (CDC) play a more active role in supporting local and state health authorities in use of federal HIV prevention funds. Particular attention would be placed on ensuring that local or state epidemiologic profiles closely inform resource allocation. In the past, CDC staff did periodic program reviews with local and state health authorities. These could be reinstated.
- Asking health departments for “Statements of Alignment.” These statements would accompany health departments' annual reports to CDC, much as departments now must provide a statement of concurrence from community planning bodies. The statements of alignment would either confirm that allocation of prevention funding reasonably matches local epidemic conditions or explain why it does not.
- Improving transparency in the use of prevention funding. CDC should annually publish its use of funds-both funds utilized by local and state authorities and those spent by CDC's central office. This reporting would track allocations toward different activities and target populations.
Similar types of accountability approaches should also be employed at other federal agencies engaged in HIV prevention, including the Substance Abuse and Mental Health Services Administration.
GOING TO SCALE IN COMMUNITIES AT ELEVATED RISK
Intensive prevention services are not reaching many of those at elevated risk of infection. For example, a 2006 survey indicates that only a relatively small share of gay men and other men who have sex with men (MSM) had participated in HIV prevention interventions during the previous 12 months.8 A more effective prevention effort will require interventions delivered and sustained at a scale that can have impact on incidence in the communities at the center of the domestic epidemic.
Although numerous studies have established the HIV prevention efficacy of some behavioral interventions, there is scant evidence of the population-level impacts of many HIV prevention approaches. Through the Diffusion of Evidence-Based Interventions program, CDC has identified a variety of HIV prevention programs for which there is evidence of effectiveness. Yet as others have observed,9,10 many of these interventions are dated, do not adequately address some groups at elevated risk, and are difficult to deliver at scale.
Isolated small-scale prevention programs alone will not have a major impact in reducing infection rates. A much greater emphasis is needed on developing, testing, and fielding programs that can demonstrate measurable impact on incidence. In many cases, this refocus of emphasis will mean adopting approaches that combine multiple interventions tailored to those at elevated risk. Research portfolios at the National Institutes of Health and CDC should be developed with the goals of advancing knowledge about what will have impact at a population level and expanding operations research that can guide delivery of these interventions in the field.
FOSTERING COMMUNITY-BASED EFFORTS
Community-based organizations (CBOs) are the front line in HIV/AIDS prevention and service delivery. They play a major role in translating knowledge and cultural competence among communities of color and other high-risk populations into health promotion and behavior change. CBOs are in a position to understand the unique circumstances that drive HIV infection in the communities they serve, to develop and deliver culturally appropriate HIV prevention and related services to high-risk populations, and to form enduring partnerships with these populations.11
Since the beginning of the HIV/AIDS epidemic, CBOs have developed prevention interventions in the response to HIV/AIDS, and among them are culturally competent programs that address the unique needs of racial, ethnic, and sexual minority populations. These interventions were being developed and implemented in the absence of widespread availability of evidence-based HIV behavioral interventions.12 Most often, the CBOs developed their interventions in collaboration with communities they serve, incorporating innovative strategies and approaches for prevention and demonstrating sensitivity to local populations' values and norms.13-15
Although the CDC has long recognized the importance of effective and evidence-based interventions with community-based indigenous (home-grown) prevention strategies and interventions and has recently given more attention to their development, greater support is needed for these efforts. Many CBOs need assistance in building organizational capacity; they also need additional resources to evaluate newly developed interventions. Today, many CBO-led evaluations are limited to determining participant satisfaction or are expressed simply as basic outputs (eg, quantities of condoms distributed or numbers of intervention sessions completed).16,17 To broaden the reach of locally developed interventions, CBOs need support to evaluate interventions within communities, demonstrate efficacy, and improve the effectiveness.18
Perhaps most importantly, CBO-led evaluations will enable the most vulnerable populations to hold their own communities accountable and will help expand the impact of community-based, culturally appropriate, and efficacious HIV prevention interventions that can reach those most at risk.
LOOKING BEYOND THE INDIVIDUAL
We know that context is key in the HIV epidemic. Individual behaviors are deeply influenced by social, economic, and other factors-a particularly relevant point in this epidemic because many people at elevated risk are part of communities facing multiple concerns. For them, interventions that seek only to affect individual decisions may be insufficient to address the complex factors in personal vulnerability.19,20 As Fenton and Dean21 have written, “It is increasingly unacceptable for those planning and delivering prevention services to claim that addressing SDH (social determinants of health) is outside their jurisdiction.” The task ahead is to create a system in which those active in health policy and programing are supported in working collaboratively to address social factors. We need a system that fosters far more coordination across providers and establishes funding streams that support action on social determinants. Community Transformation Grants, created by health reform, are an important opportunity to address the community context of HIV and other health challenges.
We also know that risk is not determined solely by the behavior of an individual. Far more attention is needed to the dynamics of sexual networks in the HIV epidemic. This is clear from work by Hallfors et al22 who found that although risk for HIV and STD acquisition is heightened among young white adults who engage in high-risk behaviors, young adults who are black are at elevated risk whether or not their personal behaviors are “high risk.” Wohlfeiler and Ellen23 call for a “new generation of structural interventions on sexual networks,” that reach people through Internet sex sites, gay sex clubs, and other venues with prevention and testing services and, where appropriate, policy interventions. The authors point out that policy interventions have been fundamental to success of injury and tobacco control and can play an important role in HIV. An example: regulations mandating that sex venues in San Francisco remove doors from private rooms so that monitors can ensure clients practice safer sex.24 Given mounting evidence of the prevention impact of HIV treatment, wider access to and uptake of HIV treatment is another policy priority in the effort to lower HIV incidence.
The new National HIV/AIDS Strategy presents an important opportunity to improve America's HIV prevention effort. But to overcome the years of stagnation in prevention outcomes, we need a response characterized by accountability, appropriate targeting, and sufficient scale. We also have to measure interventions by their ability to make an impact at the population level and to ensure that these interventions are addressing the central factors driving incidence.
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