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CDC’s “Advancing HIV Prevention” Initiative Examined During Forum in Recognition of World AIDS Day

A panel addressed various aspects of the Centers for Disease Control and Prevention (CDC)’s “Advancing HIV Prevention” initiative at a December 5 forum. The forum capped a week of events held in recognition of World AIDS Day on December 1, and was sponsored by The Center for Interdisciplinary Research on AIDS (CIRA) and the Institution for Social and Policy Studies (ISPS).

David Paltiel responding to opening speakers.

The program began with comments about the initiative from opening speakers Ron Valdiserri, Deputy Director of the National Center for HIV, STD, and TB Prevention at CDC, Chris Andresen, Health Program Supervisor in the AIDS and Chronic Diseases Division at the Connecticut Department of Public Health (DPH) and Terje Anderson, Executive Director of the National Association of People with AIDS (NAPWA). The initiative was announced by CDC in April, 2003.

Valdiserri began by providing background information about why the initiative was launched. Beginning in 1995, the number of new AIDS cases and deaths due to AIDS began to fall in the United States due to improved treatment, which changed the HIV prevention environment. The changed environment is characterized by the perception that HIV is no longer a major threat, the incorrect belief that a reduced viral load makes an HIV positive person non-infectious, difficulty in maintaining safer sex, and the fact that many young people have never been personally affected by HIV. In addition, there is unequal access to prevention services for members of racial and ethnic minority groups.

Valdiserri argued that HIV prevention issues have “fallen below the radar screen” and that the United States is not effectively providing ongoing prevention efforts to people who are receiving good medical treatment for HIV/AIDS. That failure is a problem because between 850,000 and 950,000 people in the United States are currently living with HIV/AIDS. Thus, there is more opportunity to transmit the virus than ever before. Of those living with HIV/AIDS, between 180,000 and 280,000 are unaware of their HIV status and may be unwittingly infecting their partners.

Valdiserri noted that many people are not tested for HIV until late in the course of the infection, which is problematic because it is best to intervene before demonstrable damage has been done to the immune systems of infected people and because the vast majority of those infected take steps to modify their behavior after learning of their status.

Robert Heimer responding to opening speakers.

Valdiserri said that the Advancing HIV Prevention initiative is aimed at reducing barriers to early diagnosis of HIV infection and increasing access to and use of quality medical care, treatment and prevention services for persons living with HIV. The goal is to reduce HIV transmission. The initiative has four priority strategies, which are to make voluntary HIV testing a routine part of medical care, to implement new models for diagnosing HIV infections outside of medical settings, to prevent new infections by working with those diagnosed with HIV and their partners, and to further decrease perinatal HIV transmission.

Following Valdiserri, Andresen described the efforts that DPH is making in each of the initiative’s priority areas, some of which were in place prior to announcement of the initiative, and some of which are being developed in response to it. With respect to the first priority, making voluntary HIV testing a routine part of medical care, Andresen noted that DPH had already initiated HIV counseling and testing training for OB/GYN providers and other health care providers, and that, pending funding, it plans to expand that training to include a wide variety of non-DPH funded health care providers. With respect to the second strategy, implementing new models for diagnosing HIV infection outside of medical settings, DPH had already initiated HIV testing in non-traditional settings like methadone and other drug treatment centers and community vans. It has also started an implementation pilot program using the OraQuick rapid HIV test. With respect to the third priority, preventing new infections by working with persons diagnosed with HIV and their partners, Andresen said that people living with HIV have been a Connecticut HIV Prevention Community Planning Group priority since 2002. Among other strategies, DPH has been providing HIV prevention capacity building for agencies providing services to people with HIV, runs the Early Linkage and Referral Initiative (E.R.L.I.), which links those receiving medical care for HIV/AIDS with prevention services, funds prevention case management programs for people with HIV, and runs the Companion Awareness and Risk Education (C.A.R.E.) Program, which assists with and provides partner notification. Future plans include new opportunities for partner counseling and referral services, and making HIV positive people a top priority for HIV prevention services in DPH’s comprehensive plan for 2005. DPH has already requested additional funds, to be competitively bid, to implement HIV prevention interventions that relate to the initiative. With respect to the fourth strategy of further decreasing perinatal transmission, Andresen noted that the Yale New Haven Rapid Testing Project offers rapid testing to pregnant women and has been in place for a couple of years, that state-funded prenatal HIV counseling and testing programs are in place at Bridgeport Hospital, the Hospital of St. Raphael and St. Francis/Mt. Sinai. Andresen also noted that since Connecticut’s perinatal testing law was implemented in October of 1999, the numbers of infants infected with HIV has decreased.

NAPWA’s Anderson provided a critique of the initiative, stating that it was flawed from inception. He argued that the initiative was politically inspired by the Bush administration, that it was announced without prior community consultation, that it is overly reliant on medical settings and individual level interventions, that it displaces important on-going interventions, that certain aspects of it lack a sound scientific basis, that it has the potential to increase the stigma and blame placed on HIV positive people, and that it lacks a plan for care and treatment of the cases of HIV infection identified as a result of the testing it will generate. He argued that the initiative lacks those interventions that have “potential to be lightening rods,” but that would make it more effective, such as social marketing, and condom and needle availability. However, he argued that the initiative’s goals of increasing knowledge of HIV status and providing prevention services for HIV positive people are important, and shared by NAPWA. His suggestions for improving the initiative included demanding additional resources for prevention and care, embracing a full range of prevention approaches, choosing interventions that have been scientifically proven to work, using language that fights stigmatization and recognizes that both HIV positive and HIV negative people have a role in prevention, and establishing a national plan for care and treatment of those identified as HIV positive as a result of the initiative.

Following Valdiserri, Andresen and Anderson’s presentations, a responder panel including Robert Heimer, Associate Professor of Epidemiology, June Holmes, Chair of the (New Haven) Mayor’s Task Force on AIDS, Shawn Lang, Assistant Director of the Connecticut AIDS Residence Coalition, Brian Libert, HIV Counseling and Testing/Outreach Prevention Coordinator at Community Health Services, Dominick Maldonado, AIDS Education Coordinator at the New Haven Health Department and A. David Paltiel, Associate Professor of Public Health commented on issues raised by the opening speakers.

Heimer agreed that improved prevention efforts are necessary, but said that the key question is “what constitutes effective prevention.” He argued that risk takers know that they are taking risks and need aggressive messages that are likely to be politically controversial in order to change their behavior. Paltiel echoed Anderson’s concern that the CDC initiative does not provide a way to treat the cases of HIV infection that will be identified as a result of the testing it will generate.

-Story by Christy Gordon.