How HIV Prevention Has to Change
By Chris Collins
October 14, 2010 - Tom Frieden, director of the Centers for Disease Control and Prevention (CDC), has included the domestic HIV/AIDS epidemic on his short list of "winnable battles" in public health. We could dramatically reduce the number of new HIV infections in America below the current annual rate of 56,000. But without important changes in the way our country addresses HIV/AIDS, in five years there may well be more new infections each year, not fewer.
Any discussion of HIV prevention should start with the good news. Numerous research studies have demonstrated that HIV prevention can be effective. Community-driven and publicly funded HIV prevention helped bring the HIV infection rate down dramatically from its peak in the mid-1980s, and prevention programs averted more than 350,000 new infections between 1991 and 2006.1 And yet the HIV infection rate has not fallen in over a decade and is likely creeping upward. HIV continues to have a devastating impact on the hardest hit communities, including gay men, African Americans, and Latinos.
President Obama’s National HIV/AIDS Strategy, released in July, sets the worthy goal of reducing HIV infection by 25% over five years. It pledges reforms in the U.S. approach to AIDS, including improved coordination, accountability, and targeted use of resources for populations most at risk. These are all critically important measures, but alone are not sufficient to reach the President’s Strategy goals. To do that we’ll need systemic change in HIV prevention. Here are some of the priorities:
First, increase and make better use of resources. Domestic HIV prevention receives only about 3% of total federal HIV spending. A new analysis from David Holtgrave at Johns Hopkins University suggests that increased investments in HIV prevention now will yield savings down the road.2 Funding also needs to be used more wisely, and hard choices need to be made about deploying resources where they can have greatest impact at the Federal, state and local level.
What is needed: In his FY 2012 budget proposal, the President should make the resource increases necessary to accomplish Strategy goals.
Second, make lower incidence the primary focus. It sounds obvious, but the goal of HIV prevention should be to bring down the HIV infection rate, also called HIV incidence. Yet too many publicly funded prevention programs operate on a small scale and do not reach many of those at elevated risk. Four out of five gay and bisexual men report not being reached with individual or group prevention programs in the prior year.3
In one recent CDC survey of gay men sampled in 21 urban centers a shocking 71% of young Black gay men living with HIV were not aware of their status.
What is needed: Operational plans now being drawn up by federal agencies to implement the National Strategy must detail a process for identifying prevention services associated with reducing HIV incidence and not just HIV risk behavior, as well as for bringing the most effective prevention services to the scale necessary for making a measurable impact on the hardest hit communities.
Third, address the context of vulnerability. We have to deliver prevention messages that can help people modify their behavior, along with condoms, syringe exchange, and other proven prevention approaches. But reducing HIV incidence will also require increasing the reach of comprehensive services including AIDS treatment, frequent voluntary HIV testing, prevention programming for people living with HIV, and supportive services such as housing.
A person’s risk behavior is very different from their likelihood of becoming infected with HIV. For example, African-American gay men do not practice riskier sexual behavior than their white counterparts, and have lower risk profiles in some respects. But an African-American gay man is at far greater risk of becoming HIV positive. This is due to several factors outlined by Greg Millett and colleagues,4 including higher rates of sexually transmitted infections (STIs) and lower rates of both AIDS treatment and knowledge of HIV status.
Antiretroviral therapy lowers HIV viral load and evidence suggests it may reduce the likelihood of infecting others, so identifying people living with HIV and giving them the opportunity to receive appropriate care should be a top prevention priority. Yet one out of three people living with HIV/AIDS in America is not in care.5 Greater uptake of treatment and other services depends on innovative approaches to overcoming social barriers to health care utilization, including stigma, racism, and homophobia.
What is needed: National Strategy operational plans must address HIV prevention as part of a coordinated effort to expand voluntary HIV testing and delivery of AIDS treatment and STI services. Federal contracts should reflect the critical role of all HIV service providers in linking people with appropriate treatment and prevention interventions, and helping people living with HIV stay in care. Community prevention providers will continue to have a critical role in prevention services, though in some cases their work would broaden to include helping people access and stay in care, and delivering services on a wider scale.
HHS has announced a plan to work across its agencies to expand integrated services in areas with high HIV incidence. It’s an excellent approach that can be the leading edge of a successful Strategy if the program has the necessary resources, brings services to scale, and reaches those who have thus far not received the services they need.
Finally, get the answers we need to have greater impact. Ultimately a cure and a vaccine are necessary to bring the HIV epidemic to an end, and there is new hope on both these fronts that justifies increased research investments. But for the near term, we must make better use of the interventions at hand. Research efforts across the US government need to tell us more about how to expand the reach of comprehensive programming, provide people with services they feel safe and comfortable using, and address the social and structural factors driving vulnerability to HIV infection. As Tom Coates and colleagues6 have observed, HIV prevention research has paid woefully insufficient attention to assessing programs that can be delivered broadly enough to impact overall incidence, including scaled up individual and small group interventions, and other approaches.
What is needed: National Strategy operational plans should reinforce the critical coordination and planning role of the Office of AIDS Research (OAR) at the National Institutes of Health and outline specifically what research is needed short and long term to accomplish Strategy goals on time.
We have the tools to dramatically reduce HIV infection rates, and in fact prevention experts from the CDC and Johns Hopkins University estimate7 that HIV incidence could be reduced by 40% or more in five to ten years. Now we need the leadership to put these tools to work in a reinvigorated, strategic, and adequately resourced national effort.
Chris Collins is Vice President and Director of Public Policy at amfAR, the Foundation for AIDS Research. Recommendations for National HIV/AIDS Strategy implementation developed by a group of 21 Strategy advocates are available here.
1 Farnham, PG, et al, Medical Costs Averted by HIV Prevention Efforts in the United States, 1991-2006, Letter to the Editor, Journal of Acquired Immune Deficiency Syndromes, 2010;54:565-567
2 Holtgrave, D, On the epidemiologic and economic importance of the National AIDS Strategy for the United States, JAIDS, 1 Oct 2010; vol. 55, issue 2, pp 139-142
3 CDC, HIV in the United States: at a Critical Crossroads, August 2009,
4 Millett, GA, et al, Explaining disparities in HIV infection among black and white men who have sex with men: a meta-analysis of HIV risk behaviors, AIDS 2007, 21:2083-2091
5 The White House, National HIV/AIDS Strategy for the United States, July 2010
6 Coates, TJ, Behavioral strategies to reduce HIV transmission: how to make them work better, Lancet 2008; 372: 669-84
7 Hall, HI, et al., Estimated future HIV prevalence, incidence, and potential infections averted in the United States: a multiple scenario analysis. J Acquir Immune Defic Syndr. 2010 Oct 1;55(2):271-6.