persons who are HIV-infected. Increasingly, in this country, those at high risk are women, youth, and racial and ethnic minorities. While this priority may seem logical, however past HIV prevention activities have not focused on HIV-infected persons because of concerns about increased discrimination, prejudice, and the stigma associated with HIV/AIDS. While these concerns are still valid, the benefits of antiretroviral treatments, the growing evidence of ongoing risk behaviors in identified infected persons, and the need to access infected individuals in confidential and professional health care settings compels their inclusion in prevention efforts. However, directing prevention efforts to those who are infected and monitoring the course of the epidemic requires an effective HIV surveillance system, which currently does not exist.

Additionally, federal expenditures on HIV prevention activities appear to be allocated to states in rough proportion to the distribution of persons with AIDS. Indeed, achieving such a proportional allocation appears to be the current goal. If we were considering HIV treatment, then this basis for distributing resources would be reasonable. However, such a distribution model does not prevent the maximum number of new infections; it ignores the differential cost of preventing new infections across prevention activities, and it uses inappropriate data (i.e., AIDS surveillance) to make resource allocations for more current HIV incidence-driven needs.

HIV prevention efforts also must be selected with more attention given to cost-effectiveness. Not only did the Committee find that there is limited information on the cost-effectiveness of current prevention strategies, but we also discovered that virtually none of the actors in HIV prevention at the federal, state, and local levels even thinks about cost-effectiveness as a guiding principle. The Committee acknowledges that cost-effectiveness alone is insufficient as a determinant of resource allocation, since such matters as fairness and equity also deserve consideration. The nation may decide to spend some HIV prevention dollars on a particular group, even if this results in fewer infections prevented overall. But in doing so, the cost of such a decision, in terms of forgone infections prevented, should be clearly acknowledged.

Finally, the Committee was struck by how severely social barriers still deter HIV prevention. For example, the nation is spending approximately $440 million in federal and state funds over five years on abstinence-only sex education—in the absence of any evidence that this approach is effective, much less cost-effective—solely because of social forces that prevent effective comprehensive sex education courses from being offered. Further, in an effort to make the blood supply as safe as possible, the nation has spent $60 million to prevent an estimated eight new infections, or $7.5 million for each infection prevented. Yet, the federal government bars its



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