Introduction: Rethinking HIV Prevention
At the request of the U.S. Centers for Disease Control and Prevention (CDC), the Committee examined current HIV prevention efforts in the United States, with the objective of devising a sound framework for a national HIV prevention strategy and suggesting institutional roles within this framework for the CDC and other public and private-sector agencies. Our examination yielded three firm conclusions. First, prevention works. The nation needs to focus on strategies proven to reduce behaviors (such as having unprotected sex or sharing drug injection equipment) that risk transmitting or acquiring HIV. Such strategies are especially important because an effective HIV vaccine is not likely to be available in the near future. Second, by better allocating available funds, even more HIV infections could be averted. Third, social forces and risky behaviors fuel the spread of HIV. Poverty, racism, homophobia, and the stigma attached to HIV infection and AIDS seriously impede HIV prevention efforts. The Committee’s reasons for reaching these conclusions, and a set of recommendations, follow in the substantive chapters of this report. In this introduction, we briefly justify these key findings and the implications that flow from them.
The Committee adopted the principle that the explicit goal of a national strategy should be to avert as many new HIV infections as possible with the resources available for prevention. One implication of this proposed goal is that HIV prevention activities will be most successful if they are directed at the persons most likely to transmit or acquire HIV—that is, those who have unprotected sex or who share drug injection equipment with
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
funds from being spent to ensure drug users access to sterile drug injection equipment, a highly cost-effective prevention strategy for those who are at high risk of acquiring HIV because they use injectable drugs.
The succeeding sections of this report lay the foundation for the Committee’s strategic vision for HIV prevention. Chapter 2 builds the case for a national surveillance system that identifies new HIV infections. Chapter 3 illustrates the value of allocating resources according to the cost and effectiveness of alternative programs, and it shows why evaluation is key to informing allocation decisions. Chapter 4 emphasizes the value still to be gained from closer integration of prevention into the clinical setting, and Chapter 5 points to the importance of filling the gap between research findings and effective action in the community. The promise of new technologies and the need for continued investment in research are the subject of Chapter 6. Finally, Chapter 7 tackles the underlying social conditions and attitudes that have hampered prevention efforts from the outset of the epidemic and continue to do so today.
Throughout its deliberations, the Committee has been motivated by the conviction that more can be done to prevent HIV infection. Doing better will require a new way of thinking about cost-effectiveness as a guiding principle for HIV prevention. It will require new leadership, accountability, and coordination; the Committee believes that, for HIV prevention efforts to have maximum impact, there must be a strong, clear leadership structure in the Department of Health and Human Services. Doing better will also require directing prevention efforts to those who are HIV-infected and those—women, youth, and racial and ethnic minorities—who are the new faces of the epidemic. It will require more effective translation of HIV prevention interventions that are successful in research settings into activities that are effective in communities. And it will require removing obstacles that impede the implementation of those interventions that we now know to be effective.