Advancing HIV Prevention: New Strategies for a Changing Epidemic

Advancing HIV Prevention (AHP) is an initiative to reduce barriers to early diagnosis of HIV infection and increase access to quality medical care, treatment, and ongoing prevention services for people living with HIV.

This initiative was created in response to several factors.

• Declines in new HIV infections have leveled off.
• Increases in sexually transmitted diseases and risk behaviors have led to a possible increase in new HIV infections.
• Not enough people know their HIV status.
• People who know their HIV status can protect themselves and their partners.
• A simple, rapid HIV test is available.
• Opportunities for preventing mother-to-child HIV transmission are being missed.

Four strategies are used to advance HIV prevention.

• Make voluntary HIV testing a routine part of medical care. CDC is working with medical associations to ensure that all health care providers include HIV testing, when indicated, as part of routine medical care.
• Use new models for diagnosing HIV infections outside medical settings. The use of rapid HIV tests can increase access to early diagnosis and referral for treatment and prevention services.
• Prevent new infections by working with HIV-infected persons and their partners. CDC published the Recommendations for Incorporating HIV Prevention into the Medical Care of Persons with HIV Infection.
• Further decrease mother-to-child HIV transmission. CDC promotes routine HIV testing of pregnant women and routine screening of any infant whose mother was not tested.

Although AHP emphasizes voluntary HIV testing, it does not endorse mandatory testing. AHP capitalizes on rapid test technologies, interventions that bring persons who are unaware of their HIV status to HIV testing, and behavioral interventions that provide prevention skills to persons living with HIV.

Overall, 9 health departments and 16 CBOs have been awarded $23 million over 2 years to develop models and demonstrate feasibility of putting the 4 AHP strategies into practice. As the first round of projects comes to a close, lessons learned are being used to develop tools for widespread use. The following demonstration projects are under way.

AHP Demonstration Projects for State and Local Health Departments
HIV Rapid Testing to Improve Outcomes for Partner Counseling, Testing, and Referral Services (PCTRS).
For this project, health departments in Colorado, Chicago, Los Angeles, Louisiana, San Francisco, and Wisconsin have been awarded contracts totaling $2.7 million. As of June 2004, all 6 health departments had incorporated HIV rapid testing into their PCTRS activities. by March 2005, they had tested 279 partners of persons with a diagnosis of HIV and found that 25 (9%) of these partners were HIV-infected.

Routinely Recommending HIV Testing as Part of Regular Medical Care Services.
In 4 health department jurisdictions, 12 facilities in urban areas with high prevalence of HIV have been funded to evaluate the feasibility and sustainability of offering HIV testing to eligible clients as a routine part of medical care in clinical settings. The facilities, which include emergency departments, outpatient clinics, and a dental clinic, are in Wisconsin, Massachusetts, Los Angeles, and New York State. All facilities started testing by June 2004. Each will test at least 1,500 persons per year and will facilitate access to care for at least 80% of those whose test results are positive. As of March 2005, 9,578 people had been tested and results were positive for 83 (0.9%).

Routine Rapid HIV Testing of Inmates in Short-Stay Correctional Facilities.
State health departments in Florida, Louisiana, New York, and Wisconsin have been funded to offer HIV rapid testing and prevention counseling as a standalone procedure to male and female inmates. All inmates are confidentially notified of their test results at the time of rapid testing. Inmates with preliminary positive HIV rapid test results are offered confirmatory HIV testing and result notification. Inmates with a positive confirmatory result are referred to appropriate care, treatment, and prevention services. From January 2004 through March 2005, a total of 16,676 rapid tests have been conducted. Of these, 256 (1.5%) were reactive. Of the 236 persons who consented to confirmatory HIV testing, 200 had confirmed positive test results; of these, 121 (61%) were newly identified infections. Routinely offering voluntary rapid HIV testing with other STD screening as a component of the medical evaluation may increase use. Provision of consistent, high-quality counseling and testing services could potentially build trust between inmates and staff and improve program acceptance and success. A comprehensive guidance document on implementing HIV rapid testing in jails will be developed after project activities have been completed.

AHP Demonstration Projects for CBOs
Prevention Case Management for Persons Living with HIV/AIDS (now called Comprehensive Risk Counseling and Services).
Funding has been awarded to 9 CBOs to provide prevention case management (PCM) to HIV-infected persons who have many and complex needs for HIV risk reduction. The CBOs are in Maryland; Massachusetts; Michigan; Missouri; California; Pennsylvania; New York; and Washington, DC. As of April 2005, 719 HIV-infected persons had been screened. Of the 546 HIV-infected persons who were eligible for PCM because of continuing risk behaviors, 402 had enrolled in PCM and attended an average of 4 to 7 sessions. HIV infected persons may need a variety of services, such as substance abuse counseling, to help them reduce and eventually eliminate their high-risk behaviors. It is important for such services to be readily available to clients in PCM.

Rapid HIV Testing in Nonclinical Settings.
Funding has been awarded to 8 CBOs to provide rapid HIV testing in nonclinical settings, such as parks, shelters, and night clubs. The settings are in Los Angeles; San Francisco; Detroit; Washington, DC; Kansas City, Missouri; Boston; and Chicago. As of March 2005, 180 (1.5%) of the 12,334 persons tested were HIV-infected.

Using Social Network Strategies for Reaching Persons at High Risk for HIV Infection in Communities of Color.
Funding has been awarded to 9 CBOs in 7 cities to demonstrate the feasibility of using social network strategies to reach persons at high risk for HIV infection and provide them HIV counseling, testing, and referral services. The CBOs are in Philadelphia (2); Orlando; San Francisco (2); New York; boston; Lafayette, Louisiana; and Washington, DC. In October 2003, funding was awarded to 9 CBOs in 7 cities to demonstrate the feasibility of using social network strategies to reach persons at high risk for HIV infection and provide them HIV counseling, testing, and referral services. As of September 2004, the 133 enlisted recruiters had referred 814 persons from their social, sexual, or drug-using networks to get tested for HIV. For the 46 (6%) who received positive test results, this was the first time they learned that they were HIV-infected. Preliminary findings indicate that social network strategies are effective for reaching people and accepted by a variety of people, regardless of gender, age, race and ethnicity, and HIV risk category.

AHP Demonstration Projects for Primary Care Providers Incorporating HIV Prevention into Medical Care Settings.
Funding has been awarded at 6 sites to help providers incorporate HIV prevention into medical care. The sites are in Chapel Hill; Denver; Atlanta; Nashville; Brooklyn; and Kansas City, Missouri. Of an anticipated 1,200 patients, 1,124 were recruited in 2004. All sites completed provider training and have started a patient intervention called Positive STEPs (Striving to Engage People). Follow-up interviews are in progress and will end by December 2005. HIV prevention materials developed for the project have been well received by participating clinics and may be suitable for future use in other HIV clinics.

Other Demonstration Projects
HIV Testing in Historically Black Colleges and Universities and Alternative Venues and Populations.
New models for diagnosing HIV infection by providing greater access to HIV testing and prevention and care services are being tested in sites that serve migrant and seasonal farm workers, communities with transgendered persons, communities with Native Americans, and historically black colleges and universities. These people are among those less often reached by health promotion efforts. Information from this project can be used to reduce the barriers that make it difficult for communities to access HIV testing and services.

Antiretroviral Treatment and Access Study II (ARTAS II).
To improve access to HAART for people who have just received a diagnosis of HIV, linkage case management is being explored at 11 sites: 5 health departments and 6 CBOs. Whereas the first ARTAS study showed linkage case management to be effective, ARTAS II will compare rates of linkage to HIV care providers before and after instituting linkage case management. Findings will strengthen our understanding of how well linkage case management works in typical HIV program settings in the United States.

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CDC’s HIV Prevention Strategic Plan
The HIV Prevention Strategic Plan is CDC’s original approach to the challenges of the third decade. Published in 2001, it became a blueprint for actions to reduce HIV and AIDS in the United States and around the world. Although it is a CDC plan, its success depends on collaboration with many organizations and agencies, each of which is essential to achieving the plan’s goals, objectives, and strategies.

Overarching Goal
Decrease new HIV infections in the United States by half (from 40,000 to 20,000 new infections per year), focusing particularly on eliminating racial and ethnic disparities.

Four national goals have been set to accomplish this in the United States.

• Decrease by at least 50% the number of persons at high risk of acquiring or transmitting HIV infection by delivering targeted, sustained, and evidence-based HIV prevention interventions.
  The top 5 priority populations are
  • HIV-infected people
  • MSM
  • Adolescents
  • IDUs
  • Sexually active women and heterosexual men who are at risk for HIV
• Through voluntary counseling and testing, increase from the current estimated 75% to 95% the proportion of HIV-infected persons who know they are infected.
• Increase from the current estimated 50% to 80% the proportion of HIV-infected persons who are linked to appropriate prevention, care, and treatment services.
• Strengthen the capacity nationwide to monitor the epidemic, develop and implement effective HIV prevention interventions, and evaluate prevention programs. International Goal To assist in reducing HIV transmission and improving HIV/AIDS care and support in partnership with resource-constrained countries.

International Goal
To assist in reducing HIV transmission and improving HIV/AIDS care and support in partnership with resource-constrained countries.