Progress Toward Healthy People 2010 Targets

The following discussion highlights objectives that met or exceeded their 2010 targets; moved toward the targets, demonstrated no change, or moved away from the targets; and those that lacked data to assess progress. Progress is illustrated in the Progress Quotient bar chart (see Figure 13-1), which displays the percent of targeted change achieved for objectives and subobjectives with sufficient data to assess progress.

At the time of the midcourse review, progress had been made toward achieving the objectives and targets set for 2010. Data were available to measure the progress of 14 objectives and subobjectives. One subobjective exceeded its target. Ten objectives and subobjectives moved toward their targets, one objective was static, while one objective and one subobjective moved away from their targets.

Objectives that met or exceeded their targets. The target for the number of new cases of perinatally acquired AIDS (13-17b) was exceeded. New cases declined from a baseline of 82 new cases in 2002 to 57 cases in 2003, surpassing the target of 75 cases. Prevention of perinatal HIV transmission requires routine HIV screening of all pregnant women and the use of appropriate antiretroviral and obstetrical interventions that begin during the pregnancy and continue through the first few months of the infant's life.¹¹ Together, these actions can reduce the rate for mother-to-child HIV transmission to 2 percent or lower.⁸ HRSA continually monitors the number and proportion of babies tested who are born to HIV-positive mothers enrolled in programs funded under the Ryan White CARE Act, the number of children receiving care and treatment, the number of pregnant HIV-positive women in care, and the number of pregnant women on prophylaxis. The reduction of babies born infected with HIV is also apparent in CARE Act programs. This decline is attributable, in part, to the emphasis placed on testing high-risk women of child-bearing age, enrolling those women testing positive into primary care, and ensuring that pregnant women are provided with appropriate primary care for therapy and prenatal care through CARE Act providers.¹²

HHS plans to issue revised recommendations through CDC for HIV screening of adults, adolescents, and pregnant women in health care settings. Incorporating routine HIV testing into the standard battery of tests related to pregnancy has the potential to increase the proportion of pregnant women who are tested for HIV.¹³ Accordingly, HHS recommends that HIV testing be a routine screening procedure. Also recommended is implementing rapid HIV testing in postnatal settings for infants of women not tested prenatally.¹⁴ In an effort to further increase the number of pregnant women who get tested for HIV, many States have implemented opt-out perinatal HIV testing for all pregnant women whereby HIV screening is included as part of routine medical screening, unless the woman specifically declines an HIV test.

Objectives that moved toward their targets. Ten objectives and subobjectives moved toward their targets.

A reduction in new AIDS cases per 100,000 persons aged 13 years and older (13-1) occurred—from 19.5 cases per 100,000 in 1998 to 17.6 cases per 100,000 in 2003. The 2010 target is 1 case per 100,000. Between 1998 and 2003, a decline was observed in AIDS cases among men aged 13 years and older who have sex with men (13-2), and this objective achieved 2 percent of the targeted change. During the same period, new AIDS cases among persons aged 13 years and older who inject drugs (13-3) declined, achieving 99 percent of the targeted change. A reduction occurred in new cases of AIDS among adolescent and adult men who have sex with men and inject drugs (13-4), and this objective achieved 55 percent of the targeted change. Condom use in the partners of unmarried females aged 18 to 44 years (13-6a) achieved 30 percent of the targeted change between 1995 and 2002. To further improve monitoring of behaviors among persons at high risk for HIV, CDC has implemented a national HIV behavioral surveillance system.¹⁵

HIV testing in tuberculosis patients aged 25 to 44 years (13-11) increased, achieving 20 percent of the targeted change.

Three of four measurable subobjectives related to the proportion of HIV-infected adolescents and adults who receive testing, treatment, and prophylaxis consistent with current PHS treatment guidelines (13-13) demonstrated improvement. Use of any antiretroviral therapy (13-13c) demonstrated 33 percent of the targeted change, highly active antiretroviral therapy (13-13d) achieved 51 percent of the targeted change, and Mycobacterium avium complex prophylaxis achieved 29 percent of the targeted change (13-13f).

These subobjectives reflect complex dynamics in HIV disease and treatments. Not all patients respond equally well to antiretroviral therapy. For many patients, adherence to difficult treatment regimens is also a barrier to sustained viral load suppression. The increasing problem of drug resistance, coupled with the use of CD4 cell counts that are used as measurement criteria, adds to the complicated treatment decision process. Treatment has also affected the need for prophylaxis against opportunistic infections. Some scenarios are difficult to capture in a study or surveillance system, and the result is misleading data. Examples include patients with increased CD4 cells due to highly active antiretroviral therapy (HAART) who no longer meet the recommendation for Pneumocystis carinii pneumonia prophylaxis and patients who stop HAART due to adverse side effects or who use an individually tailored drug therapy not specified in the PHS treatment guidelines.

To assist HIV clinicians in providing clinical care consistent with PHS guidelines, the AIDS Education and Training Center program implements training programs, documents, and mentoring services, while the Warmline service advises and provides information to clinicians on PHS guidelines and antiretroviral management of HIV.^{16, 17} In addition, HRSA grantees provide HAART and prophylaxis therapies to clients in CARE Act-funded programs through the AIDS Drug Assistance Program (ADAP). The results are measured by the number of persons in ADAP, the number of persons receiving HAART, demographics of the individuals served through ADAP, and the proportion of eligible people in care receiving antiretrovirals.¹⁸

Deaths from HIV infection (13-14) decreased—moving from a baseline of 5.3 deaths directly attributable to HIV per 100,000 persons in 1999 to 4.9 deaths per 100,000 persons in 2002, achieving 9 percent of the targeted change.

Objectives that demonstrated no change. Survival of persons more than 3 years after diagnosis of AIDS (13-16) remained static at 83 percent between the 1998 baseline and 1999.

Objectives that moved away from their targets. One objective and one subobjective moved away from their targets at the time of the midcourse review. Between 1997 and 2003, HIV counseling and education for persons in substance abuse treatment programs (13-8) decreased from 58 percent to 57 percent, moving away from the 2010 target of 70 percent. P. carinii pneumonia prophylaxis in HIV-infected patients (13-13e) declined from 80 percent in 1997 to 70 percent in 2002 and moved away from the target of 95 percent. One reason for this trend away from the target is that the effectiveness of HAART therapy given at an earlier stage in the disease has dramatically reduced the need for P. carinii pneumonia prophylaxis.

Objectives that could not be assessed. Data to assess progress toward their targets were not available for new HIV/AIDS cases (13-5), condom use among sexually active unmarried males (13-6b), testing according to guidelines (13-13a and b), HIV diagnosis prior to AIDS (13-15), perinatally acquired HIV/AIDS (13-17a), and heterosexually transmitted HIV/AIDS in women (13-18).

Data are expected by the end of the decade for the following objectives and subobjectives: new HIV/AIDS cases (13-5), condom use among sexually active unmarried males aged 18 to 44 years (13-6b), treatment of individuals with HIV according to guidelines (including viral load and TB skin testing [13-13a and b]), HIV diagnosis prior to AIDS (13-15), perinatally acquired HIV/AIDS (13-17a), and heterosexually transmitted HIV/AIDS in women (13-18). With respect to objective 13-15, individuals are being offered and provided the opportunity to receive counseling and testing throughout selected CARE Act sites.¹⁹ Data are being collected for the number of persons receiving counseling and testing, the number of persons testing positive, and the number of persons returning for their results.

The CARE Act programs primarily test individuals at clinical sites and refer those persons with new infections to clinical care. Data have shown that persons tested at clinical sites are more likely to return for their results than those tested elsewhere, thus increasing the opportunity to receive referral for clinical care and decreasing the interval between HIV infection and AIDS diagnosis.

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