Surveillance
CDC’S HIV/AIDS surveillance system is the nation’s source for key
information used to track the epidemic. CDC funds and assists state
and local health departments, which collect the information. Health
departments in turn report their data to CDC so that information
from around the country can be analyzed to determine who is being
affected and why.
The ultimate surveillance goal is a nationwide system that combines
information on AIDS cases, new HIV infections, and behaviors and
characteristics of people at high risk so that CDC can track the
epidemic and direct HIV prevention funding to where it is needed
the most.
Tracking AIDS Trends
During the 1980s, AIDS cases alone provided an adequate picture
of HIV trends because the time between infection with HIV and
progression to AIDS was predictable. This predictability, however,
has diminished since 1996, when HAART became available. Access,
adherence, and response to HAART affect whether or when HIV
progresses to AIDS. Thus, trends in AIDS cases alone no longer
accurately reflect trends in HIV infection. AIDS trends do, however,
continue to provide important information about where care and
treatment resources are most needed.
Tracking HIV Trends
By April 2004, all states had adopted some type of system for
reporting HIV diagnoses to CDC. Tracking HIV trends is challenging
and depends on several factors, such as how often people are tested,
when during the course of their infection they are tested, whether
and how test results are reported to health departments, and how
case reports (with personal identifiers removed) are forwarded
to CDC.
A major advance has been the development of the serologic testing
algorithm for recent HIV seroconversion (STARHS). STARHS
is a way of analyzing HIV-positive blood samples to determine
whether an HIV infection is recent or has been ongoing. In 2001,
an expert panel agreed that STARHS is the best method available for measuring
new HIV infections. After funding 5 areas to pilot
test this method, CDC has now funded a total of 34 areas to include
STARHS in their HIV incidence surveillance activities.for measuring new HIV infections. After funding 5 areas to pilot
test this method, CDC has now funded a total of 34 areas to include
STARHS in their HIV incidence surveillance activities.
Monitoring HIV Risk Behavior
Behaviors are monitored with regard to risk taking, HIV testing,
care seeking, and adhering to treatment for HIV. CDC obtains
behavioral information from several different populations.
General population
Several federally supported surveys collect information about HIV related
behaviors of the general population. They are conducted
periodically so that trends can be evaluated. Here are a few
examples.
- CDC conducts the behavioral Risk Factor Surveillance System,
the National Survey of Family Growth, and the National Health
Interview Study.
- The National Opinion Research Center (University of Chicago)
conducts the General Social Survey, with indirect support from
CDC.
- The Substance Abuse and Mental Health Services Administration
conducts the National Survey on Drug Use and Health.
People who are HIV-infected
MMP (Morbidity Monitoring Project) is a new surveillance
system designed to collect information from HIV/AIDS patients who
received care from randomly selected HIV care providers. In 2004,
CDC awarded funds to 20 states and 6 cities for this project. MMP
collects information about access to and use of HIV care, treatment,
and prevention services and prevalence of behaviors that can result
in HIV transmission and affect disease outcomes (like adherence to
therapy). Information is collected from medical records and patient
interviews. Patients are selected in a way that will make the data
nationally representative for persons who are living with HIV/AIDS
and receiving care. Data for planning, evaluation, monitoring, and
allocation of resources will be available by the
end of 2006.
People who are at high risk for HIV
The NHBS (National HIV Behavioral
Surveillance System), for populations at high
risk, began in 2003. NHbS conducts surveys
in cities with high levels of AIDS among
MSM, IDUs, and heterosexuals at high risk to
determine their risk behavior, testing behavior,
and use of prevention services. In the first cycle,
MSM were interviewed in 17 cities. The second cycle will interview
IDUs in 25 cities. In 2006, CDC will expand the system to include
heterosexuals at high risk. For states with medium and low
levels of AIDS, CDC provides technical assistance and support for
behavioral surveys among MSM at specified events, such as gay
pride.
HITS (HIV Testing Survey) primarily interviewed adults who
were not HIV-infected but were at high risk for HIV infection. HITS
collected information about what motivates people to get tested for
HIV and what behaviors place people at risk for HIV. HITS was
conducted in 24 states during 1995–2003. Data analyses from HITS
are ongoing. Monitoring HIV Counseling and Testing Behavior
The HIV Counseling and Testing System (CTS) has been used
since 1989 to monitor CDC-funded HIV counseling and testing
services. Through this system, each CDC-funded HIV counseling
and testing episode is reported to CDC and includes information
about demographics, self-reported behavior, and HIV test results.
Data from this system are used to guide the development of HIV
prevention programs in response to the needs of the community.
beginning in 2005, CTS will be replaced by the Counseling,
Testing, and Referral (CTR) module of the Program Evaluation
and Monitoring System (PEMS). Data collected by CTR have
been updated to include information on new testing technologies
and client referrals to medical care and other services and to
be consistent with other PEMS data collection and reporting
requirements.
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Prevention Programs
The primary component in CDC’s fight against HIV/AIDS is HIV
prevention programs. Programs consist of interventions intended to
change risky behavior and improve the health of the people served.
Interventions include encouraging early HIV diagnosis; delivering
counseling, testing, and referral services; providing educational
programs and materials; and training peers to be role models. They
are delivered to individuals, groups, and communities in places such
as storefronts, gay bars, health centers, housing communities, faithbased
organizations, and schools. Street outreach techniques such
as using mobile testing vans, offering incentives for participation or
referral, and recruiting peers are some of the ways to reach as many
people as possible. CDC provides leadership, capacity building assistance, and funding
for programs at the state, local, and community levels. CDC funding
supports staffing, program infrastructure, implementation and
evaluation of interventions. In many instances, CDC requires that
those who receive funding for programs (grantees) have a proven
track record of providing effective programs. CDC also strives to
ensure that interventions meet local needs. Specifically, CDC asks
that interventions be science based and culturally proficient; that is, they should meet the cultural needs, expectations, and values of
the populations they serve. Community planning helps ensure that
priorities for HIV prevention are determined locally with input from
affected communities and that they are consistent with scientific
findings about what interventions are most effective for decreasing
HIV transmission.
Evaluation (to measure program effectiveness) is an important part
of prevention programs. Programs funded by CDC are required
to collect and submit evaluation data so that CDC can track and
identify the most effective programs. CDC’s evaluation efforts take
several forms.
- Evaluation guidance outlining the types of data each funded
health department must collect from its grantees
- Regular reviews of each funded health department to evaluate
effectiveness in community planning
- Ongoing reviews of funded CBOs
In addition, CDC researches the effectiveness of HIV prevention
interventions and the diffusion of these interventions. CDC’s
Prevention Research Synthesis Project identifies interventions that
have proven effective with various groups. The Replicating Effective
Programs (REP) project takes proven interventions and packages
them in a tool kit for distribution. CDC’s Diffusion of Effective
behavioral Interventions (DEBI) project then looks at ways to get
these effective interventions to a broader audience.
Health Departments
CDC funds and works with 65 state, local, and territorial health
departments to support prevention efforts and programs for
people living with HIV and people at risk for HIV. All 65 health
departments provide HIV counseling and testing services, which
include referral and partner notification. A requirement for CDC
funding is the development of a community planning process, which
unites health departments and community members in developing
an HIV prevention plan that reflects their local epidemic and guides
HIV prevention efforts in their local area. Health departments also
use CDC funds to support CBOs (indirect funding).
Nongovernment Organizations
CDC supports community-based, faith-based, and other nongovernment organizations in building partnerships for HIV
prevention. These efforts provide interventions for populations at
high risk, including people of color, MSM, substance abusers, and
correctional facility inmates. To help people living with HIV/AIDS
access prevention and treatment services, these organizations also
provide HIV counseling and testing services and programs.
Public-Private Partnerships
CDC works with business and labor groups to enhance the health,
productivity, and well-being of workers and their families living
with, affected by, or at risk for HIV/AIDS. The business Responds
to AIDS (bRTA) and Labor Responds to AIDS (LRTA) programs
are worldwide public-private partnerships that serve as a resource
to business and labor on a full range of HIV/AIDS issues. These
partnerships set up workplace and related programs that combat
complacency and stigma and support community activism,
volunteerism, and corporate philanthropy.
Another CDC partnership is AIDS: Act Now! This public-private
effort has a council of 50 members from business, faith-based,
public health, and HIV communities, and the media. In addition,
5 alliances focus on issues such as leadership, youth, media, HIV
testing and clinical care, and Internet technology. In total, CDC
has obtained the support of more than 100 partners who volunteer
their time to explore how they can use their resources, influence,
and outreach capabilities to enhance HIV prevention efforts in
communities most affected by HIV and AIDS. As communities
of color disproportionately bear the effects of the epidemic, most
activities under AIDS: Act Now! are directed toward these groups.
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Prevention Strategies
Among CDC’s strategies for HIV prevention are
- providing up-to-date scientific information through guidelines
- promoting early diagnosis of HIV infection
- addressing the unique prevention needs of HIV-infected persons
- building the capacity of health departments and CBOs to deliver effective prevention programs that reduce risk for HIV
transmission
- increasing the quality of HIV prevention programs through
evaluation
Guidelines
Guidelines are written recommendations for health care providers
in the public and private sectors. They are developed after
consultations with health care providers, public health officials,
patient advocates, and policy experts. They are based on available
scientific evidence; where evidence is incomplete, the “best practices”
opinions of specialists in the field are used.
Revised Guidelines for HIV Counseling, Testing, and Referral
(2001)
Guidelines for HIV counseling, testing, and referral (CTR) were
published in 1986 and revised in 1994. After a massive effort to
review all current scientific evidence, obtain recommendations, and
reach agreement on recommendations, CDC published the Revised
Guidelines for HIV Counseling, Testing, and Referral in 2001. Using
an evidence-based approach, these guidelines advise providers of
voluntary HIV CTR how to improve the quality and delivery of HIV
CTR. They underscore the importance of early knowledge of HIV
status and of testing that is more accessible and available.
Revised Recommendations for HIV Screening of Pregnant Women
In 1995, the US Public Health Service issued guidelines
recommending universal counseling and voluntary HIV testing of
all pregnant women and treatment for those infected to prevent
mother-to-child HIV transmission. Subsequently, mother-to-child
HIV transmission declined dramatically. In 2001, the Revised
Recommendations for HIV Screening of Pregnant Women were
published. These guidelines strengthen the recommendation that all
pregnant women be tested for HIV as part of routine perinatal care,
while preserving a woman’s right to make her own decisions about
testing. Recommendations for Incorporating HIV Prevention into the
Medical Care of Persons Living with HIV
In 2003, CDC, the Health Resources and Services Administration,
the National Institutes of Health, and the HIV Medicine
Association of the Infectious Diseases Society of America
developed recommendations to help clinicians incorporate HIV
prevention into the medical care of HIV-infected individuals. These
recommendations include
- screening for HIV transmission risk behaviors and sexually
transmitted diseases
- providing behavioral risk-reduction messages in the office and
referral for other prevention interventions and related services
- facilitating the notification and counseling of sex partners and
needle-sharing partners
Procedural Guidance for Selected Strategies and Interventions
for Community-based Organizations Funded Under Program
Announcement 04064
The Procedural Guidance provides information to CBOs about the
interventions that are allowable under Program Announcement
04064. It is available at www.cdc.gov/HIV/partners/pa04064_cbo.
htm.
HIV Prevention Community Planning Guidance
This guidance, revised in July 2003, defines CDC’s expectations
for health departments and HIV prevention community planning
groups involved in HIV prevention community planning. These and
other CDC recommendations and guidelines are available at www.cdc.gov/HIV/pubs/guidelines.htm.
Advancing HIV Prevention: New Strategies for a Changing
Epidemic
Advancing HIV Prevention (ined effort of CDC and
other agencies (government and nongovernment). It is designed
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. It emphasizes the use of public
health approaches proven effective at reducing new infections and spread of disease, such as appropriate routine HIV testing;
identification of new cases; partner counseling, testing, and referral
services; and increased availability of treatment and prevention
services for HIV-infected persons and their partners. AHP is
described in more detail in Section 5, The Future.
Other CDC-funded projects help communities improve referrals to
care and prevention services.
- Project HEART (Helping Enhance Adherence to
Antiretroviral Therapy), a clinic-based behavioral intervention
for patients who have not previously received HAART
- Partnership for Health (Safer Sex and Adherence
Intervention for HIV Outpatient Clinics), an intervention
encouraging health care providers to promote safer sex and
adherence to therapy
- INSPIRE (Interventions for HIV-Positive Intravenous
Drug Users: Research and Evaluation), a behavioral
intervention to help IDUs decrease their risk for HIV, increase
access to care, and increase adherance to HAART
Capacity Building
CDC recognizes that organizations funded to conduct HIV
prevention, such as health departments and CBOs, often
face challenges to meeting the increased prevention needs of
populations at high risk for HIV and other sexually transmitted
infections. Examples of these challenges are the need
- to diversify the funding base to help sustain prevention services
- for effective behavioral interventions that are based on science
and are culturally competent
- for competent staff
- for effective strategies to link HIV-negative and HIV-infected
persons at high risk to services (testing, prevention, and care)
The goal of CDC’s HIV prevention capacity building program is to
ensure that health departments and CBOs receive scientifically
sound and culturally appropriate capacity building assistance
through the following:
- technology transfer—translating scientific research into
programs and practice
- technical assistance—providing expert programmatic, scientific,
and technical consultation and support to health department and
CBO staff
- training—building the knowledge, skills, and abilities that
health department and CBO staff need to deliver effective
HIV prevention interventions and to effectively sustain the
organizational infrastructure needed to support HIV prevention
services
- information dissemination—sharing information through print
materials, meetings, Web sites, and mass media
Diffusion of Effective Behavioral Interventions (DEBI) is
an example of capacity building using technology transfer to
disseminate science-based behavioral interventions. DEbI endorses
the interventions that are identified by CDC’s Prevention Research
Synthesis Project.
These interventions are
- Community PROMISE (Peers Reaching Out and Modeling
Intervention Strategies for HIV/AIDS Risk Reduction in
their Community), a community-level intervention based on
behavior change theories
- Healthy Relationships, a small-group intervention for people
living with HIV and AIDS
- Holistic Health Recovery Program, a group-level program to
reduce harm and promote health for HIV-infected IDUs
- 3MV (Many Men, Many Voices), a group-level STD/HIV
prevention intervention for MSM of color
- Mpowerment, a community-level intervention for young
MSM
- Partnerships for Health, a provider-delivered
counseling program for people living with HIV/AIDS
- POL (Popular Opinion Leader), an intervention
to identify, enlist, and train key opinion leaders to
encourage safe behaviors in their social networks
- RAPP (Real AIDS Prevention Project), a program
to involve the community in reducing HIV risk and unintended
pregnancy by increasing condom use
- Safety Counts, an intervention for active injection drug and
crack cocaine users, aimed at reducing high-risk drug use and
sexual behaviors
- SISTA (Sisters Informing Sisters About Topics on AIDS),
a group intervention for African American women, to help them
increase condom use
- Street Smart, a skills-building program to help runaway and
homeless youth practice safer sexual behaviors and reduce
substance abuse
- TLC (Together Learning Choices), an intervention for young
people, 13–29 years old, who are living with HIV
- VOICES/VOCES (Video Opportunities for Innovative
Condom Education and Safer Sex), a video-based
intervention to increase condom use among heterosexual African
American and Hispanic men and women who visit STD clinics
A second group of interventions will follow. Plans call for diffusion of
more behavioral interventions as well as structural and biomedical
interventions.
Evaluation
Evaluation activities focus on results by
- managing and measuring program performance
- improving the quality of HIV prevention programs
- promoting accountability
Program Performance Indicators
As specified in the President’s Management Agenda, CDC has
incorporated program performance indicators into its cooperative
agreements with HIV prevention providers. The purpose is to
improve performance and accountability of programs. beginning in
2005 all directly funded health departments and CBOs will report
on measures of HIV prevention planning, service delivery, and
evaluation activities. The performance indicators will be used to
monitor progress in critical areas of HIV prevention. The specific
components of HIV prevention programs addressed by the indicators
include
- HIV infections
- community planning
- prevention activities
- Counseling, testing, and referral services
- Partner counseling and referral services
- Prevention for HIV-infected persons
- Health education and risk-reduction activities
- Prevention of mother-to-child HIV transmission
- evaluation of reporting compliance
- capacity building activities
PEMS (Program Evaluation and Monitoring System)
CDC has developed PEMS to strengthen monitoring and evaluation
of HIV prevention programs. PEMS is to be used by health
departments and CBOs funded through CDC HIV prevention
cooperative agreements. PEMS is a secure Internet browser-based
software program for data entry and reporting. PEMS software
was first released in the fall of 2004 to 42 health departments and
27 CBOs. It allows grantees to collect agency, community planning,
and program plan data. The next release, scheduled for fall 2005,
will enable grantees to enter client-level data and report to CDC.
by the end of 2005, PEMS will be available to over 200 agencies
nationwide. PEMS will ensure that CDC receives standardized,
accurate, and thorough program data from health department and
CBO grantees. The data include
- agency information
- program plan details
- client demographics
- referral outcomes
- HIV test results
- partner elicitation and notification
- client use of services
- behavioral outcomes
- community planning priority populations and interventions
These data will allow more comprehensive reporting of HIV
prevention activities, fiscal information, and community planning
information. These data will help HIV prevention stakeholders
examine program fidelity, monitor use of key program services
and behavioral outcomes, and calculate and report the program
performance indicators. PEMS will help CDC monitor, evaluate, and coordinate HIV
prevention programs and support the rapid set-up of special studies
and evaluation projects.
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Research
Among its many HIV research activities, CDC is involved in
research related to
- diagnostic tests
- microbicides
- vaccines
Diagnostic Tests
Since November 2002, the Food and Drug Administration has
approved 4 rapid HIV tests. These tests offer many advantages
over conventional HIV blood tests. Sample collection is easier (for
example, from a finger prick or oral fluid), and they
are easy to use outside of traditional laboratories so
they are suitable for doctors’ offices and community
and outreach settings. Perhaps the biggest benefit
of rapid tests is their ability to give results in 30
minutes or less. because test results are available
quickly, rapid HIV tests dramatically increase
the number of people who get tested and find out
their results that day. This represents a significant
public health achievement because those who know
they are infected with HIV can get treatment.
Evidence also shows that persons who know they are infected adopt
changes that dramatically reduce their risk of transmitting the virus
to others. Rapid HIV tests also help further reduce the number of infected
infants born to HIV-infected mothers. HIV transmission from
mother to infant can be decreased by almost half if antiretroviral
treatment is started during labor.
CDC is involved in many areas of rapid HIV testing, such as the
following:
- Evaluating the accuracy of rapid tests
- Providing training on rapid tests
- Publishing information in the scientific literature
- Maintaining an updated Web site
- Helping other federal agencies introduce rapid HIV testing into
their projects
- Funding demonstration projects
In 2003, CDC funded 21 health departments and CBOs for 2-year
demonstration projects for rapid HIV tests. These awards are used
for incorporating rapid testing into routine medical care, partner
counseling and referral services, short-stay correctional facilities,
nonclinical settings, and social networks. These projects have shown
that rapid tests are an important part of HIV prevention efforts.
Microbicides
CDC is actively involved in research to identify and test potential
HIV microbicides. Microbicides are gels, creams, or suppositories
that can kill or neutralize viruses and bacteria. When applied in
the vagina before sexual intercourse, they can protect against some
sexually transmitted diseases. A safe, effective, and affordable
microbicide against HIV could help to prevent many new infections.
Thailand
CDC collaborated with the Thailand Ministry of Health and the
Population Council to conduct Phases I and II (safety and efficacy)
clinical trials of Carraguard, a candidate vaginal gel microbicide,
in HIV-negative women and heterosexual couples. Testing of other
compounds will begin in 2005.
Botswana
CDC is collaborating with the Botswana Ministry of Health to
develop a site for Phases I, II, and III (safety and efficacy) testing
of microbicide candidates. Plans are under way to begin Phase I
studies in 2006.
United States CDC is conducting preclinical (animals and laboratory) and Phases
I and II clinical trials of potential new HIV microbicides. In its own
laboratories, CDC is also examining the toxicity and efficacy of some
microbicides against HIV.
Drugs to Prevent HIV (chemoprophylaxis)
CDC is conducting studies to test an antiretroviral agent, tenofovir
disoproxil fumarate. Tenofovir will be tested for safety, tolerance,
and effectiveness when used by people at risk before exposure to
HIV. Clinical trials began in 2005. Finding a drug that effectively
prevents HIV without increasing drug resistance could significantly
affect HIV prevention strategies.
Botswana
CDC is collaborating with the Botswana Ministry of Health to
conduct safety and efficacy trials of tenofovir among heterosexual
persons at risk for HIV infection.
Thailand
CDC is collaborating with the Thailand Ministry of Health to
conduct safety and efficacy trials of tenofovir among IDUs.
United States CDC is conducting clinical trials among MSM to test for the safety of
tenofovir.
Vaccines
The intervention most anticipated by everyone working to stop the
HIV/AIDS epidemic is a vaccine to prevent infection. CDC is no
stranger to vaccine development (considering its experience with
other vaccines such as measles, hepatitis b, polio, and smallpox), but
developing an HIV vaccine presents unique challenges. For example,
it is critical that no one (whether involved in the studies or not)
abandon safer sexual and drug-related behaviors proven to prevent
HIV infection. Overall, vaccine development must not endanger
progress already made in HIV prevention.
Until a vaccine is available, and even afterwards, we must continue
to reinforce the already proven methods of HIV prevention.
CDC’s HIV vaccine research focuses on conducting and evaluating
HIV vaccine trials in the United States and elsewhere. CDC played
an important role in the world’s first 2 efficacy trials of HIV vaccine
candidates. Although the results indicated that the vaccines
were not effective in reducing the risk for HIV infection, the trials provided critical information that will guide
future research on HIV vaccines. Through
an agreement with the National Institutes
of Health and through membership in the
Partnership for AIDS Vaccine Evaluation,
CDC is currently contributing to the US
government’s effort to develop a safe and
effective HIV vaccine.
United States
CDC collaborated with a US vaccine
developer, VaxGen, in the world’s first
efficacy trial of an HIV vaccine (AIDSVAX b/b gp 120). At 6 sites,
CDC also sponsored extensive substudies on how the vaccine
affected risk behavior.
Thailand
CDC collaborated with VaxGen, the bangkok Metropolitan
Administration, and Mahidol University to test the efficacy of a
vaccine (AIDSVAX b/E gp 120) in bangkok. CDC helped develop
counseling, educational, and prevention materials. CDC and the
Thai government also identified persons willing to participate and
to be followed up to evaluate risk behaviors and infection. CDC also
worked with the community to build the understanding and support
necessary for such a trial. CDC, Thai health officials, and VaxGen
ensured that participants received appropriate risk-reduction
counseling and were fully informed about how the trial worked, the
potential risks and benefits, and the importance of maintaining good
risk-reduction behaviors during the trial. CDC also evaluated the
clinical care and disease progression of participants who become
HIV-infected during the trial.
Africa
Along with Emory University and the National Institutes of Health,
CDC helped develop a prototype vaccine (HIV-1 subtype A/G DNA+MVA) for people in West/Central Africa. CDC is also helping
with preparations for HIV vaccine clinical trials in West/Central and
East Africa. In Cameroon and Kenya, CDC is collaborating with
Ministries of Health to help develop the capacity to conduct HIV
vaccine clinical trials.
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