Opportunities and Challenges

Continued progress toward the AIDS-related targets can be achieved in the following ways:

• Early diagnosis and delaying the onset of AIDS through medical treatment among persons infected by HIV.
• Expanding HIV testing so that infected persons are diagnosed earlier.
• Making HIV testing a routine part of medical care.
• Identifying new methods and venues to access and test infected persons to improve early diagnosis.²⁰

CD4 count and viral load are two indicators of the progression of HIV that are used to determine treatment of HIV-infected persons. CARE Act programs ensure that these two factors will be tested among new HIV-infected clients and that quality management programs will be implemented in primary care service delivery. Both of these requirements serve to ensure that individuals are receiving early diagnosis and are enrolled in appropriate medical care and treatment that will, in turn, increase survival rates.

The AHP initiative seeks to reduce barriers to early diagnosis of HIV infection as well as increase access to quality medical care, treatment, and ongoing prevention services for persons with HIV. It emphasizes the use of public health approaches already proven effective in reducing new infections and the spread of disease.²¹

The AHP initiative also expands current HIV prevention strategies and models other approaches that have proven efficacious in preventing infectious diseases. Demonstration projects are under way to test the feasibility of the strategies and will provide detailed information to implement the initiative's four strategies: making HIV testing a routine part of medical care, creating new models for diagnosing HIV infections outside medical settings, preventing new infections by working with persons diagnosed with HIV and their partners, and further decreasing mother-to-child transmission by incorporating HIV testing among routine prenatal tests.²²

The demonstration projects for the Implementation of Rapid HIV Testing in Historically Black Colleges and Universities and Alternative Venues and Populations²³ address the first two strategies. These projects will demonstrate new models for diagnosing HIV infection through greater access to rapid HIV testing, along with prevention and care services for persons diagnosed with HIV. New models are being tested in sites that serve migrant and seasonal farm workers, communities with transgender persons, communities with members of the American Indian or Alaska Native population, and historically black colleges and universities. In addition, the Social Networks Demonstration Project, which investigates the feasibility of using social network strategies to reach persons at high risk for HIV infection and to provide them with HIV counseling, testing, and referral services, focuses on the second strategy to create new models for diagnosing HIV infection outside medical settings.²⁴

CDC recommends that all States and Territories adopt confidential, name-based surveillance systems to report HIV infections. Such HIV reporting has been shown to be accurate and reliable. Studies have found that HIV surveillance conducted using name-based patient identifiers produces better data than coded patient identifier-based surveillance systems.²⁵ Currently, 45 State and local health departments have adopted name-based reporting.

Interventions intended to change risky behavior and improve the health of the persons served are a major component of HIV prevention efforts sponsored through HHS. Among these programs are the Compendium of HIV Prevention Interventions with Evidence of Effectiveness²⁶ and the Diffusion of Effective Behavioral Interventions (DEBI) project.²⁷ The compendium offers science-based interventions that work to prevent HIV transmission. All interventions selected for the compendium came from behavioral or social studies that had both intervention and control/comparison groups and positive results for behavioral or health outcomes. It is also the source of certain interventions for the DEBI project, which focuses on moving prevention strategies proven effective into prevention practice by diffusing evidence-based individual-, group-, and community-level HIV prevention interventions to health departments and community-based organizations nationwide.

Behavioral interventions offer opportunity for progress and are being diffused by HHS through CDC and health departments.²⁸ These interventions include the following:

• The Sisters Informing Sisters about Topics on AIDS project specifically targets sexually active African American women. This group-level gender- and culturally relevant intervention is designed to increase condom use among the partners of African American women.
• Many Men, Many Voices is a seven-session group-level STD/HIV prevention intervention for gay men of color. The intervention addresses behavioral influencing factors specific to gay men of color, including sociocultural norms, sexual relationship dynamics, and the social influences of racism and homophobia.
• VOICES/VOCES²⁹ is a single-session group-level video-based intervention designed to increase condom use among heterosexual African American and Hispanic/Latino men and women who visit STD clinics. Participants, grouped by gender and ethnicity, view an English or Spanish video on HIV risk behaviors and condom negotiation, take part in a facilitated discussion on barriers to and negotiation of condom use, and receive samples of condoms.
• Healthy Relationships³⁰ is a five-session small-group intervention for men and women living with HIV/AIDS. Using Social Cognitive Theory, which states that persons learn by observing other people practice a new behavior, the intervention focuses on developing skills and building self-efficacy and positive expectations about new behaviors through modeling behaviors and practicing new skills.

HHS addresses behavioral and other preventive issues related to HIV/AIDS through CDC and primary care issues through HRSA. HRSA's HIV/AIDS Bureau's primary focus is on the provision of primary care services to individuals diagnosed with HIV who are uninsured or underinsured. HRSA also implements programs in conjunction with CDC and through its other programs that emphasize prevention. Some of the projects include:³¹

• Prevention for HIV Infected Persons in Primary Care Settings is designed to evaluate different models of providing prevention interventions for HIV-positive patients in clinical care settings.
• Outreach, Care, and Prevention to Engage HIV Seropositive Young MSM of Color is designed to develop and evaluate the innovative service models for reaching HIV-infected young men who have sex with men not engaged in clinical care and linking them to appropriate clinical, supportive, and preventive services.
• HHS's Prevention with Positives guidelines is integrated into AIDS Education and Training Center (AETC) training and is intended to prioritize and integrate prevention with positive clinical guidelines into AETC provider training.
• National Perinatal HIV Consultation and Referral Services (Perinatal Hotline) provides advice from HIV experts and answers on indications and interpretations of HIV testing, consultation on treating HIV-infected pregnant women and their infants, and a referral service to connect HIV-infected pregnant women and exposed infants to experienced HIV providers.

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