IV. Steering Committee
Chaired by the overall EPR Chairs and composed of each of the panel Co-chairs, the Steering Committee was a leadership trust for the ERP and provided a forum for sharing and integrating process and substantive issues occurring throughout the review. Over the course of the meeting, the Steering Committee met twice daily to clarify procedures, share emerging insights on common themes, and transfer lessons learned. The two overall Chairs divided the five panels between them to monitor their process and deliberations and offered support and clarification when needed.
On the final day, following the summary presentations by each of the panels, the Steering Committee reconvened to address the specific, crosscutting guiding questions assigned to it. The overall Chairs proposed a process that would respect the unique expertise of the panel Co-chairs and encourage their discourse as peers. The overall Chairs reviewed the proposed questions with the Steering Committee and asked the members to determine whether any additional issues should be added or questions be further refined. To address the questions, the panel Co-chairs whose subject matter was most related to each question were asked to provide their responses first. Thus, one by one, the most relevant expert perspectives lead the committee's discussion of each question.
After the panel Co-chairs provided their responses, the remaining Steering Committee members were invited to validate or offer differing or additional perspectives. Questions were addressed in order in a step-by-step fashion with each of Co-chairs from the topic panels providing their perspective in sequence. Out of this process, a norm of consensus emerged in the Steering Committee with broad peer affirmation or concurrence of lead expert opinions, coupled with committee members' additions or refinements. Most notably, no exceptional disagreements were expressed for the themes, guidance, and recommendations summarized below.
Surveillance. There was strong consensus in the Steering Committee that the CDC plays a unique and central role in public characterization of the epidemic and its impact. In addition, the Steering Committee recognized that the surveillance system also has a potentially important role to play in supporting direct prevention efforts, such as partner services. However, as the epidemic and prevention efforts and approaches have evolved, surveillance has not evolved in parallel, thereby introducing new challenges for the surveillance branch. Surveillance activities should first and foremost emphasize the evolution of the epidemic and its impact (i.e., case numbers, new infections, and associated behavioral, sociodemographic, and geographic risk factors). As critical as the surveillance function is, there was consensus that efforts were needed to make surveillance data available more quickly and to ensure that these data were used to shape local intervention efforts.
Priority Setting. The Steering Committee expressed strong uniform concern that there is no public understanding or knowledge of DHAP's priority setting and decision-making process. Despite explanations in the background document about the annual DHAP retreat, the Steering Committee did not recognize that event as a transparent priority-setting process. Neither the Steering Committee nor many of the DHAP personnel who presented data at the EPR meeting could clearly articulate the manner in which program or resource priorities were set, either in the Division as a whole and within the individual branches. This lack of decision-making transparency was a great concern of the Steering Committee. The Steering Committee recommends that an improved and more transparent process be identified and used by DHAP.
Intra-Division Communications. Communications between DHAP leaders, especially between the program and research branches and between the program and surveillance branches, need improvement. These communications issues raise concerns about the timely translation of surveillance and research findings into DHAP programs and public health practice and about how perspectives from practice and program arenas infuse research priorities and surveillance requests. Internal communications issues also raised concerns about overall coordination and collaboration within DHAP and among offices and branches both in Atlanta and in the field.
- Current mix of activities across populations and mission areas
- Current resource allocation across populations and mission areas
- Translation and dissemination of research findings
How proportional is the current mix of DHAP's programs and activities to the needs of its priority populations?
- The SC agreed that the current focus based primarily on population demographics is no longer sufficient and that there should be additional emphasis across all populations based on behaviors and the context in which risk behaviors occur. At the program level, the SC believes that targeting by race/ethnicity alone is stigmatizing and limiting and, while a possible mechanism for allocation of resources, is focused on immutable characteristics of persons at risk and does not adequately prioritize persons of all backgrounds whose behaviors and/or context (social networks, prevalence, co-occurring factors, etc.) place them at risk.
- The SC strongly recommends that new strategies and interventions be developed based on social determinants of health (e.g. poverty, education, geography), including issues related to MSM and injecting drug users. The SC recommends specifically that new combination strategies emphasize the role of social determinants in addressing risks for gay men, including the issues of societal, institutional, and internalized homophobia.
- The SC recommends that DHAP programs and activities be tied to clear outcomes. The SC specifically recommends that number of infections averted should be identified as a specific outcome measure. Outcome measures articulated by the President's Emergency Plan for AIDS Relief (PEPFAR) could be used as models.
- The SC emphasized that the question should not be whether the appropriate portion of prevention services is being devoted to specific populations but whether populations at greatest risk receive the appropriate level of prevention services.
- The SC expressed concern regarding the proportionality of resources for low prevalence areas and questioned whether adequate resources were devoted to their populations. Specifically, the SC recommends that DHAP reconsider the appropriateness of requiring low prevalence areas to undertake the same activities as higher prevalence jurisdictions without adequate infrastructure, capacity, and resources.
How appropriate is the current mix of activities across mission areas (i.e., surveillance, research, program, capacity building/technical assistance, and evaluation)?
- The SC agreed that there is a need for more resources for surveillance activities, especially for core surveillance, due to an increase in national prevalence and due to the greater amounts of data being reported to and analyzed by the CDC and utilized by other federal agencies such as HRSA.
- The SC agreed that from a planning perspective, the current mix is not sufficient. The SC recommends improved capacity at the national level for planning and for translation of strategic objectives into operational plans. The SC also recommends creation of an annual report card showing progress to attain strategic goals, objectives, and outcomes.
- The SC agreed that there are insufficient resources for the research program at DHAP. The SC recommends that given resource limitations, clearer research priorities should be set and research activities should focus on those priorities.
- The SC recommends that DHAP have more effort devoted to the translation of research into practice, that these efforts be timely, and that practice observations should be used to better inform the DHAP research agenda. The SC recommends translational research be prioritized in contrast to the current "topic-based" research strategy.
- The SC recommends that DHAP expand the cultivation of grassroots interventions being used by community-based organizations (CBOs) and document successful grassroots interventions for replication. The SC recommends that DHAP quickly expand the number and types of approved interventions to more fully develop the prevention portfolio available for dissemination and to better serve the variety of prevention constituencies. The SC specifically recommends developing more interventions using communication strategies, social marketing, and structural interventions, which are currently inadequate.
- The SC noted that capacity-building support for indirectly funded CBOs is currently inadequate and should be improved.
How appropriate is DHAP's current allocation of resources across mission areas?
The Chairs recommended reframing this question into two separate but related questions:
Is the allocation for DHAP appropriate? Is DHAP's current allocation of resources across mission areas appropriate?
The Committee offered the following analysis and recommendations:
- General allocation needs to be aligned with DHAP priorities and translated into outcomes across programs.
- The SC agreed that it is important that DHAP's activities be based on available surveillance data, and that DHAP ensure that its activities match the nation's prevention needs. However, the SC expressed that it had no confidence in the current match.
- There is some difficulty in assessing this question due to internal inefficiencies and redundancies, and overlaps in areas, including research and surveillance. Nonetheless there are not enough resources, even in light of DHAP's inefficiencies and redundancy.
- The SC recommends that HIV/AIDS resources across CDC be included in any review of resource allocation. The agency should ensure that all HIV/AIDS-related resources allocated to other parts of CDC are used consistently with DHAP's strategic priorities and goals or be allocated to DHAP for use in achieving DHAP's national goals for HIV prevention.
- The SC strongly recommends that DHAP's priority-setting and decision-making processes become more transparent and public. The SC noted that some DHAP activities appear to be carried out merely as a continuation of existing activities that may no longer be relevant, while new areas are not getting sufficient attention. Without clearer and more transparent priority and decision-making processes, these perceptions will continue.
- Support for core public health functions, such as surveillance and evaluation, need to be bolstered and safeguarded. The SC noted that in surveillance, resources for core infrastructure have been level funded even as circumstances change. This is unacceptable.
- New areas of research on interventions, such as structural interventions to address social determinants and social marketing, do not have adequate resources.
- In terms of behavioral research, current resources are insufficient, and they should be allocated to different research priorities (e.g. more translational research, the effects of social determinants on health behavior, and study social marketing efforts), and allocations should support greater interaction with health departments and work with non-government researchers.
- The SC also noted that low morbidity areas could use DHAP or CDC technical assistance support to learn strategies to carry out their CDC requirements within their current limited resources. SC recommends that CDC address these concerns.
- The SC pointed out that there are public and internal expectations of collaboration and coordination within DHAP, but the DHAP Office of the Director (OD) does not have resources and staff to carry out this function. Additional allocations should be made to strengthen collaboration and coordination.
- There are multiple possible synergies among prevention programs and science and research projects that can be achieved through greater interaction among the various divisions in addition to those that can be achieved within DHAP. Some synergy may be achieved if collaboration is required of funded activities.
- There is a need for stronger leadership to address cost efficiencies. There is a need for a thorough assessment of what is not working, for greater support for enhancing infrastructure at the community and health department levels, and to address social determinants of health.
How adequate are DHAP's efforts at translating and disseminating research findings and incorporating new knowledge into action?
- Overall, the SC found that DHAP's efforts at translating and disseminating research and incorporating new knowledge into action are inadequate in relation to the scope of the national HIV epidemic.
- The SC recommends that DHAP improve internal collaboration (especially between program and research branches) in the planning and implementation of any research project. The Task Force model can be used for coordination of efforts and more effective translation of findings, which is something DHAP does very well.
- The Capacity Building Assistance (CBA) model, which works via national, regional and local technical assistance organizations, should be better evaluated to determine its effectiveness.
- The Diffusion of Evidence Based Interventions (DEBIs) has relied on the gathering of evidence-based approaches that are not uniformly adequate or helpful to the implementers at the community level. While the model has helped CBOs increase the science base and formal structures of their interventions, the model has been limited in reach and application. The SC recommends that additional strategies targeting specific populations be created to make the DEBI portfolio more comprehensive and more effective. Examples include, but are not limited to, evidence-based social marketing initiatives and evidence-based structural interventions.
- DHAP must create stronger linkages between researchers and practitioners to exchange information on science and implementation.
- Many community-level prevention practitioners have been able to develop successful interventions within their programs, and these "homegrown" interventions would be useful to expand the scope of DHAP-approved or funded prevention activities. The SC strongly recommends that these interventions should be evaluated, expanded, cultivated, and offered widely.
To what extent does DHAP have adequate capacity and sufficient resources to address its mission, goals, and priorities?
- Current capacity is not adequate, and additional funding is required to support core public health functions, such as surveillance, evaluation, and program development.
- The SC did not have sufficient information on what was being funded to determine whether resources were applied in the right proportions. The information in the Professional Judgment Budget provided useful guidance, but was not the definitive answer as to what additional resources are needed. However, the SC strongly recommends that the Professional Judgment Budget be used as the starting point for planning for the future.
- The SC recommends improvements in DHAP business management. DHAP is not effectively supported and is sometimes hampered by the Procurement and Grants Office (PGO). In addition, the SC recommended that DHAP leaders and branches receive additional skills, guidance, and staff capacity to manage effectively the size and variety of business processes and funds entrusted to them.
What are the principal gaps in DHAP's programs overall?
- There is very little use of data from other disease surveillance systems to inform program planning or prevention approaches for HIV. DHAP is not fully prepared for addressing HIV prevention in a changing health care environment; it is not prepared to represent HIV prevention perspectives in health care reform discussions; and it is unprepared for responding to health care changes in the future should health care reform become a reality.
- The SC found that DHAP's use of technology for prevention is inadequate, and DHAP has played an inadequate role in assessing and incorporating new technology.
- The SC recommends more timely collection and dissemination of data gathered through surveillance and evaluation back to programs at the state and local levels so that the information can be used more quickly for program improvement.
- The SC recommends enhancing health services research that goes beyond cost-benefit analyses and planning and that goes beyond a mere comparison of new activities and the absence of activities. The SC noted that optimization modeling can be useful in this regard; as can standard cost-effectiveness analyses in which multiple policy/program options are compared to each other, rather than compared just to the status quo.
- The SC suggests that DHAP pursue new methodologies that address prevention from a holistic perspective, where the individual can be viewed from various angles by practitioners and structural interventions developed to meet the individual's various prevention needs.
- A significant gap in DHAP programs is its ability to provide adequate support for programs and jurisdictions in rapidly scaling up effective interventions (or sets of interventions) and testing initiatives to meet growing needs and opportunities. SC recommends that this serious gap be addressed and remedied.
What is DHAP's unique role in HIV prevention within CDC?
The SC recommended combining the two sections on DHAP's role for HIV prevention within the CDC and in the United States into the following two sections.
What is DHAP's unique role for HIV prevention for the United States?
The SC recommended combining the two sections on DHAP's role for HIV prevention within the CDC and in the United States into the following two sections.
Are DHAP's intramural organizational structure, operations, and business management functions efficient and appropriate?
- The SC stressed that there must be a significant streamlining in the contracts, grants, and cooperative agreements approval process within the PGO. DHAP's timeliness and effectiveness is significantly hampered by the inadequate or unhelpful processes, resources, and support of PGO. The SC also noted that PGO appears to make frequent decisions that have direct programmatic impact and that PGO does not consistently defer to program expertise regarding substantive programmatic matters.
- The SC expressed serious concerns regarding the internal culture of CDC and DHAP. The SC noted persistent clashes between "science" and "program/community" perspectives; between staff with medical doctor versus Ph.D. degrees; and between "biomedical" and "behavioral" prevention perspectives. The SC recommends that these conflicts be assessed and addressed because they may prevent the implementation of innovative practices and because they may limit the useful exchange of information and ideas between programs, branches, and staff.
- The SC also noted perceived clashes between "top-down" vs. "collaborative" priority-setting and decision-making within DHAP. This clash was perceived by the SC as a major barrier to DHAP operational effectiveness. The SC recommends that this issue be assessed and addressed as well.
- The SC further noted that the current emphasis on staff publishing also may hamper DHAP's effectiveness, as it diverts attention away from immediate programmatic concerns (although it is necessary to add credibility to CDC's work).
- The SC recommends that CDC reconsider and eliminate the Coordinating Center structure. The SC noted that this structure is a drain on division-level resources and has not demonstrated a useful purpose. The SC unanimously voiced that it should be removed.
- The SC expressly agreed that there should be better coordination with the Global AIDS Program (GAP) to avoid duplication of effort and DHAP staff and resources going to GAP.
- The SC endorsed CDC's reconsideration of the operational prominence of DHAP and assess whether DHAP should be a standalone Center for HIV/AIDS Prevention within CDC. The SC expressed concerns about the existence of two operational units that operate as DHAP and recommended that the impact of this dual structure on paper be examined in order to ameliorate its impact on operations. The SC also questioned the wisdom of domestic and global activities being separate and how this bifurcation impacts coordination of activities and collaboration. The SC suggests that CDC explore combining DHAP and GAP into a single Center for HIV/AIDS Prevention.
What are the unique strengths that CDC brings to the national prevention agenda?
- The SC noted that CDC, through its data gathering capacity in the areas of surveillance, behavioral, and biomedical research, can bridge science into practice in ways no other federal agency can. When coupled with its ability to provide funding to external partners and provide leadership, the agency is uniquely positioned to fundamentally impact public health practice.
- The Community Planning Process has been successful in integrating voices of the health departments and the community to a concerted planning process. The SC recommends that CDC incorporate the principles of community planning in its own planning processes.
- CDC has the unique ability to mobilize public opinion to HIV prevention with great authority. The SC expressed their desire for CDC and DHAP to bring more voice to HIV prevention in the United States and to address underlying issues such as stigma and discrimination.
- CDC can also bring researchers and practitioners together to set priorities for research and to obtain evaluation data on program effectiveness.
- It is DHAP's unique role to prevent HIV transmission in the United States. In order to accomplish this, CDC must anticipate the trajectory of the epidemic and set up an effective prevention framework to anticipate and respond to the future trajectory of the epidemic.