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Program Response to Recommendations

November 3, 2009

In April 2009, the Division of HIV/AIDS Prevention (DHAP), National Center for HIV/AIDS, Viral Hepatitis, STD and TB Prevention (NCHHSTP), Centers for Disease Control and Prevention (CDC) convened an External Peer Review to (1) provide DHAP with objective input and guidance on its programmatic and scientific priorities and direction; (2) provide input for a new DHAP HIV prevention strategic plan; and (3) provide a platform for development of a national HIV prevention strategy that incorporates stakeholder perspectives and needs.  The review was conducted under the auspices of CDC's Board of Scientific Counselors (BSC).  It included all DHAP programs and activities, organized into the following topic areas, each addressed by a separate panel:

  • planning, prioritizing, and monitoring,
  • surveillance,
  • biomedical interventions, diagnostics, laboratory, and health services research,
  • behavioral, social, and structural interventions research, and
  • prevention programs, capacity building, and program evaluation.

A Steering Committee with representatives from each panel addressed cross-cutting issues, DHAP's overall priorities, balance of activities, resource allocation, and research-to-program translation and dissemination activities.  Final recommendations from the External Peer Review were submitted to DHAP in October 2009.  Several overarching themes are noted below:

National leadership for HIV prevention

The reviewers stressed the importance of DHAP providing greater national leadership for HIV prevention, noting that CDC is uniquely able to mobilize public opinion and should bring more prominence to HIV prevention in the United States.  DHAP agrees that it should play a more visible, active, and authoritative leadership role in HIV prevention.  This is a high priority for the Division's new Director.  DHAP will be developing a new HIV prevention strategic plan in the upcoming months, and will address this issue during that process.

Reviewers emphasized the need for a National HIV Prevention Plan – likely to be part of a National HIV/AIDS Strategy.  DHAP agrees that HIV prevention is a critical component of a National HIV/AIDS Strategy.  The Division is hopeful that its new strategic plan will inform the development of a National HIV/AIDS Strategy.

Effective use of data for planning and monitoring

The reviewers emphasized the importance of strategic planning for, and monitoring of, HIV prevention activities at the national level.  They recommended that DHAP make more effective use of data from multiple sources for strategic and annual planning and for monitoring progress toward achieving the Division's goals and objectives.  They also recommended that DHAP create an annual "report card," summarizing progress toward attaining strategic goals, objectives, and outcomes.  DHAP agrees with these points and intends to expand its use of a wide array of data from its surveillance and program monitoring systems – and data from other sources, as appropriate – to further inform its planning activities.  The Division is developing a national monitoring and evaluation (M&E) plan that includes performance indicators, annual targets, and a more systematic, integrated approach for using data for decision making.  The M&E plan will provide an overall framework for monitoring our progress against the epidemic and also contribute to the Division's strategic and annual planning.  DHAP will provide an annual summary report showing progress toward achieving goals and objectives.

Prioritization and transparency

A dominant theme across the panels was the need for DHAP to improve its priority-setting and decision-making processes and ensure that they are clearly and openly described.  DHAP acknowledges the need to improve these processes; explain the rationale for decisions; and make the processes and resulting decisions more transparent to internal staff and external partners.  More transparent, thoughtful processes will minimize the appearance of subjectivity and have the potential to further improve operational effectiveness.  The Division will address these issues in strategic planning and commit to posting the priority-setting and decision-making processes, along with priority goals and objectives, on the Internet.  The Division will also strive to more effectively disseminate its strategic and M&E plans to internal staff and external partners and will post them on the Internet.

Social determinants of health

The reviewers recommended that, in planning and targeting resources, DHAP emphasize factors other than demographic characteristics, especially behavioral, social, contextual, and structural factors that place individuals at risk.  DHAP recognizes the multiplicity of factors driving the epidemic and agrees that the other factors noted by the reviewers are critical to consider in planning and targeting resources.  In addition, there are profound racial/ethnic disparities in the HIV epidemic due to factors such as higher HIV prevalence, higher levels of unrecognized infection, and higher sexually transmitted disease rates that are affected by social determinants of health.  In its planning processes, DHAP will seek an appropriate balance among various demographic, behavioral, social, contextual, and structural characteristics that can be used to guide research, programmatic activities, and resource allocation.  In addition, DHAP will work with NCHHSTP's Office of Health Equity to incorporate a social determinants of health approach into the Division's work.

Translation of research into practice

The reviewers recommended that DHAP place greater emphasis and priority on timely translation of research into practice. The reviewers noted that DHAP has developed a strong system for translation and dissemination of effective behavioral interventions, but that the process needs to be accelerated and the number of available interventions increased.  DHAP agrees that timely translation of research into practice is crucial, understands the importance of improving the research translation process, and is working on streamlining the process to improve its timeliness.  The reviewers also noted that the Division does not have a similar, systematic approach for translating and disseminating biomedical interventions or related strategies.  DHAP agrees that more should be done to ensure dissemination and implementation of effective biomedical and clinic-based interventions and will address this need during strategic planning.  Recognizing that the flow of information between research and program should be bidirectional, reviewers recommended that DHAP make better use of program experience to inform its research agenda.  DHAP strongly agrees with the importance of a feedback loop that allows program experience to influence the research agenda and ensure that it is relevant and applicable to our programs.  The Division will explore strategies for creating and maintaining this feedback loop.

Focus on translational, operations, and health services research

Reviewers noted that, because of its research experience and strong involvement in prevention programs, DHAP is well positioned to conduct translational and operations research, and suggested that the Division expand these activities.  DHAP agrees that translational and operations research should be division priorities, and has attempted to expand its efforts in these areas; however, resources have been limited by prior-year commitments and scarcity of new resources for research.  In its strategic planning, the Division will consider mechanisms for expanding its activities in these areas.  The reviewers recommended that DHAP expand its health services research activities.  DHAP agrees that increased focus on public health systems and services research may yield valuable information for guiding health policy and improving programs, but notes that it will be necessary to think carefully about the scope of the effort, the critical research questions to be addressed, and the need for additional resources to support this effort.  DHAP will consider these issues in its strategic planning process.

Community- and practice-based research and community-developed interventions

Reviewers recommended conducting research in community- and practice-based settings to maximize its generalizability and feasibility.  DHAP agrees, and will work to ensure that research projects involve health departments and community-based organizations (CBOs) whenever possible and that interventions developed in DHAP-supported projects are shaped by input from organizations that will ultimately use them.  DHAP also recognizes that health departments and CBOs may have developed interventions that appear highly effective and could fill critical gaps, but have not been rigorously evaluated (i.e., community-developed or "homegrown" interventions).  DHAP will consider expanding its efforts to identify and evaluate such interventions.

Communications, coordination, and collaboration

The reviewers recommended that DHAP explore opportunities for greater communication, coordination, collaboration, and synergy within the Division (e.g., cross-branch workgroups), with other CDC entities (e.g., the Global AIDS Program), with other federal agencies (e.g., the National Institutes of Health [NIH]), and with other external partners (e.g., health departments, CBOs, non-governmental organizations, private foundations, industry).  DHAP agrees with these recommendations and is committed to improving communication, coordination, and collaboration on all these fronts.  The Division will develop and maintain an accessible, detailed inventory of collaborations, within and external to CDC, to facilitate these efforts.

Building capacity and supporting programs in the field

The reviewers emphasized the need for additional resources to increase current capacity and support for core public health functions, such as surveillance (especially core surveillance), research (including new areas of research on interventions, such as structural interventions to address social determinants), program development, and evaluation.  DHAP agrees that available resources and capacity are not sufficient to adequately support core public health functions and will consider this in the strategic planning process.  The reviewers suggested that DHAP improve its ability to support programs and jurisdictions in rapidly scaling up effective interventions and strategies to meet growing needs.  DHAP agrees with the importance of being able to rapidly scale up effective interventions.  However, resource limitations and administrative and regulatory requirements limit the Division's flexibility, and there is little surge capacity.  Capacity-building assistance (CBA) is available to prevention programs through the CBA Program, which has been redesigned and began a new project period in 2009.  DHAP will monitor the new program to assess its adequacy in meeting constituents' needs.  The reviewers commented that, although core surveillance provides the foundation for prevention and care programs, DHAP does not have adequate capacity or resources devoted to supporting core surveillance activities, which have increased dramatically in volume and complexity. DHAP agrees that it needs to support core surveillance with adequate resources, both internally and in health departments, as this system has evolved and changed over the years and level funding is not sufficient.  The upcoming strategic planning process will allow the Division to consider priorities and align resources accordingly.

Enhancing internal capacity

Reviewers noted a general need for additional staffing and resources within DHAP.  Some areas in which need for additional staff was mentioned specifically include developing and implementing the Division's strategic planning processes and national-level M&E plan,  strengthening coordination and collaboration among branches within DHAP, providing technical assistance to jurisdictions for surveillance, expanding health services research, developing and implementing guidelines, and providing scientific and evaluation support for program staff.  DHAP acknowledges the need for additional staff in these and a number of other areas.

In addition to the overarching themes described above, the individual panels made many topic-specific recommendations.  The following are some key examples:

  • The Surveillance Panel noted that jurisdictions are eager to have additional information to inform prevention and specifically mentioned HIV incidence estimates derived through back-calculation.  The panel requested that technical assistance be available if such approaches could be applied locally. CDC is currently preparing a detailed description of the back-calculation methodology and data requirements.  Once the methodology has been documented in detail, CDC plans to make analytic programs available; however, implementation on the local level will require local statistical support and will only be possible in areas with very mature and stable HIV reporting systems.
  • The Surveillance and Prevention Programs Panels noted the importance of the link between surveillance and prevention programs and noted that greater coordination between surveillance and program within DHAP would facilitate surveillance-program collaboration at the local level. DHAP agrees that the ultimate goal of surveillance is to provide information that can be used for public health action. The Division's upcoming strategic planning process will be an opportunity to reflect critically on the ways in which we can better support the link between surveillance and program.
  • The Biomedical Interventions Panel discussed DHAP's important role in conducting animal model research – a niche no other entity can currently fill – and recommended that these projects continue.  DHAP notes that this was also the recommendation of a recent external review of the Laboratory Branch, and plans to continue these activities.
  • The Biomedical Interventions Panel noted the importance of the DHAP's role in developing diagnostic assays for monitoring acute and recent HIV infection and confirming HIV infection and recommended that the Division continue activities in this area.  However, the panel also noted that other entities work in this field.  DHAP agrees with the panel's recommendation that the Division continue to play a role in developing diagnostic assays and coordinate this work with other federal agencies and private sector entities.
  • The Behavioral Interventions Panel recommended that DHAP focus its behavioral research on Phase 1 (formative) research that develops and pilot tests new interventions, and Phase 4 (operations) research.  DHAP generally agrees with this perspective.  The Division acknowledges that rigorous testing of new interventions should not be its primary focus and that closer coordination with NIH is needed to ensure that NIH-funded research better addresses unmet public health needs.  The Division notes, however, that it has played a key role in developing and rigorously testing evidence-based behavioral interventions that address specific gaps in the availability of interventions for populations at greatest risk, and believes it should continue to play a leadership role in addressing unmet intervention needs.  In strategic planning, the Division will consider expanding its role in operations research and rigorous program evaluation.
  • The Behavioral Interventions Panel recommended that core determinants of risk behavior and behavior change should be emphasized in its interventions and intervention research rather than membership in a given subpopulation.  DHAP and other research and evaluation projects have demonstrated that interventions developed for one population can, at least in some cases, be successfully adapted for use in another population.  The ability of interventions to be adapted for use in multiple populations is critical given the limited availability of interventions that have been tested with various groups at increased risk of HIV infection.  DHAP recognizes the clear need for additional research and program monitoring that address the process of adapting interventions as well as the implementation and outcomes of adapted HIV interventions.
  • The Behavioral Interventions Panel recommended that the focus of interventions should be based on epidemiological research regarding specific practices that place individuals and communities at increased risk for HIV infection.  DHAP agrees with this perspective.
  • The Prevention Programs Panel noted the need for a combination of effective approaches, to include structural and biomedical interventions, and recommended that policy and program be guided by science.  The panel specifically addressed interventions that promote syringe access and safe disposal of syringes, and noted that the ban on use of federal funds for syringe exchange programs has prevented CDC from supporting this strategy.  DHAP agrees and is prepared to promote and incorporate this strategy into our prevention portfolio, should the ban be lifted.
  • The Prevention Programs Panel recognized the importance of community planning and its ability to increase accountability, transparency, community participation, community leadership capacity, and policy capacity.  However, the panel recommended that DHAP explore new and more flexible models for assuring and maintaining community input.  The panel also recommended a redefinition of the nine essential elements of a comprehensive HIV prevention program, noting that the elements need to be revisited and revised, as appropriate.  DHAP has conducted an extensive process over the past two years to collect information from internal and external partners about the current community planning process.  Input from that process is being used to inform revision of The Community Planning Supplemental Guidance.  The essential elements will also be reassessed as the community planning guidance is revised.
  • The Prevention Programs Panel acknowledged the need for increased focus on public health workforce development, retention and competencies.  DHAP agrees that these are great challenges and notes that, although a number of learning and technical assistance opportunities are available to grantees to help support the development of emerging leaders and the sustainability of executive leaders, there are still not enough resources to meet the demand.

As noted above, DHAP will be developing a new HIV prevention strategic plan in the upcoming months.  The extensive input received through the External Peer Review will serve as a foundation for that process, as well as for planning within individual branches.  The Division will carefully consider the recommendations provided by the reviewers as it develops the new strategic plan and will report back to the BSC the outcome of the strategic planning process in one year.

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Appendix

Peer Review Chairs, Co-Chairs, Liaisons, & Coordinators

Peer Review Chairs

Edward "Ned" Hook III, M.D
Jesse Milan, JD

Panels

Planning, Prioritizing, and Monitoring

Panel Co-Chairs DHAP EPR*
Liaison(s)
CDC LM**
Panel Leader(s)
David Holtgrave, Ph.D
David Muñar
Julie Scofield
Chris Cagle, Ph.D.
Sam Dooley, M.D.
Dale Stratford, Ph.D.

**External Peer Review
**Leadership Management

Surveillance

Panel Co-Chairs CDC Liaison(s) CDC LM
Panel Leader(s)
Douglas Frye, M.D.
Amy Zapata, MPH
Amy Lansky, Ph.D, MPH James Heffelfinger, M.D., MPH

Biomedical Interventions, Diagnostics, Laboratory, and Health Services Research

Panel Co-Chairs CDC Liaison(s) CDC LM
Panel Leader(s)
Kenneth Mayer, M.D.
Mark Thrun, M.D.
Bernie Branson, M.D. Peter Kilmarx, M.D.

Behavioral, Social, and Structural Interventions

Panel Co-Chairs CDC Liaison(s) CDC LM
Panel Leader(s)
Cynthia Gomez, Ph.D., M.Ed.
Seth Kalichman, Ph.D.
Cynthia Lyles, Ph.D.
Rich Wolitski, Ph.D.
David Purcell, JD, Ph.D.

Prevention Programs, Capacity Building, and Program Evaluation

Panel Co-Chairs CDC Liaison(s) CDC LM
Panel Leader(s)
Marjorie Hill, Ph.D.
Beth Meyerson, M.Div, Ph.D.
Janet Cleveland, M.S. Rashad Burgess, M.A.

CDC Peer Review Project Officer
Laura Coker

CDC Leadership Management Coordinator
Linda Valleroy, Ph.D.

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