Additional barriers and challenges have been recognized by CDC. These insights are described below in reference to each goal.

Goal 1. Despite numerous HIV prevention activities for this goal, there are several challenges in further reducing HIV risk behaviors. Effective interventions for African American and Latino MSM, and other priority populations, do not exist or have not been packaged for dissemination. Intertwining epidemics of substance abuse, poor mental health, STDs, poverty, violence and other structural factors play a critical role in placing persons at risk for HIV. The effects of HIV treatment have impacted public perception about the severity of and susceptibility to HIV.

“Prevention burnout and fatigue” are causing some communities to ignore CDC’s prevention messages. Barriers exist to scaling-up the dissemination of evidence-based interventions and adequately meeting the demands of communities. Resources have not been sufficiently allocated to specific activities and local needs of certain communities. Minimal progress has been made in determining the optimal mix of prevention strategies to achieve the greatest impact at both national and local levels.

Goals 2 and 3. While there are numerous HIV prevention activities for goal 2 of the Plan, there are several challenges in increasing VCT. Most HIV testing is performed outside of public health settings. HIV counseling and testing sites that are supported by CDC dollars only administer ~5% of all HIV tests in the United States. State laws impact the legality and feasibility of implementing rapid test programs. Reimbursement issues have not been resolved to date. The integration of HIV screening programs into existing care settings poses a number of barriers.

Similarly, there are several challenges in increasing linkages to appropriate HIV prevention, care and treatment services. Traditional disparities in accessing care still exist among some groups (e.g., racial and ethnic minorities, MSM, injection drug users). Competing priorities, time constraints, and other barriers are significant issues for HIV care providers. Reimbursement issues for case management are unresolved. Activities to develop and sustain capacity to collect high-quality data on clinical outcomes and access to care are extremely difficult for health departments, providers and CBOs to implement.

Goal 4. Although numerous HIV prevention activities have been implemented for this goal, several challenges remain related to monitoring, evaluating, and delivering programs. Variations in reporting policies and priorities for HIV surveillance increase complexity. The tension between monitoring treatment and care versus incidence has not been resolved to date. The intervention portfolio and pipeline for HIV are limited for MSM of color and other specific populations. Efforts to adapt and tailor existing interventions for certain groups are extremely difficult.

Community norms play a critical role in the content of interventions and “appropriate” or “acceptable” messages to deliver. Several issues related to PEMS have not been sufficiently addressed, such as privacy and confidentiality for non-infected persons, data collection versus expanded testing, and lack of capacity and resources to compile PEMS data. Local needs continue to compete with federal capacity in the areas of scaling-up surveillance systems or interventions, and to provide assistance in the face of shrinking resources and restrictions on new hires and travel.

There are additional reasons why CDC has not achieved the overarching goal to reduce new infections by half:

1. Policy limitations affect what interventions are implemented and how resources are directed.
2. Scientific factors such as the epidemiology and transmission dynamics of HIV in the United States, behavioral factors, and public “optimism” with HIV treatment.
3. Contextual factors influence

HIV transmission in the United States, including gender inequality and other societal issues; poverty, homelessness and other socioeconomic issues; mental health and substance abuse; and stigma, racism and homophobia.

HIV transmission is ongoing. HIV rates and transmission among MSM, African Americans, and heterosexual women continue to play a critical role in the HIV epidemic. “Prevention fatigue” has increased the difficulty in sustaining behavioral interventions.

Better interventions have not been developed to address geographic, risk, and racial/ethnic diversities of the HIV epidemic in the United States. Methamphetamine use serves as a strong barrier to implementing behavioral interventions. National data are not available on risk behaviors among out-of-school, homeless and runaway youth. Legislative barriers still exist in implementing new HIV testing and counseling and models. Issues related to stigma have not been adequately addressed in the United States.