Ms. Jennifer Kates, Vice President and Director of HIV Policy at the Kaiser Family Foundation and a Strategic Plan Workgroup member, described issues that would affect the Strategic Plan. Of the total FY’06 federal budget of $2.6 trillion, $21.1 billion or <1% was devoted to HIV/AIDS prevention, care, treatment and research. Although this amount represented a small percentage of the total FY’06 federal budget, federal funding for HIV/ AIDS dramatically increased from $0 in 1981 to $22.8 billion in the President’s FY’07 budget request.
In FY’06, 55% of the federal HIV/AIDS budget was mandatory as a result of Medicaid, Medicare, Supplemental Security Income, Social Security Death Index, and Federal Employees Health Benefits programs. The remaining 45% of the federal HIV/AIDS budget was discretionary as a result of annual Congressional appropriations for the CARE Act and HIV/AIDS research, global, housing and prevention programs. Discretionary funding decreased from 1981-2006 because more persons are now living with HIV and are eligible for mandatory care and income assistance programs. For example, 50% of federal funding for HIV/AIDS was allocated to research in FY’82, while 58% was allocated to care and treatment and only 4% was allocated to prevention in FY’06.
Federal agencies are the primary recipients of domestic HIV prevention funding with the majority of these dollars allocated to CDC. Of $869 million in federal funding for domestic HIV prevention in FY’06, CDC received $719 million or 83%. CDC distributes these funds to states, cities, CBOs and other programs. Other recipients of HIV prevention funds include other federal agencies, state and local governments and private-sector groups.
CDC’s federal funding for domestic HIV prevention increased from $0 in FY’82 to $719 million in FY’06 based on nominal dollars. However, the FY’06 amount is nearly the same as FY’92 dollars based on inflation. The President’s budget requests for domestic HIV prevention increased from $872 million in FY’05 to $956 million in FY’07. Of the President’s FY’07 budget request of $956 million for domestic HIV prevention, $808 million or 85% would be allocated to CDC, including a $93 million proposed increase.
In FY’05, CDC/DHAP distributed $374.6 million or 59% of its total $633.8 million budget to state and local health departments. DHAP allocated the remainder of the budget to capacity-building, intramural programs, directly funded CBOs, research, program evaluation and interagency agreements. DHAP’s HIV prevention funds to the top ten states in FY’05 ranged from ~$77.3 million to New York to ~$15.8 million to Massachusetts.
CDC’s HIV prevention budget is an important factor that CHAC must consider in providing guidance on the updated Strategic Plan. For example, CDC’s revised HIV testing guidelines for routine screening are targeted to persons 13-64 years of age. According to the most recent U.S. Census estimates, ~200 million persons account for this population in the United States. Of this population, ~1.2 million are HIV-positive. Of this population, ~250,000 are HIV-positive and do not know their status. CDC’s resources are targeted to reaching this population, informing these persons of their status, and making linkages to care.
Of ~1.2 million HIV-positive persons in the United States, 25% are undiagnosed, 25% are diagnosed and not in care, and 50% are in care. PLWHA had the following insurance coverage based on 1996 data: 31% with private insurance, 29% with Medicaid, 13% with Medicaid/Medicare, 6% with Medicare, and 20% uninsured. More recent data collected in 2002 from 17 HIV clinics throughout the country showed a change in insurance coverage of PLWHA: 34% with Medicaid, 16% with private insurance, 13% with Medicaid, 4% with Medicaid/Medicare, and 28% uninsured.
Data collected from 25 states from 1994-2000 showed that private insurance accounted for 33% of PLWHA at the time of diagnosis, Medicaid accounted for 22%, other public or government programs accounted for 19%, and no insurance accounted for 27%. Data collected in 2004 from 35 areas showed that 61% of AIDS diagnoses were made >12 months after HIV diagnoses.
Data collected in 2002 on HIV testing by facility and diagnosis showed that hospitals, emergency rooms and community clinics diagnosed most HIV-positive patients. Data collected in 2003 on PLWHA by awareness of serostatus showed that undiagnosed persons were more likely to be AA and Hispanic based on race/ethnicity and MSM and heterosexual based on transmission.
Ms. Kates summarized key points for CHAC to consider in providing further guidance to CDC on implementation of the updated Strategic Plan. The Strategic Plan and revised HIV testing recommendations target two populations: all persons 13-64 years of age for routine screening and a subset or <1% of the population that is estimated to be HIV-positive and undiagnosed. The undiagnosed population is more likely to be uninsured persons of color, rely on public assistance, infected through sexual contact, and present to emergency rooms and community clinics.
Linkages to the care system will be critical in implementing the updated Strategic Plan and revised HIV testing recommendations because ~50% of diagnosed persons have no access to care and 39% are diagnosed late. ADAP waiting lists; other barriers to the care system; and resources from federal, state and local systems will need to be addressed to implement the Strategic Plan.
Dr. David Holtgrave, of Johns Hopkins Bloomberg School of Public Health, provided additional data on issues that will affect the Strategic Plan. Since the mid-1980s, successful HIV prevention programs have led to a decrease in the number of new infections in the United States from 160,000/year to ~40,000/year. The investment in HIV prevention also resulted in societal cost-savings. Modeling has been performed to estimate the number of new infections that would have occurred each year without HIV prevention programs. The scenarios projected that ~1.5 million infections were prevented in the United States from 1985-2000.
The rate of HIV transmission from PLWH to seronegative partners dramatically decreased from ~100% in the early stage of the epidemic to 4% in 1990. These data showed that at least 96% of PLWH were not transmitting HIV in a given year. HIV transmission rates are estimated to be 8.8%-10.8% in persons who are unaware of their HIV seropositivity and 1.7%-2.4% in persons who are aware of their HIV seropositivity. C&T play a major role in the significant differences in HIV transmission rates between the two groups. A paper that is in press showed a strong relationship between resources and HIV incidence after 1985.
The overarching national goal in the 2001 Strategic Plan was to reduce the number of new HIV infections in the United States from an estimated 40,000 to 20,000 per year by 2005 with a particular focus on eliminating racial/ethnic disparities in new HIV infections. The November 18, 2005 edition of the MMWR contained an article on HIV/AIDS diagnoses collected from 33 states with name-based reporting systems from 2001-2004. Over the four-year period, 157,252 diagnoses were made in the 33 states. These data suggested that HIV incidence in the United States was well over 40,000/year in the United States in 2005.
Sub-goal 1 in the 2001 Strategic Plan was by 2005, to decrease by at least 50% the number of persons in the United States at high risk for acquiring or transmitting HIV infection by delivering targeted, sustained and evidence-based HIV prevention interventions. Progress on this goal is uncertain due to unclear language and the lack of national sexual behavior data. However, a published study showed that HIV-positive persons reduced risk behaviors by 68% after learning of their HIV seropositive. Other data showed that ~11.7%-11.9% of the general U.S. population were at heightened risk of HIV due to sexual transmission, drug use risk behaviors or a current STD.
Sub-goal 2 in the 2001 Strategic Plan was by 2005, to increase from the current estimated 70% to 95% the proportion of HIV-infected persons in the United States who know they are infected through voluntary C&T. The lack of progress on this goal was demonstrated by CDC’s estimate of a 73%-76% awareness level of HIV in 2005.
Sub-goal 3 in the 2001 Strategic Plan was by 2005, to increase from the current estimated 50% to 80% the proportion of HIV-infected persons in the United States who are linked to appropriate care and treatment services. The lack of progress on this goal was demonstrated by a 2004 Institute of Medicine report that estimated only 49.7% of persons in need of highly-active ART actually received therapy.
For the updated Strategic Plan, the national goal should be maintained to reduce new HIV infections in the United States to 20,000/year or less by 2010 and place particular emphasis on racial/ethnic health disparities. However, the goal should be expanded to monitor progress with annual report cards on the national investment; develop process measures for policy implementation, reduce barriers and service delivery; and assess annual outcomes. The goal will continue to be important because 5-26.3 million persons are seronegative, but have behavioral risks for HIV infection. CDC has estimated that ~1.1 million PLWH are in the United States. Of this population, ~25% are unaware of their status.
A meta-analysis showed that after PLWH obtain C&T, ~16% will still continue to engage in risk behaviors. Based on these data, several sub-goals should be considered for the updated Strategic Plan. Risk behaviors should be decreased and serostatus awareness should be promoted. Care and treatment should be available to all persons who need these services.
Information should be more widely disseminated to the general public to combat stigma of HIV. CDC should partner with the National Institutes of Health (NIH) to invest in and conduct research on new interventions to decrease stigma. Serostatus-specific HIV prevention efforts should be targeted to HIV-positive persons; recently tested HIV-negative persons who are at continued behavioral risk of infection; persons who are unaware of their HIV status; and the general population.
A paper that is in press analyzed the potential impact of HIV seropositivity awareness on HIV incidence via C&T. The data showed that prevented HIV infections could be achieved by lowering the transmission rate from 9% to 2%. An analysis that is currently under review for publication examined the costs and consequences of four HIV testing scenarios. The analysis showed that if HIV screening rates were increased to 52% in the target population, ~65 million persons would need to be tested and ~56,000 seropositive persons would be reached. Total program costs of this effort were estimated at ~$864 million. The gross cost per avoided infection was estimated at $237,149. To provide care and treatment for newly-diagnosed persons, ~$961.3 million would need to be set aside in the first year. Overall, the analysis demonstrated that ~$1 billion would be needed to support a new Strategic Plan.
Dr. Holtgrave summarized several issues for CHAC to consider in providing additional guidance to CDC on implementing the Strategic Plan. C&T and serostatus awareness are important interventions, but are not sufficient to achieve an “HIV disease elimination” program. As a result, HIV prevention interventions should be designed to include individual, dyad, family, group, community and structural levels, such as laws, policies, environments and social determinants. HIV prevention interventions should also focus on sexual, perinatal and parenteral transmission, including interventions for small groups, communities and housing. Structural interventions should be designed to strengthen social capital at the community level to impact STDs, AIDS and teen pregnancies.
HIV prevention programs have changed the course of the epidemic in the United States, but additional progress must be made to further reduce the number of new infections. Previous efforts should be scaled-up to conduct activities in the future and allocate resources for these initiatives. HIV prevention programs have decreased incidence, but flat funding of these activities must be addressed. Targeted HIV C&T might have substantially more public health benefits than opt-out testing at the same cost.
Additional promotion of serostatus awareness via C&T might decrease the national annual incidence of 40,000 new HIV infections to 25,000-30,000 for a true HIV disease elimination program in the United States. However, serostatus awareness will play a minimal role in further reductions in incidence. A multi-component, multi-level and comprehensive National Plan for HIV Prevention, Treatment and Care for the United States is urgently needed as soon as possible. The new national plan should be supported by substantial resources to provide high-quality HIV care and treatment to persons newly diagnosed with HIV through C&T campaigns.
To guide the discussion, Dr. McGuire and Mr. Milan emphasized the importance of CHAC providing guidance on models and resources for implementation of the updated Strategic Plan and the need to develop a new National Plan for HIV Prevention, Treatment and Care.
Several CHAC members suggested additional issues that should be considered in implementing the updated Strategic Plan.
- A new strategy should be developed to collect surveillance data on diseases to ensure these variables are clearly defined.
- Data from the HIV prevention economic models should be re-analyzed to determine cost-savings from HIV-positive persons who were diagnosed, received care and engaged in safer practices.
- The intersection between violence and HIV should be included in structural interventions.
- CDC should attempt to allocate resources and take other actions at this time to advance toward an HIV disease elimination program.
- Quantifiable goals should be incorporated into the updated Strategic
Plan to assist in obtaining a justified budget that is based on the science
and actual numbers of HIV-positive persons.
- CHAC should make strong recommendations for increased funding to reduce the number of new HIV cases. For example, language could be included in the updated Strategic Plan or a companion document to emphasize that new resources will be needed to implement the prioritized interventions and other innovative strategies to further decrease the number of new HIV infections per year.
- The Strategic Plan should outline approaches to address new barriers to providing HIV prevention, education treatment and care in the future. For example, the change in the CARE Act legislation for HIV-positive persons to be identified through name-based reporting systems in 2007 might undermine these efforts.