Dr. George Roberts, Associate Director for Prevention Partnerships in NCHHSTP and co-chair of the CHAC Strategic Plan Workgroup, covered the following areas in his report. From May 2005-May 2006, CHAC approved the establishment of the workgroup to review performance of the 2001-2005 Strategic Plan and make recommendations for updating the Strategic Plan during a three-year extension. The workgroup was formed with two co-chairs and 30 members. The workgroup convened two face-to-face meetings and presented its report to CHAC during the previous meeting.
The workgroup established several objectives to fulfill its charge. Priority goals, objectives and broad strategies of the Strategic Plan would be reexamined. Progress to date in reaching the goals and objectives would be discussed. Reasons for the nation not achieving some of the goals would be discussed. Gaps and necessary revisions in the goals and objectives would be identified. Recommendations would be made for prioritizing objectives under each goal. Strategies would be recommended to revise the Strategic Plan to achieve greater progress and success.
Numerous activities were conducted from July 2005-May 2006 for the workgroup to achieve the objectives. Background materials were reviewed, such as relevant articles by CDC and external researchers, related plans, guidelines and technical information. Presentations were made on several issues, including CDCís funding and activities for each goal, racial disparities, biomedical interventions and prevention effectiveness.
Strategies to increase the likelihood of reducing HIV transmission by 50% were presented to the workgroup from community, health department, care and policy perspectives. Progress and barriers to reaching goals and objectives were reviewed. Recommendations were made on updating the goals and objectives.
The workgroup identified a number of barriers to achieving the goals and objectives. The Strategic Plan was not accompanied by a social marketing campaign to increase public awareness and engage stakeholders. Endorsement of the Strategic Plan at national and community levels was lacking and led to minimal coordination and collaboration. The scope and relevance of the Strategic Plan to other federal agencies were not well defined.
The Strategic Plan did not delineate macro-level and structural factors that influence HIV transmission. Resources were inadequate. Targeting of the Strategic Plan to MSM and communities of color was ineffective. Effective preventive interventions were lacking for communities of color, particularly AAs and MSM. HIV prevention, C&T and care systems were disconnected.
Several common themes emerged from the workgroupís discussions on updating the Strategic Plan. An overarching racial/ethnic disparities goal should inform implementation of objectives and strategies for all goals. A clear distinction should be made between goals and objectives related to PLWH and seronegative persons at risk of HIV infection. Goals and objectives related to care should be better specified, particularly for maintaining persons in care. Stronger language should be developed to emphasize the need for routine and available HIV testing in multiple settings, including non-healthcare facilities.
Interventions should be targeted to structural and social norms that lead to risk. Biomedical strategies should accompany behavioral interventions. Interventions should be targeted to persons with acute HIV infection as a strategy to interrupt transmission during highly infectious periods. Targeting for populations at highest risk of acquiring and transmitting HIV should be improved and based on incidence rather than prevalence.
The workgroupís major recommendations are highlighted as follows. To maintain the overarching numeric goal for reducing new infections, AAs should be prioritized at the highest level, within the overarching goal, and within each individual goal. MSM should be prioritized within the goals as appropriate. Racial/ethnic minority populations with a disproportionate burden of disease or incidence should be prioritized.
Under goal 1, separate prevention goals should be created for PLWH and seronegative persons at risk of infection. Goals on testing and linkage to care should be updated. A new goal should be added to address stigma and discrimination. Goal 4 on surveillance and capacity-building should be eliminated because strategies and objectives for these issues should be included in all goals.
The workgroup proposed five specific goals for the updated Strategic Plan:
- Goal 1: By 2008, decrease by at least Y% the number of PLWH at risk of transmitting HIV.
- Goal 2: By 2008, decrease by a least Y% the number of persons at risk of acquiring HIV.
- Goal 3: Increase the percentage (from X% to Y%) of persons [of HIV-positive persons] in the United States who know their HIV infection status through routine testing in diverse settings.
- Goal 4: By 2008, increase from the current estimated ??% to ??%, the proportion of persons with HIV who are receiving appropriate prevention, care and treatment services.
- Goal 5: Increase public awareness of HIV and reduce HIV-related stigma and discrimination.
The workgroup recommended several issues that should be considered in updating all goals and objectives across the Strategic Plan.
- Improve all goals and objectives to achieve better targeting. For example, testing efforts should be differentially targeted by prevalence and incidence. The efficacy of improving interventions with the most infectious persons should be determined. Specificity should be increased for populations and settings where linkages to care would occur.
- Develop and use improved models to differentially assess efficacious and cost-effective interventions and describe an optimal mix of interventions. Include an expanded focus on system and structural interventions and necessary mobilization in this framework.
- Analyze resources at the objective level to allow goal targets and funding allocations to be adjusted and monitored over time.
- Develop a strategy regarding expanded resources for care.
- Develop a mechanism to appropriately align evaluation and capacity-building activities and resources in prior goal 4 across the new goals and objectives.
- Establish resources, necessary federal and other partners, and other scale-up models.
- Acknowledge that success of the updated Strategic Plan will depend on taking different approaches, clearly defining a road map, and implementing a detailed mobilization strategy.
- Monitor and annually report on progress of the goals.
To guide the discussion, Dr. McGuire and Mr. Milan informed CHAC that CDC needs specific guidance to take next steps on the updated Strategic Plan. For example, CHAC should consider whether the originally proposed three-year extension should be expanded for an additional two years for a five-year updated Strategic Plan. CHAC should identify solid strategies for CDC to allocate HIV prevention resources. CDC should not be placed in a position of attempting to achieve the updated Strategic Plan goals in the current environment of inadequate resources.
CHAC applauded CDCís efforts to support the workgroupís charge of updating the Strategic Plan. Most notably, CDC provided data and a wealth of expertise to assist the workgroup in making recommendations. Several CHAC members made suggestions for CDC to consider in finalizing the updated Strategic Plan.
- A strong disclaimer should be included in the Strategic Plan to emphasize that the goals cannot be achieved without adequate resources. The language should also note that insufficient funding was the major cause of the failure to reach the previous Strategic Plan goal of reducing HIV transmission by 50%.
- CDC should leverage resources with federal partners and other sectors over time to develop a National Plan for HIV Prevention, Treatment and Care.
- CDC should take advantage of existing opportunities to pilot HIV prevention initiatives in collaboration with federal partners. For example, 5% of Substance Abuse and Mental Health Service Administration (SAMHSA) block grants is set aside for HIV/AIDS in key states, but this option should be expanded and available to all states. The 5% set-aside in SAMHSA block grants is not restricted in terms of pre-/post-test counseling and wraparound services. Due to current and future budget cuts, communities must be able to take advantage of HIV/AIDS dollars from sources other than CDC.
- The Strategic Plan should not be extended for an additional two years at this time due to current uncertainties, such as the upcoming implementation of CDCís revised HIV testing recommendations, existing flaws in PEMS and severe budget constraints.
- CDC should sponsor another workgroup meeting to identify and discuss other priority populations for HIV prevention, such as AA heterosexual men, AA women, youth, Hispanics and Alaska Natives. Prioritization of MSM and AAs in the Strategic Plan could be misinterpreted to mean that HIV is only a problem in these two populations.
- CDC should develop accountable, realistic, reasonable, attainable and measurable indicators to monitor progress of the Strategic Plan.
Dr. Robert Janssen, Director of DHAP, clarified that DHAP has not yet formally responded to the workgroupís recommendations on the updated Strategic Plan because internal discussions are still underway. However, he described several actions DHAP is considering to finalize the updated Strategic Plan.
DHAP intends to target resources to HIV testing of AAs and MSM if funds are allocated in the FYí07 appropriation for the Presidentís rapid HIV testing initiative. DHAP is currently obtaining input from external partners on its heightened response to the HIV epidemic in the AA community. DHAP expects to release a concrete plan from this effort in early 2007. The guidance will reflect feedback DHAP gathered from its previous consultations and other activities to address the HIV epidemic in the AA community. DHAP will develop new strategies and use existing methods to sustain previous mobilization efforts in the AA community.
DHAPís senior leadership will convene a budget and strategic planning retreat on November 28, 2006 that will include a review of all Strategic Plan objectives and identification of the top ten priorities across all goals. In preparation of the retreat, DHAP developed and added new objectives to the Strategic Plan goals that are consistent with the workgroupís recommendations.
DHAP is collaborating with and obtaining input from both internal and external partners to develop a model for allocating resources and analyzing the impact of the HIV epidemic. DHAP expects to review results of the model in January or February 2007. The data will assist DHAP in determining whether existing HIV prevention interventions are appropriate or if new models should be developed focusing on cost-effectiveness, the efficacy of interventions and the impact of the HIV epidemic.
DHAP incorporated stigma into each objective to address the workgroupís new goal on this issue. CDCís revised HIV testing guidelines also address stigma by recommending universal screening instead of testing on the basis of risk factors.
DHAP will develop performance indicators to monitor progress on the Strategic Plan. DHAP expects to create annual targets for national HIV incidence and will develop other annual measures after CDCís existing monitoring systems are refined.
Dr. Janssen concluded his comments by expressing strong support of the workgroupís proposed recommendation for an additional two-year extension for a five-year updated Strategic Plan.