Background

Of the estimated number of persons living with HIV in the United States, 47% are African American, 34% are white, 17% are Hispanic, <1% are Asian/Pacific Islander, and <1% are American Indian/Alaskan Native. By mode of exposure, an estimated 45% of persons living with HIV are MSM, 22% are IDUs, 5% are both MSM and IDUs, 27% were exposed through heterosexual contact, and 1% had an undetermined exposure.

Summary Analysis of Performance Indicators

CDC has developed three indicators (Indicators 5-7) to monitor Goal 1. Indicator 5 monitors the percentage of students in 9th through 12th grade who reported safer sexual behaviors defined as: a) never having engaged in sexual intercourse, b) were not sexually active in the past 3 months, or, c) if they had sexual intercourse in the past 3 months, they used a condom. Data are from CDC’s Youth Risk Behavior Survey (YRBS). Trends in the sexual behaviors of adolescents may indicate how well messages to reduce sexual risk are being incorporated into the lives of young people. Between 1999 and 2003, the percentage of 9th-12th graders who engaged in safer sexual behaviors increased from 85% to 88% (the percentage who were abstinent increased from 50% to 53% during this period). These data include only youth attending school and may not be representative of youth not in school, who may be at higher risk for HIV.

Indicator 6 monitors the percentage of persons diagnosed with HIV infection for >12 months who did not use a condom at last vaginal/anal sex when the status of the partner was unknown. Condom use among HIV-infected persons who have sex with HIV-negative persons or those whose status is unknown is an important indicator of ongoing risk behaviors that lead to HIV transmission. The data for this indicator are from the Supplement to HIV/AIDS Surveillance (SHAS) project. Between 2001 and 2004, the percentage of HIV-infected persons interviewed in SHAS who did not use a condom with a partner of unknown serostatus increased slightly from 12.3% to 13.4%. The SHAS project conducted in-depth interviews with a large number HIV-infected persons in a selected number of cities and states; however, the sampling methods were not uniform in these areas (some used convenience sampling and others used population-based sampling). Therefore, small year-to-year fluctuations in the data may be due to differences in samples of persons interviewed rather than true changes in behaviors. Also, during interviews, HIV-infected persons may not provide accurate information about sexual activities because of fear of negative feedback or stigma. CDC discontinued the SHAS project in 2004, and, in its place, CDC has funded the Morbidity Monitoring Project (MMP). MMP will interview a population-based sample of HIV-infected persons in care and out of care. This new approach should provide more useful data; the first data from this project should be available in 2007.

Indicator 7 is the percentage of HIV-infected IDUs (diagnosed for >12 months) who shared a needle or syringe with some in the past 12 months; data come from the SHAS project. This indicator decreased from 7% to in 2001 to 3% in 2002 and increased to 7% in 2004. As stated above, small year-to-year fluctuations in this indicator may not be meaningful due to the sampling limitations of the SHAS project. The percentage of persons sharing needles and works is nevertheless very low and supports the declining trends we are seeing in new HIV diagnoses among IDUs.

All three indicators for Goal 1 lack a direct measurement of who actually received interventions that may have had impact on changing behaviors. CDC has developed the Program Evaluation and Monitoring System (PEMS) to collect the data to address this problem. CDC is currently working with its partners to identify the best ways to implement PEMS.

Selected Activities

To address Goal 1, CDC conducted the Prevention Research Synthesis project to identify behavioral interventions with solid scientific evidence of efficacy. Based on the findings from this project, CDC develops and provides culturally competent, evidence-based HIV prevention interventions for persons at risk of acquiring or transmitting HIV through the Replicating Effective Programs (REP) and the Diffusion of Effective Behavioral Interventions (DEBI) project. These prevention interventions target specific racial and ethnic groups and subpopulations at high risk for HIV. CDC funds 65 state and local health departments, 161 directly-funded CBOs, and other partners to provide these interventions across the United States. To build the capacity among CDC partners; the agency also provides training and materials to implement these interventions. Currently, there are 14 CDC supported evidence-based prevention interventions that target both HIV-infected and uninfected persons. CDC has diffused 11 of those interventions to funded grantees. The interventions have been designed to exclusively target high-risk groups but are also adaptable to other groups. For example, 79% of directly-funded CBOs provide evidence-based prevention interventions for high-risk sexually active MSM and their partners; 58% of directly-funded CBOs provide interventions for sexually active IDUs and their partners; and 82% of directly-funded CBOs provide interventions serving high-risk sexually active women and their partners. CDC also provides DEBI trainings to individuals, state and local health departments, and directly and indirectly-funded CBOs. These efforts are complemented by an extensive capacity building assistance (CBA) program which aims to help grantees effectively implement scientifically based prevention programs. In 2004, CDC provided funding to 27 organizations to provide CBA in the adaptation, tailoring, and implementation of HIV prevention interventions for people living with HIV or AIDS, their serodiscordant partners, and others at very high risk of HIV infection.

In 2003, CDC launched the AHP initiative. The goal of the initiative is to reduce HIV transmission in the United States, particularly by expanding HIV testing and increasing the number of people who are aware of their infection. AHP focuses primarily on populations at high risk for acquiring and transmitting HIV, such as MSM, IDUs, heterosexual men and women, adolescents, and persons infected with HIV; the majority of which are racial and ethnic minorities. Through AHP, CDC refocused its prevention strategy by placing greater emphasis not only on diagnosing individuals who are unaware of their HIV status but also providing prevention services to HIV-infected persons. CDC has also directed community planning groups across the country to make people living with HIV their highest priority target population.

One key AHP strategy is to “prevent new infections by working with people diagnosed with HIV and their partners.” Results from two AHP demonstration projects: “Prevention Case Management for Persons Living with HIV/AIDS” and “Incorporating HIV Prevention into Medical Settings” has led CDC to embark on a modification of the Comprehensive Risk Counseling and Services (CRCS), formerly referred to as Prevention Case Management, guidelines to better coordinate case management for persons living with HIV with other federal agencies.

Another key AHP strategy is to further decrease perinatal HIV transmission. Effective interventions can reduce perinatal HIV transmission to less than 2% among HIV-infected pregnant women. For this reason, CDC is striving to ensure that no child is born in the United States whose HIV status (or whose mother's HIV status) is unknown. Reduction of perinatal HIV transmission is one of the nation’s most remarkable HIV prevention successes. In supporting implementation of this strategy, CDC is working with partners to promote routine prenatal HIV testing using an “opt-out” approach (i.e., pregnant women are told that an HIV test will be included in the standard group of prenatal tests and that they may decline the test), developing guidance for using rapid tests during labor and delivery or immediately post partum, providing training in conducting prenatal testing, and monitoring the integration of routine prenatal testing into medical practice.

Overall Impact of Goal 1

Between 2001 and 2005, CDC broadened the scope of its programs to include prevention programs for people living with HIV and increased the focus on the most effective prevention interventions. Through the AHP initiative, CDC provided increased funding for identifying and promoting prevention services for those living with HIV, particularly in the context of medical care. CDC identified proven behavioral interventions for those at risk for becoming infected with HIV as well as those at risk for transmitting HIV and translated those into packages for use by grantees. Thousands of HIV prevention service providers were trained on provision of these interventions beginning in 2002. CDC provided support for adapting and tailoring interventions for specific groups at risk for HIV and encouraged grantees to target services for those high-risk communities. CDC also increased access to and provision of HIV testing, one of the most effective interventions for preventing HIV transmission. People who know they are infected they are likely to change their behavior. The agency continued to work to develop and test new interventions including antiretroviral prophylaxis through trials in the United States and internationally, microbicides through laboratory studies and animal models, and prepared international sites for large scale HIV vaccine trials.

³ The funding amounts presented here represent amounts spent in 2004 by CDC's National Centers on goals 1 - 4 of CDC's HIV Strategic Plan. They exclude amounts spent on Goal 5 (to assist in reducing HIV transmission and improving HIV/AIDS care and support in partnership with resource-constrained countries) and amounts for centralized rent, utilities, and program support at CDC. They include funding transferred to CDC from HHS for the Minority AIDS Initiative.

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