On April 17, 2003, the Centers for Disease Control and Prevention (CDC)
announced a new initiative, “Advancing HIV Prevention (AHP): New
Strategies for a Changing Epidemic.” Its aim is to reduce barriers
to early diagnosis of HIV infection and increase access to quality medical
care, treatment, and ongoing prevention services for HIV-positive persons
and their partners. The AHP initiative represents a multi-agency collaboration
within the Department of Health and Human Services (DHHS). As described
in the April 18, 2003, issue of the Morbidity and Mortality Weekly
the initiative consists of four new strategies for HIV prevention:
- Make HIV testing a routine part of medical care
- Implement new models
for diagnosing HIV infections outside medical settings
- Prevent new
infections by working with persons diagnosed with HIV and their partners
decrease perinatal HIV transmission
CDC has taken steps to lay the foundation for AHP and to ensure its
success. Since announcing the initiative in April 2003, CDC has consulted
with various groups on the best ways to implement AHP strategies, including:
community-based organization (CBO) consultations (Miami, San Francisco,
New York, and Chicago)
- Full-day consultations with people living
with HIV, communities of color, medical provider groups, and experts
on stigma prevention
- Four Web conferences with health departments
- Meetings with the Congressional
Black Caucus, Federal AIDS Policy Partnership and other policy partners,
Council for HIV/AIDS,
and CDC/HRSA AIDS Advisory Committee
AHP was allocated $35 million in fiscal year (FY) 2003. Approximately
$153 million was directed toward AHP efforts in FY 2004. These funds
make up only a portion (approximately 1/6th) of the total CDC HIV prevention
budget. These funds
were used to launch a wide range of AHP projects and activities. Implementation
activities to date include:
In 2003, nine health departments and 16 CBOs were
awarded $23 million over two years to develop models and demonstrate
effectiveness for implementing
the four AHP strategies. The seven projects funded in 2003 are:
HIV testing in medical care settings serving high HIV-prevalence
- Partner counseling and referral using rapid HIV tests to
increase the number of partners who learn their HIV status.
- HIV prevention
in medical care for persons living with HIV.
- Rapid HIV testing in
jails to increase number of inmates receiving test results.
with persons living with HIV to reach high-risk persons in their
- Rapid HIV testing in non-clinical settings, such as
homeless shelters, drug treatment programs, and social events.
case management for people living with HIV who have multiple complex
In 2004, CDC awarded an additional $3.6 million to 5
health departments and 20 CBOs for two new two-year
- Antiretroviral Treatment Access Study (ARTAS)
- Implementation of Rapid HIV Testing In Alternative
Venues And Populations, Historically Black Colleges
And Primary Care Settings
Two of CDC’s recent large program announcements
have been realigned to support the key strategies of AHP. These are:
Announcement 04064—HIV Prevention Projects for Community-Based
Organizations—was revised to include an increased emphasis
on early diagnosis, entry into care, and prevention with positives.
this program announcement were made in the summer of 2004.
Announcement 04019—Capacity Building Assistance
(CBA) to Improve the Delivery and Effectiveness of HIV Prevention
for Racial/Ethnic Minority Populations—A total of $21
million was awarded across 27 organizations to provide capacity
for organizations serving communities disproportionately impacted
by the HIV/AIDS epidemic. Awards under this program announcement
in the spring of 2004.
Monitoring and Evaluation
AHP places increased emphasis on program monitoring
and evaluation. The following projects, tools, and guidance are being
or are already
- Program Evaluation and Monitoring System (PEMS) is a secure internet
browser-based application for the collection, management, and reporting
of standardized data on AHP-related HIV prevention service activities
as required in CDC’s health department and CBO program announcements.
PEMS standardized data variables and software are being developed
by CDC in close collaboration with representatives from health departments,
CBOs, and other national partners. PEMS data will enhance monitoring
of the implementation of evidence-based programs, new HIV testing
program performance indicators, and AHP strategies.
surveillance is examining implementation and results of rapid HIV
testing, including client acceptability. Thirty-one
health departments throughout the United States were funded for
this work from
July 2003 to June 2005.
- Evaluation of demonstration projects will
include feasibility and cost-effectiveness assessments. For some
of these projects,
evaluation will begin in the
winter of 2006.
- Development of new performance indicators for
funded health departments and CBOs will monitor process and outcomes
- Perinatal chart review, a project to
assess the level of integration of routine prenatal HIV testing into
in 8 states in 2004 and 7 additional states in 2005.
Rapid HIV Testing
- Developed and disseminated a model protocol
for rapid HIV testing during labor and delivery for women
- Developed “Quality Assurance Guidelines
for Testing Using the OraQuick® Rapid
HIV-1 Antibody Test” with multiple private and
- In 2003, CDC purchased 250,000 OraQuick Rapid HIV-1
Antibody Test kits for distribution to 89 health departments
and 19 funded CBOs
country. In 2004, about 279,000 OraQuick tests were purchased for
distribution. For 2005, CDC has purchased over 209,000
OraQuick ADVANCE kits. These
can test for both HIV-1 and HIV-2.
Rapid HIV Testing Training for
Health Departments and CBOs
CDC is working
with health departments and community-based organizations
(CBOs) to ensure they have the skills
and resources to incorporate
rapid HIV testing. Activities include:
- CDC and the OraQuick manufacturer,
OraSure Technologies, conducted 20 regional rapid
HIV testing training sessions in 2003 for health
departments and CBOs that plan to conduct rapid HIV testing.
An additional 20 training
sessions on rapid HIV testing were conducted in 2004. In 2005,
CDC will begin conducting train-the-trainer sessions in order
and availability of rapid HIV test training.
Keeping CDC constituents
up to date on AHP developments is a key component of
its success. Information is being
distributed through multiple channels
to a variety of audiences.
- Publications available online and in print
- Interim Technical Guidance for Selected Interventions
for Health Departments
- Procedural Guidance for Selected
Strategies and Interventions for Community-Based Organizations
- Advancing HIV Prevention: The Science Behind the
- Advancing HIV Prevention: New strategies
for a changing epidemic. MMWR 2003;52:329-332
Counseling and Referral Services to Identify Persons
with Undiagnosed HIV – North Carolina, 2001.
MMWR, 2003; 52(48):1181-1184
- Rapid Point-of-Care Testing
for HIV-1 During Labor and Delivery – Chicago,
Illinois, 2002. MMWR, 2003; 52(36):866-868
- Incorporating HIV Prevention
into the Medical Care of Persons Living with HIV. Recommendations
of CDC, the Health Resources and Services Administration,
the National Institutes of Health, and the HIV Medicine Association of
the Infectious Diseases Society of America. MMWR 2003; 52(RR12):1-24
to Readers: Protocols for Confirmation of Reactive
Rapid HIV Tests. MMWR 2004; 53(10):221-222
- Using the
Internet for Partner Notification of Sexually Transmitted
Diseases – Los Angeles County, California,
2003, February 20, 2004. MMWR, 2004; 53(06):125-131
of Increase in Perinatal Exposure to HIV Among Hispanics
--- 20 Counties, Georgia, 1994-2002.
MMWR 2004; 53(40):944-946
- Use of Social Networks to
Identify Persons with Undiagnosed HIV Infection – Seven
U.S. Cities, October 2003 – September 2004. MMWR 2005; 54(24):601-605
point-of-care testing to make rapid HIV-1 tests in labor really rapid.
Marge H. Cohen, Yolanda Olszewski, Bernard Branson, Michele Robey,
Fariday Love, Denise J. Jamieson, and Marc Bulterys, for the Mother
Infant Rapid Intervention at Delivery Study. AIDS 2003,
Vol 17 No 14.
- Recommendations for Incorporating Human
Immunodeficiency Virus (HIV) Prevention into the Medical
Care of Persons Living with HIV. Centers
for Disease Control and Prevention, Health Resources and Services Administration,
National Institutes of Health, HIV Medicine Association of the Infectious
Diseases Society of America, and the HIV Prevention in Clinical Care
Working Group. CID 2004:38 (1 January)
- Centers for Disease Control and
Rapid HIV antibody testing during labor
and delivery for women of unknown HIV status: a practical
guide and model protocol. Atlanta: Centers for Disease Control and
provides up-to-date guidelines, program news and announcements,
answers, slide presentations, and journal articles.
Perinatal HIV Prevention
provides background, guidelines/recommendations, and program
Rapid HIV Testing site
includes the rapid HIV tests approved by the FDA, how the tests
can be implemented
in different settings, and research on the effectiveness and
possible uses of the tests.
- AHP Speakers Bureau has fulfilled
AHP presentation requests from local, state, and national
organizations and CDC staff have
relating to each of the four strategies of AHP.
- Satellite broadcastsprovide updates on critical scientific and policy issues
to a wide audience across the country. AHP-related
broadcasts have included:
- Prevention with Positives: HIV Risk Reduction Strategies for
Health Care Providers
- Incorporating HIV Prevention into the Medical
Care of Persons Living with HIV
- Update on Rapid Testing for
- Rapid Testing: Advances for HIV Prevention
- Partner Counseling
and Referral Services for HIV Prevention
In addition to its demonstration projects, AHP is funding
research that will inform and guide the initiative as it moves
planned or underway include:
- Development of effective prevention
messages for persons living with HIV.
- Validation of the use
of oral fluid Western Blot testing to confirm preliminary
positive rapid HIV tests.
- Analysis of financial and organizational
factors related to integrating HIV prevention into care settings.
MIRIAD (Mother Infant Rapid Intervention at Delivery) Rapid
Testing Strategy (RTS) substudy began in July 2004 in
units at three hospitals across the southeastern US. The substudy
consists of two 3-month components. The first three months
is the “Opt-In” option
which consists of HIV counseling and testing with a signed
local HIV consent. The second three months is the “Opt-Out” option,
in which rapid HIV testing is part of the standard of care
(although the mother may decline to participate.)
of simplified messages for pre-test counseling in 2 US cities.
Implementing AHP requires cooperation and coordination
among CDC, federal partners, the public health community, and the
medical care community.
CDC is working with its partners on the following AHP-related projects:
Perinatal HIV Prevention
- Agency for Healthcare Research and Quality
(AHRQ) and the U.S. Preventive Services
Task Force (USPSTF)—reviewing
evidence for routine HIV screening for asymptomatic
adults and pregnant women.
- Health Resources and Services Administration (HRSA)—conducted
session on AHP perinatal HIV screening strategies
for a series of audio-conferences; collaborating with CDC and
of California at San Francisco
on a national perinatal HIV consultation and referral
service hotline. Also, see below under Other Partners/ Case
Reduction and Counseling
Services (CRRCS) for a brief description of a CRRCS
workgroup of which HRSA is a part.
Financial, Policy, and Operational
- Department of Veterans
Affairs (VA)—eliminating barriers
to HIV testing and prevention services in its jurisdictions
prevention services for HIV-infected patients.
AHP strategies in HRSA-funded programs; prepared
estimates of need for increased care and treatment services
persons identified through AHP; developing an operational
guide for community health centers to incorporate routine
HIV testing and prevention into
medical care of HIV-infected patients.
- Office of Population Affairs—working
with CDC to incorporate AHP strategies into family
Case Risk Reduction and
Counseling Services (CRRCS)
- CMS, Department of Housing and Urban Development
(HUD)/Housing Opportunities for Persons with AIDS (HOPWA),
HRSA, SAMHSA and CDC/DHAP—participating
in a CRRCS workgroup to develop a set of recommendations
on integrated or collaborative CRRCS systems.
- Substance Abuse and Mental Health Services Administration
with CDC to acquire expertise on implementation of a
large-scale rapid testing initiative.
- Office of Population
assistance to family planning clinics to incorporate
rapid HIV counseling
as part of routine care.
- Indian Health Service—working
with CDC to (1) implement rapid HIV testing in clinics
that serve urban
Indians and (2)
indictors for evaluation.
Perinatal HIV Prevention
- American College of Obstetricians
in development of clinical guidance for routine rapid
HIV testing of women in labor with unknown HIV status,
during pregnancy in areas of high seroprevalence.
of Maternal and Child Health Programs—conducting
a Perinatal HIV Action Learning Lab with states to foster
MCH-HIV collaborations to develop and implement local
action plans to
- CityMatch—working with high-HIV prevalence
cities to develop and implement local action plans to
- American Hospital Association (AHA) (Health
Research and Education Trust)—conducted a
survey of U.S. birth hospitals to assess perinatal HIV prevention
in labor and delivery. Developing operational guidance
and communication tools for hospitals.
- Francois-Xavier Bagnoud
Center of the University of Medicine & Dentistry
of New Jersey—developed and has conducted 8 regional
strategic planning workshops with more than 70 hospitals
throughout the U.S. to
implement perinatal HIV prevention activities in labor
particular rapid HIV testing and timely ARV prophylaxis.
The rapid testing model is being adapted for emergency
Policy, and Operational Issues
- AHA—developing operational
guidance and providing technical assistance on HIV
testing in hospitals; invited CDC to review
and comment on member
survey to gather comprehensive, up-to-date information
on HIV testing policies and practices in hospitals
- American Academy
of Emergency Medicine, American College of Emergency Physicians
and Society for Academic Emergency
CDC on the policy, legal, and financial challenges
associated with implementation of HIV screening and
testing in emergency
- Health Plans and Managed Care Representatives—advising
CDC on a study of the cost effectiveness of early
- Infectious Diseases Society of America—through
its HIV Medicine Association, partnered with CDC, HRSA, and
Health (NIH) to develop “Incorporating HIV Prevention
into the Medical Care of Persons Living with HIV” recommendations.
Business Group on Health (formerly Washington Business
Group on Health) —translating HIV
prevention strategies into actionable information
and developing a business
case to support
reimbursement of HIV prevention services. Also, assessing
HIV prevention services employers
support and additional resources needed.
- National Association
of Community Health Centers (NACHC), Migrant Clinicians
Network, and National Coalition for
model protocols and policies for community health
centers on prevention for
persons living with HIV and encouraging testing for
persons with unknown HIV status. Also, in fiscal
year 2004, CDC
an analysis of existing information and data to assess
current community health center policies and practices
screening, HIV prevention
services, and linkage of HIV-infected persons to
primary care. This analysis
is facilitating development of an operational guide
with policies and procedures on incorporating HIV
and other HIV prevention
into primary care services. Using the operational
guide, NACHC will provide on-site training and technical
and primary care clinics develop programs that address
routine HIV screening and prevention services in
primary care settings
high risk HIV-negative persons.
Health Marketing / Training
- American Academy of HIV
HIV prevention practices, knowledge, and attitudes
to inform health
AAHIVM will conduct a campaign to encourage its
members to incorporate prevention into the care of
invited CDC to review its training materials
to ensure adequate coverage of
HIV prevention and asked CDC to peer review its
HIV Medicine Self-Directed Study Guide.
- National Association
of State and Territorial AIDS Directors—included
two articles on AHP in communications to their
members and assisted in coordinating consultations
- National Minority AIDS Council—assisted
with dissemination of Advancing HIV Prevention:
Technical Guidance for Selected
and Procedural Guidance for Selected Strategies
and Interventions for Community-Based Organizations;
in coordinating consultations
- National Laboratory Training
with implementation of rapid HIV test training.
Case Risk Reduction
and Counseling Services (CRRCS)
- American Academy
of Pediatrics—will assess HIV
prevention practices of adolescent specialists
training to assist providers
in incorporating rapid HIV testing in their
Medicine Association—will assess
HIV prevention practices, knowledge, and
members to inform health marketing
efforts and will conduct a campaign to encourage
members to incorporate prevention
into the care of HIV-infected persons.
Association of Social Workers—collaborating
with CDC, CMS, HRSA, HUD/HOPWA, and SAMHSA
on the CRRCS workgroup. The
the workgroup is to develop a set of guidelines
on integrated or collaborative CRRCS systems.
Plans for 2005
As the initiative moves through its second year, CDC is providing
funds for a wide range of programs and activities to increase the adoption
of the four AHP strategies. These include:
- Evaluate how the approved interventions in the Procedural Guidance
for Selected Interventions can be adapted and tailored to other
- Support development and evaluation of simplified procedures
and materials for routine HIV screening in acute care settings.
Such procedures are
necessary to promote screening of large numbers of patients
in busy clinical settings.
- Require all health departments receiving CDC
funds to make people living with HIV the highest priority population
for HIV prevention
- Fund CBOs to implement interventions for prevention
with positives and their HIV-infected partners, testing in community
with high-risk seronegative persons, outreach, and health
education and risk reduction.
- Maintain CBO support for health
education and risk reduction activities targeting populations at
high risk for HIV.
- Guide CBOs on how to adapt, tailor, and implement procedures
and protocols for their target populations and communities.
clinicians and outreach workers to implement rapid HIV testing
in clinical care and outreach settings and prevention
with positive persons
in care settings.
- Create materials and guidelines for conducting
rapid HIV testing during routine prenatal screening and labor and
- Continue collaboration with HRSA’s Bureau of Primary
Health Care and NACHC on an analysis of community health centers’ HIV
screening, HIV prevention services, and linkage of HIV-infected
persons to primary
care. This will facilitate development of policies and procedures
on primary care services related to HIV testing and other
HIV prevention services.
- Work with federal partners to develop
guidelines for CRRCS
and patient referral.
- Collaborate with the AHA to provide
technical assistance and develop an operational guide on HIV testing
assistance will focus on hospitals located in areas with
a high prevalence of HIV throughout the United States.
in these hospitals
will be used to revise and refine the operational guide.
guidelines for HIV counseling, testing, and referral.
- Revise guidelines
for HIV partner counseling, testing, and referral services.
- Conduct post-marketing surveillance to assess the extent to which
rapid HIV testing has been used in health department and other
CDC-funded programs. In FY 2005, $1.1 million has been awarded across
18 sites for
- Review medical records of pregnant women to determine
progress toward the goal of universal screening to prevent mother-to-child
- Continue to implement PEMS in more than 200
- Provide PEMS training on data collection,
evaluation, and software use.
- Offer PEMS-related technical assistance
and support to CDC grantees funded to deliver HIV prevention services.
- Each year, CDC-funded health departments and CBOs report performance
indicators on HIV prevention planning, services,
and evaluation including
measures of AHP-related prevention service activities.
Grantees will use PEMS data to monitor their progress
indicator targets and goals.
- Continue evaluation of
- Work with the HIV Medicine Association,
the American Academy of HIV Medicine, and the American Academy
of Pediatrics to
distribute a CDC-developed
tool kit, Incorporating Prevention into the
Medical Care of Persons Living with HIV, to assist providers
encourage the adoption of HIV testing
as part of routine medical care.
- Initiate work of
the Prevention Economics Team (PET) to address economic issues
related to HIV/AIDS
PET will focus on issues
related to cost-effectiveness, health economics,
and the optimal allocation of prevention resources.
Much has been accomplished since the announcement of AHP in
mid-2003. CDC is poised to accomplish even more during 2005. Many new
and plans have been put in place and many new partners have been
enlisted. The next few years are critical to demonstrating the effect
HIV prevention approach has on curbing the epidemic and helping us
make new strides in reducing the number of annual new infections
and improving the lives of those persons who are HIV positive.