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HIV Prevention in the United States:

Expanding the Impact

Expanding the Impact
To Date
in HIV
of HIV

High-Impact Prevention

To advance NHAS, CDC and its partners are currently pursuing a High-Impact Prevention approach. This approach seeks to consider not only program effectiveness but also the overall impact on the course of the epidemic. While combining effective prevention tools is essential, it is not enough. To maximize reductions in new HIV infections, prevention strategies need to be combined in the smartest and most efficient ways possible for the populations and areas most affected by the epidemic.

CDC is working at the national level and with state and local partners throughout the United States to identify and implement the most cost-effective and scalable interventions in the geographic areas hardest hit by HIV and among the most severely affected populations within those areas. High-Impact Prevention will help achieve a higher level of impact with every federal prevention dollar spent.

CDC has already taken a number of key steps to advance this approach, including implementing an improved approach to funding distribution, expanding HIV testing, and initiating demonstration projects in many of the hardest-hit communities in the United States.

Better Geographic Targeting of Resources

In June 2011, CDC announced a new five-year HIV prevention funding opportunity that better aligns HIV prevention funding to the current geographic burden of the U.S. HIV epidemic. Funding for health departments in states, territories, and selected cities is now allocated to each area based on the number of people living with an HIV diagnosis in the area. Additionally, the majority of funding is directed to the prevention activities that are most likely to have a significant and lasting impact on the HIV epidemic, including HIV testing and comprehensive prevention and care services for HIV-infected individuals and their partners. The first-year awards were announced in January 2012.

Aligning Prevention Funds to the Epidemic

High-Impact Prevention will prioritize funding for geographic areas with the greatest burden of HIV.

Targeted Distribution of CDC Core HIV Prevention Funding—FY2016, Based on Proportion of All Americans Diagnosed with HIV Who Live in Each State
Figure 1. Aligning Prevention Funds to the Epidemic;
This graphic shows a map of the United States with each state colored to match one of the following five categories:  States where more than 10 percent of Americans with HIV live, and which receive more than 10 percent of CDC core HIV prevention funding; States where between 3 and 10 percent of Americans with HIV live, and which receive between 3 and 10 percent of CDC core HIV prevention funding; States where between 1 and 3 percent of Americans with HIV live, and which receive between 1 and 3 percent of CDC core HIV prevention funding; States where between 0.5 and 1 percent of Americans with HIV live, and which receive between 0.5 and 1 percent of CDC core HIV prevention funding; and States where less than 0.5 percent of Americans with HIV live, and which receive less than 0.5 percent of CDC core HIV prevention funding; * Targets are based on 2008 data and will be adjusted over time. New funding allocation methodology will be fully implemented by FY2016; this breakdown assumes level overall funding.
(Download High Resolution Version)

Expanding HIV Testing

CDC’s Expanded Testing Initiative
Figure 2. CDC’s Expanded Testing Initiative The Expanded Testing Initiative provided 2.8 million HIV tests in 3 years, and 18,432 people learned they were HIV-positive.
 (Download High Resolution Version)

Testing is critical to the nation’s prevention strategy. It is the only way to identify the nearly one in seven Americans living with HIV who do not know they are infected, and it is the first step in connecting them to the prevention, care, and treatment services they need. Expanding HIV testing, especially among the populations with the highest rates of HIV infection, is an integral and cost-effective component of U.S. prevention efforts.

CDC’s three-year Expanded Testing Initiative (ETI) supported state and local health department efforts to provide routine HIV testing in health care and select community settings, with a primary focus on reaching African Americans. Between October 2007 and September 2010, ETI provided nearly 2.8 million HIV tests in 25 of the U.S. areas most affected by HIV, and diagnosed 18,432 individuals who were previously unaware that they were HIV-positive.8 Estimates indicate that ETI has saved almost $2 in medical costs for every dollar invested.9 ETI has now been expanded to include testing efforts targeting gay and bisexual men, Latinos, and injecting drug users, and the provision of HIV testing in non-clinical settings, such as pharmacies.

Identifying the Combination of Approaches with the Greatest Impact

CDC is supporting Enhanced Comprehensive HIV Prevention Planning (ECHPP) demonstration projects in 12 heavily affected cities that represent 44 percent of the total U.S. AIDS cases. ECHPP funding allows local health departments to identify and begin implementing the mix of HIV prevention approaches likely to have the greatest impact in their communities, based on the profile of their local epidemic and an assessment of the gaps in current HIV prevention programs. While the exact combination of approaches varies by area, all ECHPP projects emphasize intensifying HIV prevention and testing for individuals at greatest risk; prioritizing prevention and linkage to and retention in care for people living with HIV; and directing these efforts to the populations with the highest burden of HIV.

Comprehensive Prevention in Action: ECHPP Successes

Figure 3. Participants in a rapid HIV testing training session; This photo shows a man and a woman participating in a training session for rapid HIV testing. Participants in a rapid HIV testing training session
(Download High Resolution Version)
  • In Houston, ECHPP funding allowed health officials to identify five neighborhoods in the city with particularly high rates of HIV and STDs – areas where prevention programs would have the greatest impact. In response, the Houston Department of Health and Human Services launched the Strategic AIDS/HIV Focused Emergency Response (SAFER), which delivers to these high-burden areas intensified HIV testing, services for the partners of those infected, educational workshops, condom education and distribution, and social marketing efforts.
  • In New York City, ECHPP supported modeling work conducted by the Department of Health and Mental Hygiene (DOH) to assess the impact of a range of prevention approaches, identifying prevention efforts with HIV-positive people as the most cost-effective strategy for reducing new infections in the city. As a result, the DOH is focusing efforts on a number of interventions, including implementation of the Antiretroviral Treatment Access Study (ARTAS) model. ARTAS is a CDC-developed approach in which case managers meet with patients five times within the first 90 days following their HIV diagnosis to identify and overcome barriers to receiving ongoing medical care. Research shows that nearly 8 in 10 patients who participated in ARTAS visited an HIV clinic for medical care within six months. In 2011, as part of ECHPP Phase 2, the DOH began requiring that all agencies implementing city-funded HIV testing undergo ARTAS training.
  • More Than 80 percent of Los Angeles County HIV Diagnoses Occur in Five "Hot Sports"
    Figure 4. More Than 80 Percent of Los Angeles County HIV Diagnoses Occur in Five “Hot Spots” This graphic shows a map of Los Angeles County with five colored “hot spots” shaded to illustrate that they represent 1.1 percent, 6.6 percent, 9.2 percent, 18.4 percent, and 46.3 percent, respectively, of all HIV cases reported in the county. (Download High Resolution Version)
  • In Los Angeles, ECHPP enabled analysis of integrated HIV and STD surveillance data to identify five “hot spots” where approximately 80 percent of all HIV, syphilis, and gonorrhea cases in Los Angeles County are reported, and where prevention programs will be prioritized. The integrated data analysis also made possible more sophisticated modeling that identified the underlying factors that increase HIV risk, including high STD rates, homelessness, poverty, substance addiction, and mental illness. Armed with this deeper understanding of the forces that fuel the epidemic, the county is now working to deliver more integrated health services to those living with and at risk for HIV.

* Craw JA, Gardner LI, Marks G, et al. Brief strengths-based case management promotes entry into HIV medical care - Results of the antiretroviral treatment access study-II. J Acquir Immune Defic Syndr 2008;47(5):597-606.

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