IV. Infectious Diseases

FY 2000 Performance Plan - Revised Final FY 1999 Performance Plan

HIV/AIDS

The epidemic of HIV and AIDS presents unique social, economic, and public health challenges to governments and individuals in the United States and around the world. Although significant progress has been made in understanding the disease and developing both prevention strategies and treatments since the first case was reported in the U.S. in 1981, HIV remains a deadly infection for which there is no vaccine or cure and for which there are limited treatments. An average of 100 Americans are diagnosed with AIDS every day, and approximately 100 men, women, and children become infected with HIV every 24 hours. Globally, 16,000 people become infected each day, including nearly 1,000 children.

Through June 1998, a total of 655,357 cases of AIDS among persons in the U.S. had been reported to CDC, and more than 401,000 of these persons have died. Since 1987, AIDS has risen from being the 15th leading cause of death among all Americans to the 8th. AIDS is now a leading cause of death among Americans aged 25 to 44. CDC estimates that approximately 40,000 Americans are becoming newly infected with HIV each year and that between 650,00 and 900,000 Americans are currently living with HIV.

Transmission of HIV infection can be prevented through changes in high-risk behaviors. Prevention is an important cost-effective component of the control of HIV infection. Disadvantaged populations, especially African-Americans and socio-economically stressed youth, continue to have high rates of HIV infection despite high levels of knowledge about behavioral prevention methods. Two biomedical interventions have demonstrated possibilities in reducing the spread of this deadly disease. First, antiretroviral combination therapy lowers viral load, which may translate to lower infectivity and, second, there is some evidence that treatment of other STDs can reduce the spread of heterosexually transmitted HIV infection.

CDC will increase the urgent prevention needs in ethnic and racial minority communities using funding increases received in FY 1999. This increase augments existing prevention efforts addressing disparities in health among ethnic and racial minorities. These activities include:

• Additional funding for directly funded Community Based Organizations (CBOs) - Funds will be awarded through a new program announcement, providing funding to an additional 30 - 40 community based organizations. New organizations funded will complement the existing network of 94 directly funded organizations, in terms of geographic distribution and risk group, to assure maximum prevention coverage related to the HIV/AIDS epidemic in communities of color.
• Funds will be used to expand the Community Demonstration Projects currently proposed by CDC to provide priority HIV prevention services to HIV-infected individuals. The fifteen metropolitan statistical areas (MSAs) in the U.S. with the highest rates of AIDS among racial and ethnic minority communities and 5 MSAs in lower prevalence areas will be funded, through a new program announcement, to plan and design a linked network of services in African American and/or Latino communities highly impacted by HIV, STD, TB, and substance abuse to develop linkage plans among these services. It is envisioned that next year, between 2-5 awards will be made through a new program announcement to implement community development plans.

Successful prevention of HIV transmission requires individual effort as well as the collective participation of federal, state, and local governmental, non-governmental, and international organizations. The federal government's role is critical in providing assistance to state and local health agencies and community-based organizations to implement effective HIV risk reduction and prevention programs, surveillance of the incidence of HIV and AIDS, research, evaluation, training, and technology transfer of effective interventions, prevention programs, and evaluation activities.

The following are external factors that affect accomplishing goals and objectives for the HIV program:

• All states do not have integrated HIV/AIDS surveillance systems.
• It is difficult for CDC and its partners to ask explicit questions about adolescents' sexual behaviors.
• Funding is limited for behavioral research, technology transfer, behavioral surveillance, evaluation of interventions and prevention programs, and training and education programs.
• For prevention education programs, sensitive issues exist such as abstinence vs. condom use.

Additionally, in the case of counseling and testing, it should be noted that in formulating the performance measure for this area, a number of complex factors were considered in estimating the improvement in the overall rate of persons who return for their HIV tests. The objective addressing this issue is based upon an annual evaluation of over 2.6 million HIV tests, reported from nearly 10,000 sites. The proposed 10% increase over the next two year period is viewed as a challenging, though attainable figure. The figure is not conservative, especially in view of the fact that these figures represent a relatively small percentage (perhaps 10%) of the total number of HIV tests performed in the United States each year, and that performance varies considerably by test site category. As an example, hospitals and private physicians report the lowest levels of HIV-positive patients returning (44%) and there are relatively few incentives that CDC and its partners can use to improve their rates. By contrast, CDC-supported facilities, such as free-standing counseling and testing sites and family planning sites report a return rate of over 81%. Other factors, such as improvements in testing technologies may make "results while you wait" a possibility in some settings, and will also compromise the value of retaining this as a performance objective for more than the next few years.

Every school day, 50 million young people attend over 110,000 schools across the nation. Research has demonstrated that HIV education in schools can be effective in reducing risk behaviors among youth. CDC's efforts to help State and local education agencies implement HIV prevention education programs in schools nationwide include teacher training programs, dissemination of model policies and effective prevention programs, evaluation and technical assistance. The performance measures for this aspect of CDC's HIV/AIDS prevention program monitor students' exposure to HIV/AIDS prevention education in schools and youth behaviors that affect their risk of becoming infected with HIV. The selected measures are derived from epidemiologic modeling that describes the connections and inter-relationships of policies and programs; knowledge, attitudes, and skills; health behaviors; and health outcomes.

Performance Goals and Measures

Performance Goal: Improve the ability of the Nation's HIV/AIDS surveillance system to identify incidence and prevalence of HIV infection.

Performance Measures:

FY Baseline	FY 1999 Appropriated	FY 2000 Estimate
N/A	CDC's current guidelines for security and confidentiality contained in the HIV/AIDS surveillance guidelines are updated to include minimum standards of performance for state and local and HIV/AIDS surveillance programs.	100% of states will begin to adopt recommended confidentiality standards.
Baselines will be established.	Baselines will be established for measuring incidence in selected high-risk populations.	Baselines will be established for measuring incidence in selected high-risk populations.
N/A		CDC will provide technical assistance to all states to help them develop reliable minimal estimates for HIV prevalence.
N/A	Trends in long-term survival and rates of transmission of new infections will be measured.	Trends in long-term survival and rates of transmission of new infections will be measured.

Performance Goal: Reduce the rate of heterosexually acquired AIDS cases, as well as AIDS cases related to injecting drug use and male homosexual contact, through the implementation of HIV prevention programs as part of a community planning process. Reduce the rate of perinatally-acquired AIDS cases.

Performance Measures:

FY Baseline	FY 1999 Appropriated	FY 2000 Estimate
11,500 cases 1,2 (1997). (Data for HIV FY 1999 measures will be available around May 2000).	The number of heterosexually-acquired AIDS cases will be decreased by 10% from the 1995 base of 9,300 AIDS cases diagnosed.	The number of heterosexually-acquired AIDS cases will be decreased by 10% from the 1997 base of 11,500 AIDS cases diagnosed.
15,700 cases 1,2 (1997). (Data for HIV FY 1999 measures will be available around May 2000).	The number of AIDS cases related to injecting drug use will be decreased by 15% from the 1995 base of 17,800 cases diagnosed.	The number of AIDS cases related to injecting drug use will be decreased by 10% from the 1997 base of 15,700 cases diagnosed.
21,300 cases 1,2 (1997). (Data for HIV FY 1999 measures will be available around May 2000)	The number of AIDS cases related to male homosexual contact will be decreased by 20% from the 1995 base of 28,600 cases diagnosed.	The number of AIDS cases related to male homosexual contact will be decreased by 10% from the 1997 base of 21,300 cases diagnosed.
299 cases 3 (1997). (Data for HIV FY 1999 measures will be available around May 2000).	The number of perinatally-acquired HIV/AIDS cases will be decreased by 50% from the 1993 base of 8654 cases diagnosed.	The number of perinatally-acquired HIV/AIDS cases will be decreased by 10% from the 1997 base of 2993 reported cases.

¹ Numbers represent diagnosed cases adjusted for reporting delay with risk redistributed.
² Change in baseline data from 1995 (in FY 1999) to 1997 (in FY 2000) reflects adjustments in AIDS case definitions, and availability of more accurate data.
³ These numbers do not represent actual cases of children diagnosed with AIDS. Rather, these numbers are point estimates based on cases diagnosed using the 1987 definition, adjusted for reporting delays.
⁴ Represents number adjusted for reporting delay of diagnosed perinatal AIDS cases for 1993.

Performance Goal: Among persons counseled and tested for HIV infection in CDC-supported sites, improve the percentage of persons who return for their results and post-test counseling.

Performance Measure:

FY Baseline	FY 1999 Appropriated	FY 2000 Estimate
61% (1996).	Increase the percentage of persons who return for their results and posttest counseling from 61% in 1996 to 67% in 1999 (10% relative increase).	Increase the percentage of persons who return for their results and posttest counseling from 61% in 1996 to 67% in 2000 (10% relative increase).

Performance Goal: Reduce the percentage of HIV/AIDS-related risk behaviors among school-aged youth through dissemination of HIV prevention education programs.

Performance Measure:

FY Baseline	FY 1999 Appropriated	FY 2000 Estimate
YRBS Baseline : 86% (1995).	Achieve and maintain the percentage of high school students who have been taught about HIV/AIDS prevention in school at 90% or greater.	Achieve and maintain the percentage of high school students who have been taught about HIV/AIDS prevention in school at 90% or greater.
YRBS Baseline: 53% (1995).		Reduce the percentage of high school students who have ever engaged in sexual intercourse by 15% (to 45%).
FY Baseline	FY 1999 Appropriated	FY 2000 Estimate
YRBS Baseline: 46% (1995).		Reduce the percentage of currently sexually active high school students who engage in sexual intercourse without a condom by 15% (to 39%).

Verification/Validation of Performance Measures: The number of AIDS cases reported will be monitored using the National HIV/AIDS Reporting System. The system is routinely evaluated for data quality and has very high rates of reporting completeness and timeliness. Data for this performance measure are collected on a biennial basis (during odd-numbered years) through CDC's Youth Risk Behavior Surveillance System (YRBSS), a system designed to focus attention on priority behaviors among youth that cause the most important health problems. YRBSS was developed in a partnership with numerous federal agencies, state departments of education, scientific experts, and survey research specialists. The YRBSS includes separate national, state and local school-based surveys of high school students. A recent study of the YRBSS provides evidence that this adolescent survey has good reliability in measuring health behavior.

Baseline data will be used from the 1995 YRBSS data collection because: (a) it was the most recent data available when the original measures were created and, consequently, has been used throughout the entire process to determine our targets for FY 1999 & FY 2000, and (b) the 1995 data will better allow us to illustrate trends in sexual behaviors over time.

Links to DHHS Strategic Plan

These objectives relate to DHHS Goal 1: Reduce major threats to the health and productivity of all Americans. CDC continues to work closely with the Health Resources and Services Administration and the National Academy of Sciences to implement the language in the Ryan White legislation and to evaluate the extent to which states' efforts have been effective in reducing perinatal transmission of HIV. CDC is collaborating with the Substance Abuse and Mental Health Services Administration and the National Institute for Drug Abuse on issues related to transmission of HIV/AIDS in the injecting drug using population. A working group has also been established to address health care issues in correctional institutions.

Performance Goal: Increase the capacity of community-based organizations providing HIV prevention services to persons of color.

Performance Measures:

FY Baseline	FY 1999 Appropriated	FY 2000 Estimate
94 directly funded organizations.	N/A	Fund 30 community-based organizations to provide priority HIV prevention services to HIV-infected persons.
94 directly funded organizations.	N/A	Fund 20 community development grants to expand community demonstration projects.
Total Program Funding	$657,000	$666,500

Verification/Validation of Performance Measures: By the end of FY 1999, a RFA will be developed and selected community based organizations will be funded. In FY 2000, grantees will report on the development progress and evaluation plans which will be reviewed by CDC staff.

Links to DHHS Strategic Plan

These performance objectives are related to DHHS Goals 1: Reduce major threats to the health and productivity of all Americans. Development and implementation of the plan to Eliminate Ethnic Health Disparities is an inter-agency effort within DHHS.

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