Date: Sept. 27, 2000
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NATIONAL PREVENTION STRATEGY CALLS FOR IMPROVED TRACKING AND COST-EFFECTIVE INTERVENTIONS TO CUT RATE OF NEW HIV INFECTIONS
WASHINGTON -- U.S. efforts to thwart the spread of HIV -- the virus that causes AIDS -- have slowed the rapid growth of the epidemic, but the number of new infections remains unacceptably high. A national strategy focused on better tracking of HIV infections, coupled with funding the most cost-effective prevention programs, could significantly cut new infections, says a new report from the Institute of Medicine (IOM) of the National Academies. Other key needs include making HIV prevention services for at-risk and infected individuals routine in all clinical settings and abolishing laws and policies that block the use of proven prevention strategies.
"Thousands of new HIV infections could be avoided each year if we gave greater emphasis to prevention, and were smarter in the way we spent our prevention dollars," said Harvey Fineberg, provost of Harvard University, Cambridge, Mass., and co-chair of the committee that wrote the report. "Improved treatments may have contributed to a false sense of security and a dangerous complacency but the need for prevention has not diminished one bit." Recent reports suggest a resurgence of risky behaviors among men who have sex with men, as well as increasing rates of infection in some parts of the country.
The last 15 years have witnessed a shift in the U.S. AIDS epidemic, with a dramatic decline of new AIDS cases among men who have sex with men. At the same time, the number of new AIDS cases among women, minorities, and adolescents has increased considerably. Keeping up with the changes in the epidemic requires a better tracking system and a proactive approach -- one that can deliver more effective prevention services to those at the greatest risk, the committee said.
Given these challenges, the U.S. Centers for Disease Control and Prevention (CDC) asked the IOM to develop a visionary framework for a national HIV prevention strategy. As a starting point, the committee said, the nation should adopt an explicit policy goal -- to avert as many new HIV infections as possible within the available prevention resources -- and consistently apply that goal in program management. Accomplishing this will require changes in the way the epidemic is tracked and the way federal prevention funding decisions are made.
In fiscal year 1999, the federal spending for HIV/AIDS prevention was about $775 million, which was 8 percent of the total federal spending for HIV/AIDS-related programs. Federal funding for HIV prevention largely mirrors the number of AIDS cases reported in specific populations and geographic areas. While this approach may be useful for allocating funds for treatment, it is an inappropriate basis for allocating prevention services. Funding decisions should focus on preventing as many new HIV infections as possible, the committee said.
A better system is needed for tracking new infections. "The current epidemiological surveillance system does not provide a complete or accurate picture of the incidence of HIV infection," said James Trussell, associate dean of the Woodrow Wilson School of Public and International Affairs at Princeton University, Princeton, N.J., and co-chair of the study committee. "By focusing mainly on AIDS cases, where diagnosis lags behind HIV infection by approximately 10 years without treatment and even longer with treatment, today's surveillance system looks at the past rather than to the future and tracks where the epidemic has been rather than where it is going. This lag is particularly problematic in light of the reality that the epidemic has shifted into new population groups."
The CDC should create a national surveillance system to identify new HIV infections, enabling public health officials to track recent changes in the epidemic, the committee said. Rather than trying to count every newly infected person, the committee's approach would estimate the number of new infections by testing a statistically valid sample of those at the highest risk. These individuals would be drawn from "sentinel" sites, including health care facilities -- such as clinics specializing in sexually transmitted diseases, tuberculosis, substance-abuse treatment, and family planning -- where at-risk people are likely to seek care.
To make this estimate, some of these facilities would be selected randomly, and blood samples there -- also selected at random -- would be tested for the virus, using an advanced technique that can identify recent infections. This testing would be conducted anonymously. Sentinel surveillance is already used on a limited basis, but not in a way that can produce accurate national estimates.
To estimate the number of new infections nationwide, questions would be added to nationally representative surveys asking individuals whether they had visited any of these kinds of facilities. With these results, accurate statistical estimates could be made of the incidence of HIV. Such a system would help communities better understand the epidemic they face and target prevention services appropriately.
OVERCOMING SOCIAL BARRIERS
Social, economic, and cultural forces not only shape the progression and course of the AIDS epidemic, but also influence this nation's response to it. Poverty, racism, gender inequalities, stigma, reluctance to openly address sexuality, and misperceptions about HIV/AIDS continue to fuel the epidemic and undermine the effectiveness of prevention efforts. For example, social and political pressures have led to policy and legal obstacles that block the use of proven strategies. These laws and policies should be abolished, the committee said, including elimination of federal, state, and local requirements that public funds be used for abstinence-only sex education.
Nationally, the federal government has appropriated $250 million in federal funds to be spent over five years for abstinence-only programs -- without any evidence that this approach is effective. Yet, comprehensive sex education and condom availability have been shown to reduce the risk of HIV and other sexually transmitted diseases without promoting sexual activity. This recommendation takes on added urgency given that the majority of AIDS cases reported in 1999 among adolescents were attributed to sexual activity.
Federal and state barriers to the adoption of clean needle programs for drug users also should be lifted, the committee said. There is clear evidence that these programs avert new HIV infections without increasing the level of substance abuse. At the same time, federal agencies should work to make sure that resources for substance-abuse treatment are sufficient to provide services to those requesting it. These steps are needed because sharing contaminated needles often spreads HIV. Of the 46,400 new AIDS cases reported in 1999, injection drug use accounted for 22 percent.
COST-EFFECTIVE RESOURCE ALLOCATION
While information exists about the cost-effectiveness of some HIV-prevention interventions, there has been no systematic effort to make funding decisions about prevention programs using this information. Routine evaluations are needed so interventions that do not work or that are very expensive in relation to the number of infections they prevent could be abandoned, the committee said. Using a standard cost-effectiveness model, the committee illustrated how improved resource allocation could avert significantly more new infections. Much of this evaluation should be done in conjunction with partners at the state and community levels, but the CDC and other federal agencies should be responsible for facilitating the process.
Another important step is to make better use of the opportunities presented by clinics and doctors' offices to deliver prevention messages. Medical facilities that treat patients who are at high risk or are already infected should routinely take sexual and drug histories, provide counseling and behavior modification, and offer HIV tests, the committee said. These include primary care settings, clinics specializing in the treatment of sexually transmitted diseases, drug-treatment centers, and mental health centers. The states and the federal government should explore incentives for reimbursing health care providers for the cost of these services.
Federal agencies also need to do a better job in working with state and local organizations to apply the latest research on effective prevention strategies at the community level, the committee said. Doing this may require federal agencies to increase levels of technical assistance, so service providers can adapt these research findings to local, real-world conditions. As a further step, state and federal governments should invest to help strengthen local agencies' ability to develop, evaluate, implement, and support effective programs in the community.
Federal agencies also should increase research funding to develop new or enhanced prevention technologies, especially female condoms, microbicides, new antiretroviral drugs, vaccines, and rapid testing methods for detection of HIV antibodies. Incentives for private-sector investment in these areas of research should be explored and encouraged as well.
The study was sponsored by the Centers for Disease Control and Prevention. The Institute of Medicine is a private, nonprofit institution that provides health policy advice under a congressional charter granted to the National Academy of Sciences. A committee roster follows.
Read the full text of NO TIME TO LOSE: GETTING MORE FROM HIV PREVENTION
for free on the Web, as well as more than 1,800 other publications from the National Academies. Printed copies are available for purchase from the National Academy Press Web site
or at the mailing address in the letterhead; tel. (202) 334-3313 or 1-800-624-6242. Reporters may obtain a pre-publication copy from the Office of News and Public Information at the letterhead address (contacts listed above).
INSTITUTE OF MEDICINE
Division of Health Promotion and Disease Prevention
COMMITTEE ON HIV PREVENTION STRATEGIES IN THE UNITED STATES
HARVEY V. FINEBERG, M.D., M.P.P., PH.D.* (CO-CHAIR)
JAMES TRUSSELL, PH.D. (CO-CHAIR)
Professor of Economics and Public Affairs;
Faculty Associate, Office of Population Research; and
Associate Dean, Woodrow Wilson School of Public and International Affairs
RAYMOND J. BAXTER, PH.D.
Executive Vice President
The Lewin Group
WILLARD CATES JR., M.D., M.P.H.*
Family Health Institute
Family Health International
Research Triangle Park, N.C.
MYRON S. COHEN, M.D.
Professor of Medicine, Microbiology, and Immunology;
Chief, Division of Infectious Diseases; and
Director, Center for Infectious Diseases
University of North Carolina
ANKE A. EHRHARDT, PH.D.
Director, HIV Center for Clinical and Behavioral Studies
New York State Psychiatric Institute, and
Professor of Medical Psychology
Department of Psychiatry
New York City
BRIAN R. FLAY, D.PHIL.
Professor of Community Health Sciences and Psychology, and
Director, Health Research and Policy Centers
School of Public Health
University of Illinois
LORETTA S. JEMMOTT, R.N., F.A.A.N., PH.D.*
Director, Center for Urban Health Research, and
Associate Professor of Nursing
School of Nursing
University of Pennsylvania
EDWARD H. KAPLAN, PH.D.
William N. and Marie A. Beach Professor of Management Sciences
School of Management;
Professor of Public Health
School of Medicine; and
Director of the Law, Policy, and Ethics Core, Center for Interdisciplinary Research on AIDS
New Haven, Conn.
NANCY KASS, SC.D.*
Associate Professor and Director
Program in Law, Ethics, and Health
School of Hygiene and Public Health, and
Johns Hopkins University
MARSHA LILLIE-BLANTON, DR.P.H.
Vice President in Health Policy
Henry J. Kaiser Family Foundation
MICHAEL H. MERSON, M.D.
Dean of Public Health and Chair
Department of Epidemiology and Public Health
School of Medicine, and
Director, Center for Interdisciplinary Research on AIDS
New Haven, Conn.
EDWARD TRAPIDO, SC.D.
Professor and Vice Chair
Department of Epidemiology and Public Health
School of Medicine
University of Miami
STEN H. VERMUND, M.D., PH.D.
Professor and Director, Division of Geographic Medicine
Department of Medicine, and
Director, Sparkman Center for International Public Health Education
School of Public Health
University of Alabama
PAUL A. VOLBERDING, M.D.*
Professor of Medicine, and
Director, Positive Health Program and Department of Clinical Oncology
San Francisco General Hospital; and
Co-Director, Center for AIDS Research
University of California
ANDREW R. ZOLOPA, M.D.
Assistant Professor of Medicine
School of Medicine
MONICA S. RUIZ, PH.D., M.P.H.
* Member, Institute of Medicine