April 2003

Since the first cases of HIV/AIDS were recognized in 1981, the Centers for Disease Control and Prevention (CDC) and its partners have worked to combat the epidemic. Our goal has always been to stop transmission and reduce the burden of HIV/AIDS. The new initiative, Advancing HIV Prevention: New Strategies for a Changing Epidemic (MMWR April 18, 2003; 52:329-356), supports the prevention work of the past two decades and expands and strengthens our efforts by modeling new strategies on proven approaches that have been used successfully in preventing other infectious diseases.

Stable HIV-associated morbidity and mortality, concerns about possible increases in HIV incidence, and the recent availability of a simple, rapid HIV test combined with strong prevention collaborations among communities heavily affected by HIV support the need to reassess and refocus some of CDC's HIV-prevention activities. An emphasis on greater access to testing and on providing prevention and care services for persons living with HIV can reduce new infections and lead to reductions in HIV-associated morbidity and mortality. In addition, simplifying prenatal and other testing procedures can lead to more effective use of resources that CDC provides to prevent perinatal and other HIV transmission.

CDC’s HIV prevention activities over the past two decades have focused on helping uninfected persons at high-risk for acquiring HIV change and maintain behaviors to keep them uninfected. Despite the success of these efforts in reducing HIV incidence in the late 1980’s and early 1990’s, the number of new HIV infections is estimated to have remained stable around 40,000 per year since the early 1990’s and the number of persons living with HIV continues to increase.  The next decade promises new hope as three primary areas of HIV prevention are emphasized: early detection of persons who are HIV positive and referral to treatment and care services, prevention for persons living with HIV, and prevention for persons who are at high risk for HIV infection. The new initiative emphasizes the first two of these three areas, broadening our prevention activities to strengthen our fight against HIV.

CDC, other federal agencies, and the HIV prevention community will continue their work to help ensure prevention efforts in these three areas are sustained and re-energized as an integrated approach. This broad scope will bring the best prevention science to the fight against HIV/AIDS to reduce HIV transmission, including mother-to-child transmission.

Collaboration
The new initiative will require new partnerships with extensive involvement and coordination between CDC, the public health community, and the medical care community. With the support of the federal Department of Health and Human Services, CDC and its partners, including other federal agencies, state and local health departments, community-based organizations, non-governmental providers, and professional organizations, will implement this new initiative and energize our efforts to meet the challenges of this changing epidemic.

CDC is expanding its collaboration with the Health Resources and Services Administration, the American Hospital Association, and private health care providers to coordinate the implementation of this initiative. Partners in implementation include Ryan White Care funded programs, community health centers, hospitals, and private medical plans. CDC is also working with professional medical and nursing organizations, including the American Medical Association, the National Medical Association, the American College of Obstetrics and Gynecology, the American Nursing Association, the HIV Medicine Association of the Infectious Diseases Society of America (IDSA), and the Association of Nurses in AIDS Care to solicit their collaboration and support in the development of practice recommendations, policy statements, and dissemination of the activities of the initiative.

Current Status of HIV/AIDS in the United States
From 1995 through 1998, the annual number of new AIDS cases declined 38% from 69,242 to 42,832, and deaths from AIDS declined 63% from 51,670 to 18,823. Since 1998, the decline has stabilized at approximately 40,000 incident AIDS cases and 16,000 deaths. The number of perinatal AIDS cases has declined 89% from 954 in 1992 to 101 in 2001, however approximately 300 infants are infected through mother-to-child transmission each year.

CDC estimates that 850,000 to 950,000 persons in the United States are living with HIV; of those, an estimated 25% are unaware of their infection. Evidence suggests that as many as two-thirds of the estimated 40,000 new HIV infections each year occur through transmission from persons who are unaware of their HIV-positive status. Many persons receive the diagnosis late in the course of the disease. As many as 40%-45% of persons testing positive for HIV received their first positive test results less than a year before AIDS was diagnosed. With an average of 10 years between HIV infection and an AIDS diagnosis, this suggests that people are living with HIV for many years before they are aware of their infection.

The New Initiative
This new initiative emphasizes the need for HIV testing and prevention efforts in both clinical and non-clinical settings to help increase the number of infected persons who learn their status and are successfully referred into treatment and prevention services as early as possible. An important strategy is to incorporate HIV screening into medical care services on the same voluntary basis as other medical tests in order to increase the number of persons living with HIV who are aware of their infection.

Testing in non-clinical settings is another area of focus because it is more likely to reach members of racial and ethnic minorities and persons who are at high risk for HIV. Routine testing in correctional facilities, where the prevalence of AIDS among prison populations is 5 times higher than that in the general U.S. population, will help to increase the number of persons who know their HIV status and who get the services they need while in prison and after release.

Partner counseling and referral services (PCRS) can help to ensure early diagnosis and linkage to medical, prevention and other services. In studies of HIV PCRS, 8% to 39% of partners tested had previously undiagnosed HIV infection. A range of available prevention interventions for persons living with HIV offers greater opportunity to meet the prevention needs of persons with HIV infection. These interventions range in intensity from group level interventions for persons with fewer prevention needs to intensive prevention case management for persons with multiple medical and psychosocial challenges.

Although significant reductions have been made in perinatal transmission, 6,000 to 7,000 HIV-infected women gave birth in the United States during 2000, resulting in 280-370 HIV-infected infants. For about 40% of these perinatal transmissions, health care providers were unaware of the mother’s HIV infection before delivery.

CDC is aware that increasing the focus on prevention for HIV positive individuals has the potential to be construed as stigmatizing to people with HIV/AIDS. CDC will be conducting a national consultation on HIV/AIDS Stigma in 2003 to discuss strategies to address this problem and to identify specific actions CDC and its partners can take to alleviate the potential for exacerbating the stigma already felt by those living with this disease.

The Strategies
The primary goal of the new initiative–to reduce HIV transmission–is not new. The four strategies identified to help achieve this goal focus directly on reducing barriers to early diagnosis; improving referral to state-of-the-art prevention services, medical care, and treatment; and ensuring that prevention programs are in place to assist people living with HIV. The HIV prevention initiative emphasizes the use of proven public health approaches to reduce incidence and the spread of disease. The initiative consists of four priority strategies:

Strategy 1: Make voluntary testing a routine part of medical care.
Strategy 2: Implement new models for diagnosing HIV infections.
Strategy 3: Prevent new infections by working with persons diagnosed with HIV.
Strategy 4: Further decrease perinatal HIV transmission.

Interim Technical Guidance
As one of the first steps of the new initiative, CDC has drafted this interim technical guidance for HIV prevention grantees. This guidance is just that – information to assist in your efforts to conduct HIV prevention activities. The information in this document is not a dictated set of activities. These are guiding principles, not policies, and we fully expect local experts to modify these interventions to meet the needs of the community served.

This guidance outlines 7 activities to assist with the implementation and achievement of the strategies listed above. We hope that the guidance will enhance your activity-planning efforts and, if appropriate, help spark new ideas and new directions for your current prevention activities. The guidance should also help you plan for related training needs.

The 7 activities described in the guidance are

• Routinely Recommended HIV Testing as Part of Regular Medical Care Services [Strategy 1]
• Rapid Testing in Non-Clinical Settings [Strategy 2]
• Routine Voluntary HIV Testing of Inmates in Correctional Facilities [Strategy 2]
• HIV Partner Counseling and Referral Services [Strategies 2 and 3]
• Risk Reduction for Persons Living with HIV [Strategy 3]
• Prevention in Medical Care Settings [Strategy 3]
• Achieving Universal HIV Testing of Pregnant Women [Strategy 4]

Each section of this document provides detailed background information and current knowledge on the topic; objectives; procedures for implementing strategies; how to work with partners, including overcoming barriers to implementation; a real-life example (vignette) of a current program that uses some or all of the elements in the guidance; and requirements for monitoring and evaluating activities. Each section also includes references to help you find supportive and more in-depth information on each topic, as well as resources for assistance in understanding and implementing programs. CDC is also planning demonstration projects to be conducted in 2003-2005. From these projects and from our experience implementing the interim guidance, a revised guidance will be developed for distribution at a later date.

CDC will provide training and technical assistance to its grantees to ensure that health departments and community-based organizations are equipped to provide the most effective prevention interventions to persons at highest risk for transmitting or acquiring HIV. CDC will provide guidance on implementation of these activities and will continue to improve the procedures based on your feedback and data collected over the coming year. We look forward to continuing our strong partnerships with state and local agencies in the field to implement state-of-the-art prevention interventions in order to reduce the number of new HIV infections.

More people than ever before in the course of the epidemic in the United States are living with HIV. Advances in treatment have made it possible for HIV-infected persons to live longer, healthier lives. CDC sees these persons as essential partners in HIV prevention. This new initiative is designed to give persons easier access to testing to learn their HIV status, receive appropriate treatment and prevention services, and to help protect other at-risk persons from becoming infected. We see this guidance as a first step in the new initiative to build stronger, more effective programs based on proven public health strategies. These efforts and those to come will help us realize new successes in our fight against this disease and help to build the necessary foundation to effectively target proven interventions and reduce transmission of HIV.

Resources

CDC. Advancing HIV Prevention: New strategies for a changing epidemic. MMWR 2003;52:329-332.

Advancing HIV Prevention website

State Policy Profiles developed by the Infectious Disease Society of America (IDSA) for the Health Resources and Services Administration (HRSA): http://www.hivma.org/HIV/CEN/ToC.htm

The U.S. Department of Health and Human Services: http://www.hhs.gov/

Health Resources and Services Administration (HRSA): http://www.hrsa.gov/

AIDS Education and Training Centers (AETC) National Resource Center (NRC) Web site: http://www.aids-ed.org