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Introduction One year ago, NASTAD released the National HIV Prevention Blueprint, a consensus document that expresses the collective wisdom and vision of the nation’s health departments and their communities. The Blueprint lays out a concise, yet comprehensive way forward to ending the domestic HIV/AIDS epidemic through the power of prevention. Crafted with broad input from HIV prevention leaders, the Blueprint’s principles and recommendations speak to all populations at risk for or living with HIV/AIDS and to all contexts in which HIV risk occurs. The Blueprint also outlines many difficult conversations that we, as a nation, must have if we are to make substantive progress toward ending the epidemic, including America’s legacy of indifference toward the prevention of disease; the public’s broad, yet shallow support for our work; the role that oppression, stigma and ideology play in social and health disparities; and the reality that America’s fragmented response to HIV prevention impedes the progress we all want to see. Since its release, the Blueprint has received widespread acknowledgement and regard as a foundational document in the nation’s fight against HIV/AIDS. To support national, state and local HIV prevention efforts, many stakeholders have used the Blueprint to:
Within its pages, the Blueprint does not present a host of new strategies and ideas. Instead, it leverages America’s collective “common sense” about how to end the HIV/AIDS epidemic and represents it in a unified roadmap. In keeping with this intention, the Blueprint was created to be a touchstone for anyone who is committed to ending HIV/AIDS in the United States. As this historic year comes to a close, we use this final NASTAD Prevention Bulletin to reflect back on the events that shaped HIV prevention in 2008 and provide specific reflections on three key principles from the Blueprint that saw important movement this year--providing full coverage of services and tools that prevent infection, encouraging all people living with HIV/AIDS to know their status and using structural level interventions to effect change. back to top > Better understanding of the epidemic--Incidence and Prevalence In 2008, the Centers for Disease Control and Prevention (CDC) updated the estimates of national HIV incidence in the U.S. Reported in the August 3, 2008 issue of the Journal of the American Medical Association (JAMA), CDC estimated that approximately 56,300 people are newly infected with HIV in the U.S. each year, up from a previous estimate of 40,000. Using a new methodology to calculate incidence, CDC also found that the epidemic peaked at more than 130,000 new infections in the 1980s and dropped to a low of 50,000 in the early 1990s. After increasing to the current level, new infections have remained there for more than a decade. Gay and bisexual men of all races/ethnicities, among whom new infections are on the rise, and Black Americans bear the greatest impact. CDC also released new estimates of HIV prevalence in the October 3, 2008 Morbidity and Mortality Weekly Report (MMWR). CDC estimated that 1.1 million adults and adolescents were living with diagnosed or undiagnosed HIV infection in the U.S. at the end of 2006, for a national prevalence rate of 447.8 per 100,000 people. Almost half (48 percent) of those living with HIV were gay and bisexual men. Nonwhite racial and ethnic communities bear the greatest burden of those living with HIV and represent 65 percent of living HIV/AIDS cases. The HIV prevalence rate for Blacks was 1,715 per 100,000 and 585.3 per 100,000 for Hispanics; or 7.6 and 2.6 times the rate for whites (224.3 per 100,000), respectively. The new incidence and prevalence estimates clearly highlight that HIV/AIDS is an epidemic that disproportionately impacts gay men of all races and ethnicities and Black Americans. The estimates also give a clear signal that the epidemic is far from over and, as the Blueprint clearly states, that HIV prevention remains essential to ending the epidemic in the U.S. back to top > Committee on Oversight and Government Reform Hearing and CDC’s Professional Judgment Budget In response to the release of the revised incidence estimates, the House of Representatives Committee on Oversight and Government Reform convened a hearing on HIV prevention. Oral testimony was presented to the Committee by CDC, the National Institutes of Health, NASTAD and other leaders in HIV prevention. In both oral and written testimony, common themes included in the Blueprint were raised, including the need for increased funding to support the delivery of prevention programs (including HIV testing and behavioral interventions), surveillance, integration and research, and the need for structural-level changes to support prevention efforts. David Holtgrave, Ph.D., Professor and Chair, Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, presented testimony to the Committee that argued that national HIV prevention efforts to date have been effective in preventing the spread of disease. Holtgrave’s testimony stated that prevention services have kept the transmission rate of HIV (the number of new HIV infections each year divided by the number of people living with HIV in that year) down in the U.S., despite years of inadequate funding. Holtgrave estimated that the HIV transmission rate dropped from 92.3 in 1980 to 31.2 in 1985 and to less than 5.0 in 2006. Continuing, Holtgrave reasoned that there were less than five new infections each year for every 100 persons living with HIV in the U.S., or that 95 percent of HIV-positive individuals are not transmitting HIV to their partners, a stark difference from the transmission rate of the 1980s. In addition to testimony, Committee Chairman Henry Waxman (D-California) requested that CDC’s Division of HIV/AIDS Prevention develop and submit a professional judgment budget (a budget based solely on an agency’s needs) for the hearing. The CDC professional judgment budget estimated that an additional $877 million is needed for domestic HIV prevention efforts in FY2009 (and an additional $4.784 million over five years). The professional judgment budget included 25 specific activities focusing on three programmatic priorities:
In line with recommendations from the Blueprint, CDC’s professional judgment budget clearly supports the argument that increased funding is crucial to meeting the current and future demands of the HIV/AIDS epidemic in the U.S. back to top > A Year-in-Review of Blueprint Principles: Providing Full Coverage of Services and Tools that Prevent Infection Efforts to provide services and tools that help prevent HIV infection saw progress in 2008. Last month, the Food and Drug Administration (FDA) released their final ruling on the effectiveness of condoms in preventing the spread of STDs (including HIV). The FDA’s final rule supports correct and consistent use of latex condoms as a method to reduce the risk of sexually transmitted HIV/AIDS and other STDs (spread through contact with the head of the penis). Set to take effect on January 9, 2009, the rule removes a barrier to advancing the Blueprint’s principle that tools and services that directly prevent HIV infection must be made widely available. In their fight to make clean needles and syringes readily available to all who choose to use them, advocates also created momentum in 2008. For the first time in 20 years, legislation was introduced in Congress that would eliminate laws prohibiting the use of federal funding to support syringe exchange programs, a specific recommendation in the Blueprint. H.R. 6680, The Community AIDS and Hepatitis Prevention (CAHP) Act of 2008, was introduced by Representative Jose E. Serrano (D – NY) on July 30, 2008. The bill had 25 original co-sponsors. In an attempt to better address the needs of specific populations, CDC released an Updated Compendium of Evidence-Based HIV Prevention Interventions in late 2007. The updated compendium includes 49 behavioral interventions, up from 24 in the previous compendium. CDC also added five new interventions to the Diffusion of Effective Behavioral Interventions initiative--d-up! Defend Yourself!, an intervention for Black gay men; Safe in the City (SITC), a video intervention for STD clinic waiting rooms; Focus on Youth (FOY) with Informed Parents and Children Together (ImPACT), for Black youth, ages 12-15; Modelo de Intervención Psychomédica (MIP) (Psycho-Medical Intervention Model), for Spanish-speaking persons who use injection drugs; and Partnership for Health (PfH), for patients and their providers. CDC also funded health departments, for the first time, to create strategic plans to address the HIV/AIDS epidemic among gay men, providing $4 million in one-time funds. Together, these advances help ensure that evidence-based strategies that prevent new HIV infections are increasingly available to all who choose to use them. back to top > A Year-in-Review of Blueprint Principles: Encouraging All People Living with HIV/AIDS to Know their Status Until 2007, CDC’s HIV prevention budget had not seen a meaningful increase in years. With a modest investment of $35 million in FY2007 and 2008, CDC provided funding to select states and cities to support expanded HIV testing in clinical settings. The expanded testing initiative called upon health departments to target testing efforts to Black Americans in order to promote knowledge of HIV status and linkages to care and treatment, two key principles in the Blueprint. With the additional funding, health departments have extended their networks to include non-traditional testing sites and have built necessary infrastructure and capacity to meaningfully increase testing and the identification of persons who are infected but unaware of their status. Now, in year two of the initiative, health departments are continuing to increase the number of tests being offered and the number of newly identified HIV-positive individuals that are linked to care and treatment services. CDC also released revised partner services guidelines in the October 30, 2008 MMWR, Recommendations for Partner Services Programs for HIV Infection, Syphilis, Gonorrhea, and Chlamydial Infection. The revised guidelines are a product of more than two years of intensive development and, for the first time, integrate HIV and STD partner services, a key step toward the Blueprint’s call for HIV prevention programming to recognize other real-life issues, like STDs. 2008 also saw a re-direction of federal funding to support HIV testing under the Early Diagnosis Grant (EDG) program, established through Section 2625 of the Ryan White Program. The EDG program provided more than $2.6 million to six states under two provisions: 1.) voluntary opt-out HIV testing of pregnant women and universal testing of newborns and 2.) voluntary opt-out HIV testing of clients at STD clinics and voluntary opt-out testing of clients at substance abuse treatment centers. While these efforts are important to the principles outlined in the Blueprint, no new resources were identified to support them, leaving a zero sum gain for the nation’s total HIV prevention budget. back to top > A Year-in-Review of Blueprint Principles: Use Structural-Level Interventions to Effect Change 2008 proved to be a mixed-bag year for advancing structural-level change to support the reach of HIV prevention. In particular, policies that indirectly influence the potential effectiveness of HIV prevention lost significant ground in 2008. Most notable was Proposition 8 in California, a measure that eliminated the right of same-sex couples to marry, overriding a May 2008 ruling by the California Supreme Court that held a ban on same-sex marriage violated the rights of same-sex couples. Arizona (Proposition 102) and Florida (Amendment 2) also saw anti-marriage amendments passed. Such policies continue to reinforce the disparities experienced by gay men, the population at greatest risk for HIV infection in the U.S. In contrast to these ballot initiatives, Connecticut residents voted to reject a policy that would have overrode a court decision supporting gay marriage. Similarly, policies that directly influence effective HIV prevention programming did not see much progress in 2008. First and foremost, no new federal funding was appropriated to support domestic HIV prevention, marking yet another year with no increase in appropriations for CDC’s HIV prevention programs. While advocates for lifting the ban on using federal funding to support syringe exchange gained momentum this year, the ban remains in place, as do similar policies in many states. To this end, health departments are prevented from using federal and, in some cases, state and local funding to support a service widely-proven to prevent HIV transmission. Significant federal support continued to be allocated in 2008 to support abstinence-only-until-marriage programs, despite increasing scientific evidence that questions the effectiveness of these programs. In FY2007, $176 million was granted to states to support these programs. On a positive note, the Sexuality Information and Education Council of the One significant policy win for HIV prevention came from the state of California. Governor Arnold Schwarzenegger (R) signed into law Assembly Bill 1894, making California the first state in the nation to require all private insurance companies to pay for HIV testing for individuals who choose to be tested. NASTAD has found in a previous report, that funding was the most important barrier and greatest concern associated with implementation of HIV screening, an important service for encouraging individuals to learn their status. Finally, in preparation for President-elect Barack Obama’s first 100 days in office, leaders from several national AIDS organizations came together to make specific recommendations for action. Under the umbrella of “AIDS in America,” the collective calls for renewed leadership around domestic HIV/AIDS, including adequate funding to support the work that must be done in the U.S. In a letter to the Obama transition team, AIDS in America called for leadership on six key issues:
Each of the issues outlined by AIDS in back to top > Closing In 2009, health departments will continue to support the principles and recommendations outlined in the NASTAD HIV Prevention Blueprint, like those discussed above, and will actively work to diffuse these into communities across With the successes we saw and the challenges we faced in tow, we are prepared to embark on a new year that promises great progress in our efforts toward ending the domestic HIV/AIDS epidemic. To ensure the power of prevention is realized in the U.S., we must all embrace the power of change and believe in the power of hope and, together, we can see a world free of HIV/AIDS. back to top > Meeting and Planning Calendar Capacity Building Opportunities: For a searchable database of CDC-supported capacity building trainings and events, please visit: the Capacity Building Branch’s Group Events Management System site. December 1, 2008 World AIDS Day February 7, 2009 National Black HIV/AIDS Awareness Day March 1-7, 2009 National Black Church Week of Prayer for the Healing of AIDS March 10, 2009 National Women and Girls HIV/AIDS Awareness Day March 20, 2009 National Native HIV/AIDS Awareness Day April STD Awareness Month April 5-7, 2009 4th International Conference on HIV Treatment Adherence, Miami, FL. Sponsored by the International Association of Physicians in AIDS Care (IAPAC). April 16-18, 2009 HIV/STD Prevention in Rural Communities: Sharing Successful Strategies VI, Bloomington, IN. ABSTRACTS DUE FEBRUARY 6, 2009. May 2009 Viral Hepatitis Awareness Month May 18, 2009 HIV Vaccine Awareness Day May 19, 2009 National Asian and Pacific Islander HIV/AIDS Awareness Day World Hepatitis Day May 21-24, 2009 HIV/AIDS 2009: The Social Work Response, New Orleans, LA. CALL FOR PRESENTATIONS DUE DECEMBER 31, 2008. June 8, 2009 Caribbean American HIV/AIDS Awareness Day June 27, 2009 National HIV Testing Day August 23-26, 2009 National HIV Prevention Conference, Atlanta, GA. Abstracts due DECEMBER 10, 2009. |
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Credits, Feedback
and Input The NASTAD Prevention Bulletin is edited by NASTAD staff and is written by staff and prevention experts from around the country. This publication was supported by Cooperative Agreement Number 5U62PS323958-05 from the Centers for Disease Control and Prevention. Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the Centers for Disease Control and Prevention. If you have an idea or program that you would like to include in the Bulletin, please contact Dave Kern or Lynne Greabell (202/434-8090). NASTAD welcomes feedback to issues presented in Bulletin. To submit commentary, please e-mail us at NASTAD@NASTAD.org. Electronic versions of the Bulletin are available on our webpage. |
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