AIDScience Vol. 2, No. 24, December 2002
Reflections on HIV prevention strategies in the United States in 2002
By David R. Holtgrave
Department of Behavioral Science and Health Education, and Center for AIDS Research, Rollins School of Public Health, Emory University, 1518 Clifton Road NE, Room 540, Atlanta, Georgia 30322, United States.
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ive years after the first HIV infections occurred in the United States, HIV incidence peaked at approximately 160,000 infections per year (1). Intensive HIV prevention programs helped to lower that figure to roughly 40,000 HIV infections per year by 1990, and then hold it down at 40,000 infections until the present time (1, 2). HIV infections were flat during the 1990s as well as the (inflation-adjusted) federal HIV prevention budget in the U.S. (2). Further, it was estimated that HIV prevention efforts to date have avoided a number of HIV infections equal to the size of a medium to large U.S. city, and at an overall cost-savings to society, given the costs of patient care and treatment (3).

In January 2001, the federal Centers for Disease Control and Prevention (CDC) established the following overarching national goal in an HIV prevention strategic plan: to “reduce the number of new HIV infections in the U.S. from an estimated 40,000 to 20,000 per year by the year 2005, focusing particularly on eliminating racial and ethnic disparities in new HIV infections (4).” In order to achieve such a goal, a multi-faceted, expanded HIV prevention effort is necessary (4, 5). Comprehensive HIV prevention efforts have been noted to include six major components (5):

Scientific research has well established that HIV prevention interventions can reduce some risks associated with HIV infections such as drug use or sexual behavior (6-9). Some interventions involve intensive counseling of individuals to help them understand HIV transmission modes and learn methods to protect themselves and partners from HIV infection, as well as plan strategies for reducing personal risk. Often, individual counseling is done in concert with HIV antibody testing (10). HIV counseling and testing also play critical role in the prevention of perinatal HIV transmission.

A large body of evidence suggests that it is helpful to conduct risk reduction counseling with small groups of six to ten people at a time because participants reinforce prevention messages to each other, helping to establish a social norm for safer behavior. Additionally, it helps individuals to role play ways to deal with unsafe sex situations, for example a partner pressuring for sex without a condom (11-14).

Other successful types of interventions work at the community level (15, 16). Kelly and colleagues recruited individuals identified as peer opinion leaders in gay communities and taught HIV prevention messages to these individuals. The message was then delivered back to their own communities (15). This approach ensures that the HIV prevention messengers are credible and influential information sources.

These are just a few examples of HIV prevention interventions shown scientifically to alter HIV-related risk behaviors and help to prevent transmission. Other types of successful interventions include brief video-based interventions, treatment of sexually transmitted diseases (STDs) that can be a cofactor for HIV transmission, needle and syringe exchange, and social marketing of condoms (17-20).

In spite of these successful interventions, the epidemic keeps changing over time due to changes in the communities affected by the epidemic, the availability of treatments for HIV positive individuals, and fatigue from hearing the same prevention messages repeatedly (21). This requires retargeting of prevention services (in particular to communities disproportionately impacted by HIV disease), and updating of services addressing recent developments and client concerns (for instance, regarding the availability of newer, better HIV treatments) (21). One new strategy recently described is the “Serostatus Approach to Fighting the Epidemic” (SAFE) (22). The SAFE approach to HIV prevention takes in consideration the clients’ HIV serostatus in order to provide them with custom-tailored HIV prevention messages. It also places special emphasis on helping people to learn their HIV serostatus, and assisting HIV seropositive individuals to avoid transmitting the virus to others (22). A number of research trials are now underway to test the effectiveness of behavioral interventions in avoiding the transmission of the virus by seropositive individuals (23).

Other important areas of ongoing investigation focus on vaccine and microbicide development (24, 25). Emerging areas of research are focusing on the importance of addressing structural factors (e.g., policy, legal and environmental factors) related to HIV infection. This work includes research on the importance of building strong communities that may serve as protective factors against HIV transmission. In correlational research, a relationship has been identified between a person’s housing status and the level of HIV-related risk behavior (26). Further, in state-level analysis, it has been demonstrated that STDs and AIDS case-rates are strongly related to the level of social capital (i.e., social connectedness) in that geographic area (27, 28).

A growing literature has examined the economic aspects of HIV prevention efforts. The lifetime treatment costs for HIV and AIDS have been estimated at approximately $154,000 to $195,000 (29). Approaches previously shown to be effective such as individual, small group and community level interventions have also been demonstrated to be cost-saving to society, in the sense that the costs of the prevention services are lower than the costs of medical treatment avoided (30, 31).

The costs of the unmet prevention needs in the U.S. have also been estimated (23). Conservative estimates suggest that roughly four million people in the U.S. have sexual behaviors that place them at risk of infection. In addition, approximately one million people are at risk of HIV infection due to substance use. Providing HIV prevention services to these people may cost $300 million per year for at least four years above current levels of public investment in HIV prevention programs (22, 23). Such investment is critical to reduce HIV incidence by 2005. If the national goal of reducing new infections by 50% is not met, at least an additional 20,000 people will be infected every year (32).

The consequences of failing to prevent these additional infections cannot be tolerated. The tiredness of hearing the same HIV prevention message over again cannot make us, as a society, fatigued in our caring about preventing the spread of HIV infection. While effective tools to prevent HIV infection have been developed, society has not fully used and supported these tools. Failure to utilize effective interventions during the epidemic crisis constitutes the real public health tragedy.


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