by Bob Roehr
The limitations of HIV prevention activities in the U.S. were on display at a congressional briefing on May 12. Advocates called for a doubling of the CDC's HIV prevention budget to $1.3 billion and a refocusing of activity to better address the current epidemic.
Prevention is a scant 4 percent of total domestic spending on AIDS, said Julie Scofield, executive director of the National Alliance of State and Territorial AIDS Directors.
In comparison, the international AIDS effort, known as PEPFAR, spends about 20 percent of its funds on prevention activities. "We cannot treat our way out of this epidemic," the NIH's Tony Fauci has said repeatedly in supporting prevention research and programs.
"PEPFAR requires that countries that receive U.S. dollars have a coordinated national plan before the check is cut. In the United States we don't have a national AIDS strategy or coordinated plan," said Marjorie Hill, executive director of the Gay Men's Health Crisis (GMHC), the world's oldest AIDS organization. She is among those pressing for the U.S. to adopt a national HIV strategic plan.
The CDC's HIV budget "has seen a steady decline in resources since about 2002," said Scofield. "We are getting to the point where health departments are having to look at their prevention programs and decide what it is that they can no longer support."
She traced how earlier increases in prevention funding led to a decline in the rate of new infections. But then funding stagnated and declined, even while more people with HIV were living longer and the pool of people who were capable of infecting others with the virus expanded.
"I think we have done a miraculous job of keeping the lid on the epidemic in this country, given the fact that we have declining resources and so many more people living with HIV," Scofield said.
So it comes as no surprise that the long-anticipated revised estimates are expected to show an increase in the number of new infections each year. Richard Wolitski, who last week took over as acting director of the CDC's division of HIV/AIDS prevention, said the agency now anticipates publication of that data in July.
Scofield criticized "very troubling elements" in the Bush administration's budget for HIV prevention for fiscal year 2009. There is an increase for an initiative to test more people for the viurs, but no new money.
AIDS Institute analyst Suzanne Miller said the CDC has certified 49 prevention programs as having published, demonstrated efficacy and thus are eligible for funding. But there are some glaring mismatches with the groups most affected by the epidemic.
"There are 10 interventions specifically for African American women, four for African American men, three for Hispanic women, and no interventions specifically targeted to Hispanic men." Minorities in the U.S. are disproportionately infected with HIV.
"Only four of the 49 interventions are specifically targeted to men who have sex with men (MSM). That does not match up with the reality of the epidemic," where MSM remain the single most important route of transmission of infections, both historically and in terms of new infections, Miller said. None of the four specifically target men of color.
Some nine interventions address drug use, but none involve crystal methamphetamine. Nor do any of the approved programs involve needle exchange programs, even though hundreds of those programs are in operation in the US.
"HIV does not happen in a vacuum," said Hill, there is a need to address context through "integrative service models" that address accompanying and underlying issues leading to infection, such as other sexually transmitted diseases, substance abuse, and mental health.
African American men are having less risky sex than their white contemporaries, according to analysis presented last December at the CDC HIV prevention conference, but they are becoming infected with the virus at significantly higher rates. That is largely because the background prevalence rate of HIV is higher among those they have sex with, so the same act carries greater risk of infection.
Hill said community interventions are needed "to help shift values and norms within the [high risk] communities in ways that support individuals within the context of that community." That can include building skills, self-esteem, and a sense of community within risky populations.
Abstinence-only programs have been the bane of many HIV prevention advocates. "We all know they don't work," said Hill. "Twenty-seven years into the epidemic, we should be using evidence-based interventions that have proven effectiveness."
She fears that a possible funding compromise of block grants that allows states more flexibility in using prevention funding, as was floated by Rep. Henry Waxman (D-Calif.a) at a recent hearing, might leave those jurisdictions most in need of sound prevention programs with the option of supporting failed ones.
Block grants are "one way of addressing it, but it does not get to the core of the problem, which is that evidence-based, research-proven initiatives that work should be what is guiding the funding," said Hill.
