In several U.S. cities, recent outbreaks of primary and secondary syphilis
among men who have sex with men (MSM)1 and
increases in newly diagnosed human immunodeficiency virus (HIV) infections
among MSM and among heterosexuals have created concern that HIV incidence
might be increasing. In addition, declines in HIV morbidity and mortality
during the late 1990s attributable to combination antiretroviral therapy appear
to have ended. Until now, CDC has mainly targeted its prevention efforts at
persons at risk for becoming infected with HIV by providing funding to state
and local health departments and nongovernmental community-based organizations
(CBOs) for programs aimed at reducing sexual and drug-using risk behavior.
Some recent programs have focused on prevention efforts for persons living
with HIV.2 Funding HIV-prevention programs
for communities heavily affected by HIV has promoted community support for
prevention activities. At the same time, these communities recognize the need
for new strategies for combating the epidemic. In addition, the recent approval
of a simple rapid HIV test in the United States creates an opportunity to
overcome some of the traditional barriers to early diagnosis and treatment
of infected persons. Therefore, CDC, in partnership with other U.S. Department
of Health and Human Services agencies and other government agencies and nongovernment
agencies will launch a new initiative in 2003, Advancing HIV Prevention: New
Strategies for a Changing Epidemic.
The first cases of acquired immunodeficiency syndrome (AIDS) were reported
in the United States in June 1981, and the number of cases and deaths among
persons with AIDS increased rapidly during the 1980s. During 1981-2001, an
estimated 1.3-1.4 million persons in the United States were infected with
HIV,3 and 816,149 cases of AIDS and 467,910
deaths were reported to CDC.4 During the
late 1990s, after the introduction of combination antiretroviral therapy,
the numbers of new AIDS cases and deaths among adults and adolescents declined
substantially. From 1995 to 1998, the annual number of incident AIDS cases
declined 38% from 69,242 to 42,832, and deaths from AIDS declined 63% from
51,670 to 18,823. The annual number of incident AIDS cases and deaths have
remained stable since 1998, at approximately 40,000 and 16,000, respectively.4 The number of children in whom AIDS attributed
to perinatal HIV transmission was diagnosed peaked in 1992 at 954 and declined
89% to 101 in 2001.4
Since the early 1990s, an estimated 40,000 new HIV infections have occurred
annually in the United States. During 1999-2001, in the 25 states that had
HIV reporting since 1994, the number of persons who had HIV infection newly
diagnosed increased 14% among MSM and 10% among heterosexuals. The number
of persons in the United States living with HIV continues to increase, and
of an estimated 850,000-950,000 persons living with HIV, an estimated 180,000-280,000
(25%) persons are unaware of their serostatus.3
Many HIV-infected persons do not get tested until late in their infection,
and many persons who are tested do not return to learn their test results.
In 2000, of an estimated two million CDC-funded tests for HIV, approximately
18,000 tests represented new HIV diagnoses. During 2000, of persons with positive
tests for HIV, 31% did not return to learn their test results (CDC, unpublished
data, 2000). Of 573 HIV-infected young MSM who were studied in six U.S. cities,
77% were unaware that they were infected.5 During
1994-1999, of 104,780 persons in whom HIV was diagnosed, AIDS was diagnosed
in 43,089 (41%) persons within 1 year after their positive HIV test.6
Reasons for HIV testing vary. In a study of 7,236 persons in whom HIV
was newly diagnosed, the reason given most frequently (42%) for seeking the
test was illness. Only 10% of HIV-infected men and 17% of HIV-infected women
reported that they were tested primarily because the test was offered or recommended
by a health-care facility or provider (CDC, unpublished data, 2002).
Many persons who learn that they are HIV infected adopt behaviors that
might reduce the risk for transmitting HIV.7 In
a study of 1,363 HIV-infected men and women, among the 69% who were sexually
active during the preceding 12 months, 78%-96% used a condom at most recent
anal or vaginal intercourse with a known HIV-negative partner, and 52%-86%
reported condom use with a partner of unknown serostatus (CDC, unpublished
The development of new tests for HIV creates new prospects for expanding
HIV testing to identify and treat HIV-infected persons earlier. The OraQuick®
HIV rapid test (OraSure Technologies, Inc., Bethlehem, Pennsylvania) was approved
by the Food and Drug Administration in November 2002 and categorized as a
waived test under the Clinical Laboratory Improvement Amendments in January
2003. This simple, rapid test provides HIV results in 20 minutes, can be stored
at room temperature, requires no special equipment, and can be performed outside
clinical settings. Although the use of the OraQuick® test facilitates
receipt of test results, HIV-positive test results will require confirmation
by Western Blot or immunofluorescence assays.
RS Janssen, MD, IM Onorato, MD, Div of HIV/AIDS Prevention–Surveillance
and Epidemiology; RO Valdiserri, MD, TM Durham, MS, WP Nichols, MPA, EM Seiler,
MPA, HW Jaffe, MD, National Center for HIV, STD, and TB Prevention, CDC.
The new initiative, Advancing HIV Prevention: New Strategies for a Changing
Epidemic, is aimed at reducing barriers to early diagnosis of HIV infection
and increasing access to quality medical care, treatment, and ongoing prevention
services. The HIV initiative emphasizes the use of proven public health approaches
to reducing the incidence and spread of disease. As with other sexually transmitted
diseases (STDs) or any other public health problem, principles commonly applied
to prevent disease and its spread will be used, including appropriate routine
screening, identification of new cases, partner notification, and increased
availability of sustained treatment and prevention services for those infected.
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 infected with HIV can reduce
new infections and lead to reductions in HIV-associated morbidity and mortality.2,8 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.
The initiative consists of four key strategies:
Make HIV testing a routine part of medical care.
CDC will work with professional medical associations and other partners to
ensure that all health-care providers include HIV testing, when indicated,
as part of routine medical care on the same voluntary basis as other diagnostic
and screening tests. Previously, CDC has recommended that patients be offered
HIV testing in high HIV-prevalence acute care hospitals9 and
in clinical settings serving populations at increased risk (e.g., clinics
that treat persons with STDs). This initiative adds to those recommendations
to include offering HIV testing to all patients in all high HIV-prevalence
clinical settings and to those with risks for HIV in low HIV-prevalence clinical
settings.10 Because prevention counseling,
although recommended for all persons at risk for HIV, should not be a barrier
to testing, CDC will promote adoption of simplified HIV-testing procedures
in medical settings that do not require prevention counseling before testing.
In 2003, CDC will support state and local health departments in conducting
demonstration projects offering HIV testing to all patients in high HIV-prevalence
health-care settings and referral into care, treatment, and prevention services,
and will assess the outcomes of these projects.
Implement new models for diagnosing HIV infections
outside medical settings. In 2003, CDC will fund new demonstration projects
using OraQuick® to increase access to early diagnosis and referral for
treatment and prevention services in high-HIV prevalence settings, including
correctional facilities. In addition, CBOs will pilot new models, particularly
in nonmedical settings, for diagnosis and referring persons for treatment
and prevention services. Also, because 8%-39% of partners tested in studies
of partner counseling and referral services (PCRS) were found to have previously
undiagnosed HIV infection,11 CDC will increase
emphasis on PCRS. In 2004, CDC will implement these new models through health
departments and CBOs.
Prevent new infections by working with persons
diagnosed with HIV and their partners. Although many persons with HIV modify
their behavior to reduce their risk for transmitting HIV after learning they
are infected, some persons might require ongoing prevention services to change
their risk behavior or to maintain the change. In 2003, CDC, in collaboration
with the Health Resources and Services Administration (HRSA), the National
Institutes of Health, and the HIV Medical Association of the Infectious Diseases
Society of America, will publish Recommendations for Incorporating
HIV Prevention into the Medical Care of Persons with HIV Infection. CDC
will work with professional associations to disseminate the new guidelines
to primary care providers and infectious disease specialists and to assess
their integration into medical practice. CDC will work closely with HRSA and
other partners to reach persons in whom HIV infection has been diagnosed but
who are not in ongoing medical or preventive care. CDC also will conduct demonstration
projects through state and local health departments to provide prevention
case management for persons living with HIV to reduce HIV transmission. Finally,
CDC will increase emphasis on partner notification and also will support new
models of partner notification, including offering rapid HIV testing to partners
and using peers to conduct partner prevention counseling and referral. In
2004, acting through health departments and CBOs, CDC will implement these
prevention services for persons living with HIV. CDC also will require grantees
to employ standardized procedures for prevention interventions and evaluation
Further decrease perinatal HIV transmission. CDC
will promote recommendations for routine HIV testing of all pregnant women,
and, as a safety net, for the routine screening of any infant whose mother
was not screened. CDC will work with prevention partners, including the American
College of Obstetricians and Gynecologists, the American Academy of Pediatrics,
the American Academy of Family Physicians, and the American College of Nurse-Midwives,
to disseminate the recommendations and support their implementation. CDC also
will develop guidance for using rapid tests during labor and delivery, or
post partum if the mother was not screened prenatally, and provide training
for health departments and providers in conducting prenatal testing. In 2003,
CDC will expand its activities to monitor the integration of routine prenatal
testing into medical practice.
Reporting of HIV infections to public health authorities is now required
in 49 states. In 2002, CDC initiated a pilot system to monitor HIV incidence.
To track the impact of the new initiative, beginning in 2003, CDC is expanding
this surveillance system by implementing a national behavioral surveillance
system. In addition, CDC will monitor the implementation of these new activities
through several systems, including new performance indicators for state and
local health departments and CBOs.
Stable HIV morbidity and mortality, increased numbers of syphilis and
HIV cases, and growing concern about increasing HIV incidence in some communities
require new strategies to control the spread of HIV in the United States.
Through Advancing HIV Prevention: New Strategies for a Changing Epidemic,
every HIV-infected person should have the opportunity to be tested and have
access to state-of-the-art medical care and to the prevention services needed
to prevent HIV transmission.
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