| Focus
on: Ten Things to Watch for 2004
January's Bulletin brings NASTAD's
annual "Top Ten Things to Watch" series forward with issues we've
identified as most likely to shape HIV/AIDS prevention and care
over the next year and into the future. Many of the issues are consistent
with past lists, but there are some emerging issues to pay attention
to as well. In addition to NASTAD staff, this issue includes top
ten lists from an AIDS director and a representative from a community-based
organization, as well as from NASTAD's African American and Latino
Advisory Committees.
NASTAD's Top Ten
1. 2004 Elections
In November of 2004, the next presidential election will take place
and the entire House of Representatives and one-third of the Senate
will be up for election. Our nation's elected officials will be
faced with increasingly complex and diverse challenges in addressing
the domestic HIV/AIDS epidemic and the global pandemic. The domestic
epidemic is increasingly defined by rising HIV infection rates and
insufficient access to life-saving drugs and primary care. Our national
leaders have begun to formulate a comprehensive national response
to the global pandemic, which will require a significant and sustained
infusion of resources both financial and human. Preventing HIV infection
and expanding access to care and treatment globally and at home
will require strong and continued leadership from all our national
leaders.
To raise awareness among the numerous 2004 Presidential candidates
as to the public policy issues of importance to the HIV/AIDS community,
a coalition of HIV/AIDS service, advocacy, and research organizations
launched a new website, http://www.AIDSVote.org.
The website includes a model presidential platform on HIV/AIDS to
assist presidential candidates in developing their own positions
to address the AIDS pandemic in the U.S. and globally. Many organizations
and individuals, including NASTAD, have endorsed the model platform.
The website will soon include responses from all declared candidates
to an AIDSVote.org questionnaire on HIV/AIDS issues.
The AIDSVote.org website seeks to educate the nation's current
and future leaders, as well as voters, on the issues the HIV/AIDS
community believes are critical to successfully addressing the HIV/AIDS
crisis facing our country and the globe. Some of the platform highlights
include increasing funds for the Ryan White CARE Act (RWCA), AIDS
research funding at the NIH, HIV prevention funding at the CDC,
and the development of a Medicare prescription drug plan that meets
the needs of low- income beneficiaries and people with HIV/AIDS.
The platform also endorses HIV counseling and voluntary testing,
treatment for pregnant women to reduce perinatal HIV transmission
and calls for the repeal of the ban on federal funds for needle
exchange programs. To reduce the incidences of HIV/AIDS globally,
the platform encourages candidates to commit at least $30 billion
to fight AIDS, commit funds for increased research and address the
needs of children orphaned or affected by the epidemic.
In addition to the domestic platform, the Health Global Access
Project has organized a globally focused "Stop
AIDS" campaign. The platform asks candidates to endorse a nine-point
plan to address the global pandemic.
To increase voter participation in communities of color in the
2004 elections, the National
Minority AIDS Council (NMAC) has developed the "2004 Get Out
the Vote Campaign." NMAC is providing information on HIV/AIDS issues
of importance to the HIV/AIDS community as well as links to voter
registration information.
2. Implementation of the Advancing HIV Prevention Initiative
On April 17, 2003, CDC released Advancing
HIV Prevention: New Strategies for a Changing Epidemic-United States,
2003. Building upon the Serostatus Approach to Fighting
the Epidemic (SAFE) and the HIV Prevention Strategic Plan through
2005, Advancing HIV Prevention (AHP) attempts to address
stagnation in progress toward preventing HIV transmissions. The
estimated 40,000 persons infected with HIV annually has not decreased
over the past decade, approximately one-quarter of HIV positive
individuals do not know their serostatus, and 41% of people that
test positive are diagnosed with AIDS within one year. These statistics
indicate the challenges still facing HIV prevention efforts.
Although CDC made available some money in 2003 to begin activities,
2004 will be the first full year of AHP implementation
as CDC incorporates the AHP's goals and strategies into
its activities and funding announcements. The new cooperative agreements
for health departments begin in January 2004 followed by new cooperative
agreements for capacity building assistance (CBA) providers in April
and directly funded community based organizations (CBOs) in July
(see related stories below). All of these announcements incorporate
the four strategies of AHP (see the May
and June
HIV Prevention Bulletins for more information on AHP).
2004 is also the first full year of the AHP demonstration
projects (funded in fall 2003), a combination of CBOs, health departments,
and health care providers funded to gather data on specific interventions
related to AHP. As 2004 progresses, health department and
CBO programs may shift to reflect the priorities of AHP.
However, AHP is not without controversy. Community members
expressed concerns that AHP attempts to "medicalize" HIV
prevention, shifting away from a focus on behavioral interventions
toward increased testing and access to care. AHP's strategies
focus mainly on HIV positive individuals, creating fears that it
would serve to stigmatize positive individuals and prevent them
from seeking services, as well as leaving gaps in services toward
high risk negative populations. Potential shifts in funding also
sparked criticism, particularly around the CBO program announcement.
The directly funded CBO program originally served to increase funding
and access to programs in communities of color through organizations
that were part of the community. Funding changes could potentially
leave gaps in these underserved communities. Finally, given current
strains in Medicaid and Ryan White programs, communities fear that
care and treatment will not be available to those newly diagnosed
with HIV.
CDC has taken several steps to address concerns raised by the community.
In August and September of 2003, CDC held consultations with persons
living with HIV (see the December
HIV Prevention Bulletin for details) and communities of
color respectively to address their issues related to AHP.
CDC also broadened the scope of the directly-funded CBO program
announcement to include high risk negative interventions and noted
that health departments will continue to fund behavioral interventions
through their cooperative agreements as well. At the closing of
the 2003 National HIV Prevention Conference, CDC acknowledged the
community's concerns and committed itself to work with the community
toward ensuring that successful implementation on AHP does
not leave anyone behind.
As 2004 unfolds, the effects of AHP will become clearer,
although it will take years to fully evaluate its impact. CDC, health
departments, and communities impacted by AIDS will be watching closely
to ensure that AHP has the positive influence that is its potential.
1 CDC Advancing HIV Prevention: New Strategies for
a Changing Epidemic-United States 2003. MMWR, April 18, 2003.
3. Reauthorization of the Ryan White CARE Act (RWCA)
Reauthorization of the Ryan White Comprehensive AIDS Resources
Emergency (CARE) Act is slated to occur during 2005, but in preparation
for this process, NASTAD and many other organizations have begun
work to determine positions and recommendations for reauthorizing
the CARE Act. Preparation for reauthorization will be a pressing
issue in HIV care and treatment in 2004. Two issues at the forefront
of reauthorization discussions are AIDS Drug Assistance Program
(ADAP) solvency and funding parity between states.
Fifteen ADAP programs will begin 2004 with closed enrollments or
other program restrictions, and another six anticipate adding new
or additional restrictions within the first three months of the
year. Unfortunately, the remainder of 2004 does not bode any better.
Congressional conferees approved a $38.76 million ADAP increase
for the fiscal year beginning April 1, 2004, an amount far short
of the $214 million necessary to stabilize ADAPs and meet client
demand.
Increases in state funding for ADAPs are unlikely as well. Many
states report difficulty in securing required matching funds for
federal grants, and even more are feeling a crunch within their
budgets as voluntary state spending on ADAPs is slashed to balance
budgets or funnel funds to other programs.
The ADAP funding crisis is further compounded by the CDC's emphasis
on rapid testing and identifying HIV-positive individuals not currently
in care, a seemingly ethical and conceptual conundrum as additional
infected individuals will be turning to ADAP programs for treatment.
ADAPs seem poised for critical financial crises unless a solution
for greater ADAP funding or restructuring of the program arises
during reauthorization of the CARE Act.
Increasing the amount of federal and state funding will prove to
be only part of the solution to the ADAP crisis in 2004. As with
Ryan White CARE Act Title II base funding, the distribution of funds
must also be addressed. Funding disparities between and within states
result in disparities in formulary offerings and thus in client
treatment. For example, state ADAP formulary coverage varies from
some states covering only antiretroviral drugs to other states covering
these drugs and up to an additional 445 drugs on their formulary.
Some states have eligibility criteria at 125% of the federal poverty
level (or roughly $11,075), while some others accept clients earning
up to 500% ($44,300). Reauthorization discussions in 2004 will focus
on this lack of parity, and will likely lead to further dialogue
on a definition of a minimum of core services that must be comparable
between states.
The use of HIV cases in determining formula awards within the CARE
Act will also be a major question in reauthorization. The recently
released Institute of Medicine report recommends delaying use of
HIV cases in formula awards until HIV reporting is in place in all
states and a method for un-duplicating cases across jurisdictions
with varying reporting systems is accomplished. This issue will
remain a hot topic during 2004. The IOM's report on the financing
of HIV care will also be released during 2004 and will be closely
watched in preparation for reauthorization of the CARE Act.
4. NIH Sexual Health Research
During 2003, sexual health research funded by the National Institutes
of Health (NIH) came under increasing scrutiny by select Members
of Congress. As a result, questions have been raised about NIH's
peer review process for selection of grants and the efficacy of
specific research projects. The spotlight on sexual health research
began in July during House floor debate of the FY2004 Labor, HHS,
and Education Appropriations bill. Representative Patrick Toomey
(R-PA) offered an amendment which would bar the NIH from continuing
to fund five specific grants related to sexual health. The amendment
failed by a slim margin of 210-212. The grants included studies
of Native American transgendered individuals and Asian American
sex workers. To follow up on the concerns raised by Rep. Toomey,
Reps. Joseph Pitts (R- PA) and Michael Ferguson (R-NJ) questioned
NIH Director Elias Zerhouni as to the medical benefits hoped to
be derived from the five grants during an October 2, 2003 House
Energy and Commerce Committee on the future of NIH. When Dr. Zerhouni's
staff contacted the Committee to receive information about the five
grants in question, they received an expanded list of 168 grants,
representing $100 million in research funding and relating to HIV/AIDS,
sexual health, substance abuse, and other issues. This list, prepared
by the Traditional Values Coalition, was apparently sent in error;
however, NIH contacted the grantees to alert them of a possible
congressional investigation.
As a result, Members of Congress, including Henry Waxman (D-CA),
Tom Lantos (D- CA) and several Democratic members of the Labor,
HHS Appropriations Subcommittee, have sent letters to HHS Secretary
Thompson expressing their concern over the development of a "hit
list" of grants and the potentially harmful consequences to public
health if NIH is unable to conduct research free of political interference.
In addition, numerous national research-based and sexual health-
related organizations have issued statements or written letters
to Secretary Thompson expressing support for NIH's peer review process
and support for sexual health research. Dr. Zerhouni is expected
to send a written response to the Committee on the efficacy of the
five grants in question in the near future.
In 2004, NIH will continue to be under scrutiny by the House Energy
and Commerce Committee's Oversight and Investigation's subcommittee
as part of a continuing investigation into NIH management and ethics
concerns. Reps. Billy Tauzin (R-LA) and Jim Greenwood (R-PA) have
called upon Zerhouni to turn over various records relating to all
consulting arrangements between NIH employees and drug companies
and other outside activities.
There is increasing concern in the HIV/AIDS community and elsewhere,
that the future of sexual health research funded by the NIH is in
jeopardy. This research is critical to addressing the HIV/AIDS epidemic
particularly in the areas of prevention and care and the development
of drug therapies, vaccines, and microbicides. A new coalition has
been formed, the National Alliance to Support Sexual Health Research
and Policy, comprised of numerous organizations within the behavioral
and social science, public health and reproductive health community,
The intent of the coalition is to educate policymakers regarding
the importance of research on sexual behaviors, HIV-AIDS, sexual
development, substance abuse and their impact on public health.
5. Rising Rates of HIV and STDs among Gay Men and other
MSM
Alarm continues to grow over rising rates of STDs and HIV among
gay men and men who have sex with men (MSM), a trend that has been
reported on over the past several years. MSM still account for the
largest number of infections, with up to 13,562 reported in 2000.
As with the epidemic overall, communities of color are disproportionately
impacted. Particularly alarming are studies documenting the impact
of HIV on young MSM that do not remember the early days of the epidemic.
A study in seven urban areas found that 7% of a sample of MSM between
15 and 22 were infected, with a disproportionate rate of infection
among African Americans (14%) and Hispanics (7%).1
Studies also have shown that gay and bisexual men are less concerned
about HIV infection.1 HAART optimism may be one reason for this
as better treatment options have given the impression that HIV is
not as serious an illness as it used to be. In addition to HIV,
rising rates of primary and secondary syphilis are also a concern.
In 2002, rates of P&S syphilis rose 12.4%, mainly among men, indicating
that the increases were likely occurring among MSM.2
The Epidemic in the Gay Community
Since the early days of the epidemic, AIDS has been thought of
as a gay disease. Although AIDS has always impacted numerous communities,
the gay community initially suffered the greatest impact and became
the most visible. The gay community took the early steps to care
for people infected with HIV and to send strong messages about how
people could protect themselves from infection. As a result of early
gay leadership, rates of HIV among gay men saw dramatic declines,
and an infrastructure of agencies developed to offer HIV services.
As the wider impact of AIDS became clearer, the term "men who have
sex with men" (MSM) became the term used to describe the specific
risk associated with HIV infection. The term MSM focuses on the
behavior and not how an individual identifies, an important distinction
in many communities where male same sex behavior occurs, but the
label gay is considered stigmatizing. The term also served to break
the perception that AIDS is simply a gay disease, allowing agencies
serving the gay community to develop a wider focus on issues impacting
the community. AIDS no longer overwhelmed all other aspects of being
gay.
However, there is increasing concern that gay leadership has become
the missing voice in the epidemic. While using a term such as MSM
to define risk by behavior does encompass a wider group of individuals
at risk, it can also serve to dilute peoples' perception of HIV's
impact. MSM may be thought of as only those who do not identify
as gay. Addressing the needs of MSM that do not identify as gay
remains important, and additional focus on these individuals is
needed to develop effective intervention. Yet it becomes too easy
to forget that many MSM do identify as gay and are active participants
in the gay community. The gay community needs to continue recognizing
AIDS as a priority issue and play a key leadership role in developing
effective prevention and care policy.
For the gay community and its leadership, there are several challenges
to continued leadership on HIV/AIDS. It has taken time for the perception
of AIDS as a gay disease to change. A stronger focus on AIDS could
reverse some of that progress, as well as divert attention from
other critical issues. There also appears to be a need within the
community for more comprehensive prevention messages, ones that
do not solely focus on condom use and recognize that AIDS requires
long term life changes. These messages require a holistic approach,
needing to include the co- occurring epidemics of STDs, hepatitis,
mental illness and substance abuse. Developing and delivering such
complex messages remains difficult. Finally, as one of the earliest
communities impacted by AIDS, a general sense of burnout exists
at all levels.
2004 will see increased focus on the epidemic among gay men/MSM
and the development of effective interventions to reverse this trend.
The role and the importance of leadership from the gay community
will likely be a key part of these discussions.
1 CDC Need for Sustained HIV Prevention Among Men
Who Have Sex With Men. Available at: http://www.cdc.gov/hiv/pubs/facts/msm.htm
2 CDC Primary
and Secondary Syphilis-Unites States, 2002. MMWR November
21, 2003.
6. Epidemic in African American and Latino Communities
HIV/AIDS continues to be a crisis within communities of color.
These communities accounted for over 60 percent of the estimated
numbers of persons living with HIV/AIDS at the end of 2002.1 Of
particular concern is the rate of HIV/AIDS within African American
and Latino communities. In 2001, African Americans accounted for
half (50%) of the new HIV infections reported in the United States
while Latinos accounted for approximately 19% of cases. A comprehensive
analysis of U.S. HIV cases reveals that new HIV diagnoses in 29
states increased in 2002.2 The new analysis of 102,590 people diagnosed
with HIV in the 29 states between 1999 and 2002 shows that African-Americans
continued to account for more than half (55%) the new diagnoses.
Additionally, significant increases in new HIV diagnoses were observed
among Latinos (26% increase). Because many states with large Latino
populations are not included in this analysis, Latinos may account
for an even greater percentage of new HIV infections nationally.
While men still comprise the bulk of the epidemic in these communities,
in recent years there has been a rise in cases among African American
and Latino women and adolescents.3
As we look more intensively at the disproportionate nature of the
epidemic in African American and Latino communities, there are particular
issues of concern that need to be addressed in 2004. The United
States has experienced an enormous growth in its Latino population.
With this growth comes a largely diverse mixture of cultures as
well as challenges to addressing the health needs and concerns of
this community. In terms of HIV-related behavior, according to CDC,
"HIV exposure risks for U.S.- born Hispanics and Hispanics born
in other countries vary greatly, indicating a need for specifically
targeted prevention efforts."4
Areas of concern for African Americans include the rate of HIV
infection among MSM and concerns around the impact of the epidemic
on what has been commonly referred to as "men on the down low."
Within the past few years there has also be a noticeable rise in
the rates of HIV infection among African American women. African
American women accounted for 66% of HIV cases among female adults
and adolescents reported to CDC through December 2002.5
As stigma and shame continue to prevail in communities of color
in general, challenges remain in addressing the epidemic in these
communities and ensuring equitable treatment and access to care.
The recently released NASTAD document, Addressing
HIV/AIDS: Latino Perspectives & Policy Recommendations and the
NASTAD African
American Monograph, HIV/AIDS: African American Perspectives and
Recommendations for State and Local AIDS Directors and Health Departments
released in 2001, are tools that have been developed to assist health
departments in addressing HIV/AIDS prevention and program development
for these communities. NASTAD is currently developing a "communities
of color tool-kit" that will contain specific tools and resources
for health departments in carrying out the recommendations of the
African American Monograph. Although this tool-kit is a follow-up
to the Monograph, this tool will also contain materials to address
the HIV/AIDS epidemic in Latino and other communities of color.
In 2003 we have seen HIV prevention programs face a heightened
level of scrutiny even as state level resources face massive budget
constraints. State level programs not only face increased pressure
in demonstrating the level of effectiveness of their programs, they
also face increased levels of accountability around ensuring that
resources are reaching the communities at greatest need. In 2004
there must be a renewed level of commitment to communities of color
and a more coordinated response amongst state and local health departments,
federal and national partners as well as the communities most affected.
1 Centers for Disease Control and Prevention. HIV/AIDS
Surveillance Report 2002; vol. 14 (p. 18).
2 Centers for Disease Control and Prevention. Morbidity
and Mortality Weekly Report (MMWR), November 28, 2003/ 52(47); 1145-1148.
Increases
in HIV Diagnoses --- 29 States, 1999--2002.
3 Centers for Disease Control and Prevention. Fact Sheet,
"HIV/AIDS Among African Americans: Key Facts." Updated July 2003.
4 Centers for Disease Control and Prevention. Fact Sheet,
"HIV/AIDS Among Hispanics in the United Sates." Updated March 2002.
5 Centers for Disease Control and Prevention. HIV/AIDS
Surveillance Report; vol. 14, Addendum (p. 6).
7. CBO and CBA Program Announcements
On December 2, 2003, CDC released Program
Announcement 04064 - Human Immunodeficiency Virus (HIV) Prevention
Projects for Community-Based Organizations and Program
Announcement 04019 - Capacity Building Assistance to Improve the
Delivery and Effectiveness of Human Immunodeficiency Virus (HIV)
Prevention Services for Racial/Ethnic Minority Populations.
Under these program announcements, organizations will compete for
$47 million in available funding for directly-funded CBOs and $21
million in available funding for capacity building assistance (CBA)
providers. The Minority HIV/AIDS Initiative (MHAI) is the key source
of funding for directly-funded CBOs and CBA activities.
Significant changes have been made to the program announcement
for directly- funded CBOs to make the program consistent with Advancing
HIV Prevention. Newly funded CBOs will be encouraged, but not
required, to implement rapid testing. CBOs with limited capacity
to meet regulatory and quality assurance requirements to conduct
rapid testing, including obtaining a CLIA certificate of waiver,
may find themselves unable to implement rapid testing. In addition,
for all proposed program activities, applicants must adopt CDC procedures
and protocols for interventions, including Replicating Effective
Programs (REP) and Diffusion of Effective Behavioral Interventions
(DEBI). Only interventions that are consistent with these procedures
will likely be funded. Significant new program evaluation requirements
are included. Newly funded CBOs will be required to report client
level evaluation data to CDC's Program Evaluation and Monitoring
System (PEMS). Directly-funded CBOs will be required to set baseline
level, annual targets, and overall target levels of performance
for each core indicator identified by CDC.
NASTAD and community organizations had expressed concerns about
the extent to which directly-funded CBOs would be allowed to target
prevention services, particularly health education/risk reduction
(HE/RR), to HIV negative individuals. The CBO program announcement
allows CBOs to apply for funding to conduct outreach and HE/RR for
high risk individuals; targeted outreach and counseling, testing
and referral (CTR) services for high risk individuals; prevention
interventions for individuals at very high risk for HIV infection.
However, it appears that outreach and HE/RR activities for HIV negative
individuals can be implemented only as long as they are connected
to bringing greater numbers of individuals in for HIV testing (and
linking them to care services).
Interestingly, the Capacity Building Assistance (CBA) program announcement
is vastly similar to the previous program announcement. What's new
is CDC's intention to integrate the various capacity building and
technical assistance systems for directly-funded CBOs, CBOs funded
by state and local health departments and HIV prevention community
planning groups.
Watch for the final award decisions under both the CBO and CBA
program announcements. Expect national organizations, CBOs, community
leaders and other prevention stakeholders to continue to insist
that resources under these programs target minority communities
and to closely monitor the range of interventions and programs that
receive funding under these announcements.
8. Implementation of the New Health Department Program
Announcement
In 2004, health departments will be entering into new five-year
cooperative agreements with CDC for HIV prevention programs. CDC
released Program Announcement 04012 in June 2003 for projects beginning
on January 1, 2004. While the required components of a comprehensive
HIV prevention program are basically the same as in previous years,
the emphasis of the overall program has shifted to reflect the goals
of CDC's Advancing HIV Prevention (AHP) initiative and
requirements for some components have changed. In addition, CDC
released a revised HIV
Prevention Community Planning Guidance in 2003.
To reflect the goals and strategies ofAHP, the new program
announcement emphasizes counseling, testing and referral for those
who are unaware of their HIV infection and prevention services for
people living with HIV, as well as strengthened perinatal prevention
efforts. As part of this shift, CDC is focusing efforts to make
rapid testing more available and accessible and has been holding
a series of trainings on rapid testing. As mentioned above, the
rapid ramp-up of rapid testing will likely impact the implementation
of the CTR requirements in the program announcement as states work
to ensure that testing programs meet their state statutes and administrative/regulatory
requirements.
Another facet of the increased emphasis on the goals of AHP
is increased efforts to provide prevention services for persons
with HIV. Information on effective prevention interventions for
positives has been rolling out and more should be coming in 2004.
In its revised community planning guidance, CDC made it a requirement
that community planning groups prioritize HIV infected persons as
their highest priority. Planning groups, particularly those in the
middle of multi-year planning cycles, will be continuing to look
to CDC for guidance on their expectations around making this shift
in their priorities in the coming year.
One significant addition in the program announcement furthers CDC's
efforts to increase accountability. A core set of program performance
indicators were added on which jurisdictions were required to set
up baseline measures and initial one and five-year performance targets.
Given the short timeframe for states to respond to these new requirements,
CDC is providing the opportunity for jurisdictions to revise their
baselines and performance targets over the next couple years. CDC
has analyzed the information submitted with the cooperative agreements
and will provide feedback on the indicators to jurisdictions. Along
with the indicators, CDC is developing a client-level Program Evaluation
Monitoring System (PEMS) for both health departments and directly-funded
CBOs, currently slated to be rolled out in summer 2004. Health departments
can expect further direction and requests from CDC about their evaluation
programs and the performance indicators throughout 2004.
CDC also provided more specificity around the existing programmatic
requirements for the capacity building and quality assurance components.
While these added requirements may be in line with existing practices
in many places, others may have to make adjustments to their programs
to meet these requirements. Another modification was made around
program performance reviews. In addition to the local review panel's
work to certify HIV educational materials developed through the
cooperative agreement, CDC has required a second review by the state
or local health official. The impact of this change is unclear,
but ongoing concerns around changes to existing policies around
program review panels are likely to continue in 2004.
Finally, as in other years, Congress failed to finalize a budget
before the fiscal year ended. This resulted in several continuing
resolutions in fall 2003 to keep the government running. What this
means for health department HIV prevention cooperative agreements
is that CDC will award 25% of the total cooperative agreement award
to each jurisdiction with the initial notice of grant award (December
2003). Once a budget is finalized (hopefully in January 2004), CDC
will award the remaining 75% of the funding, yet the delay in getting
the total awards to jurisdictions will create many challenges for
health departments' ability to award contracts and implement programs.
Another wrinkle is that, although it looks as though domestic HIV
prevention programs will be level funded, an across-the-board .59%
rescission in the appropriations bill will result in a $4 million
cut in CDC HIV prevention funding. The FY04 funding levels have
yet to become law, but are expected to be finalized in late January.
As of press time, the impact of this rescission on health department
HIV prevention cooperative agreements is unknown.
9. HIV Surveillance
Institute of Medicine Report
On November 7, 2003, the Institute of Medicine (IOM) released the
report Measuring What Matters: Allocation, Planning, and Quality
Assessment for the Ryan White CARE Act. The report, authorized
by the Ryan White CARE Act Amendments of 2000, examined three questions
including the accuracy of state HIV reporting systems and the ability
to use that data to make funding allocations, specifically for Title
I and II. At this time, IOM has indicated that HIV data should not
be used in funding decisions. The main reasons include the newness
of some state systems which impacts the quality of their data and
that CDC currently does not accept data from states with non-name
based reporting systems. IOM charged CDC with the responsibility
to address issues related to non-name based HIV reporting so that
data can be accepted from these states. CDC will be developing a
response to the IOM report in 2004.
New Program Announcement
In October 2003, the CDC released Program Announcement 04017 which
outlines the HIV/AIDS surveillance activities that will be funded
for the next three years. In addition to core surveillance activities,
the program announcement outlines other activities such as HIV incidence
surveillance, behavioral surveillance, HIV drug resistance surveillance,
etc. which are outlined below. These projects will be implemented
and or expanded to additional sites in 2004. The projects will further
describe characteristics of the HIV epidemic.
* HIV Incidence Surveillance
This project will provide reliable and scientifically valid estimates
of the number of newly acquired infections at the local, state,
and national level. Data obtained will help describe the epidemiologic
characteristics and risk factors for new HIV infections, identify
populations at risk for new HIV infection, focus prevention efforts
to where they are most needed and monitor HIV incidence trends.
However, many challenges remain in the development and implementation
of incidence surveillance. Estimating incidence requires additional
data on testing behavior from persons testing HIV positive. This
data can be gathered during the initial testing session, when results
are given, or as a separate follow-up with clients once results
have been given. In addition, some states require detailed informed
consent for clients that consent to incidence surveillance. Each
state may adopt a different approach to how they implement incidence
surveillance. A total of 35 sites will be funded for this project.
* Behavioral Surveillance
The objectives of this program are to: 1.) develop an ongoing surveillance
system to ascertain the prevalence of HIV risk behaviors among groups
at high risk for HIV infection for use in developing and directing
national prevention services and programs; and 2.) to evaluate the
impact of a variety of prevention efforts. The program funds the
recruiting of at-risk individuals from non-health care community
settings using a scientifically sound methodology. The program will
assess high risk behaviors and trends in behaviors over time among
adults 18 years old and older at high risk for HIV infection through
sexual behavior between men and injection drug use. Studies may
also be expanded to include high risk heterosexuals. Sites that
receive funding will be required to collaborate with CDC's directly-funded
CBOs, CBOs funded by state and local health departments, schools
of public health, universities, ethnographers and behavioral scientists.
Eligibility is limited to state and local health departments in
the top 26 Metropolitan Statistical Areas (MSA's) by the number
of people living with AIDS at the end of 2000.
* HIV Drug Resistance Surveillance
Sites funded to conduct HIV Incidence Surveillance are also eligible
to apply for funding to conduct HIV Drug Resistance Surveillance.
Sites will be funded to collaborate with the CDC in developing procedures
for obtaining the appropriate specimens to monitor transmission
of atypical strains of HIV, including antiretroviral drug resistant
strains of the virus. The project will attempt to estimate the prevalence
of antiretroviral drug resistance among people who are newly diagnosed
with HIV. Participants in this project can request an individual
report be forwarded to their clinician within 2-4 weeks of testing.
The report can be utilized by some health care providers in considering
treatment options with the patient.
10. Global AIDS
"We must meet the challenge of expanding access to HIV treatment."
Peter Piot, Executive Director, Joint United Nations Programme on
HIV/AIDS (UNAIDS)
With an estimated 40 million people living with HIV throughout
the world, never has the linkage between prevention and care been
as significant. One of the strongest weapons to reduce the burden
of disease globally is increasing access to HIV anti- retrovirals
(ARV), which as part of a prevention plan can significantly decrease
HIV transmission. Clinically, ARVs help reduce the transmission
of HIV, for example preventing mother-to-child transmission. In
addition, when clients access medications, it affords an opportunity
for health care workers to provide secondary prevention activities
for positive individuals.
The first step towards providing increased access to treatment
is to expand voluntary counseling and testing (VCT) services. The
Joint United Nations Programme on HIV/AIDS states that knowledge
regarding HIV status is an important component of preventing further
transmission. The availability and promotion of HIV counseling and
testing affords individuals greater opportunity to learn their status
and to begin taking steps to prevent transmitting the virus. VCT
affords the opportunity to link clients to additional prevention
services, and if clients are positive, counselors can provide a
direct link to care and treatment services.
Globally, WHO and UNAIDS released a detailed and concrete plan
to reach the target of providing ARVs to three million people living
with HIV/AIDS in developing countries by 2005. This is a vital step
towards the ultimate goal of providing universal access to HIV/AIDS
treatment to all those who need it. Known as "3 by 5," this program
will: provide s implified, standardized tools to deliver antiretroviral
therapy; create an effective, reliable supply of medicines and diagnostics;
support rapid identification, dissemination and application of lessons
learned and successful strategies; provide urgent, sustained support
(technical and human) for countries; and support global leadership,
strong partnership and advocacy. As part of the human support, 100,000
health care workers will be trained on how to administer combination
therapy and how to monitor clients' response to medication without
the use of laboratory tests.
In the U.S., President Bush has committed to scaling up the response
to the HIV/AIDS epidemic. In 2003, he announced the President's
Emergency Plan for AIDS Relief, a five-year, $15 billion initiative
to turn the tide in combating the global HIV/AIDS pandemic. This
commitment of resources will help the most afflicted countries in
Africa and the Caribbean (12 in Africa and 2 in the Caribbean) fight
the war against HIV/AIDS and extend and save lives. Specifically,
the initiative is intended to prevent 7 million new infections,
treat 2 million HIV-infected people and care for 10 million HIV-infected
individuals and AIDS orphans.
The urgency to combat this disease has never been more evident.
As all sectors come together to rally behind this issue, the increased
political will and financial commitments of governments and private
foundations allow programs like the Global Fund to Fight AIDS, TB,
and Malaria to help Ministries of Health and non- governmental organizations
in developing countries improve their infrastructure and build the
human resource capacity necessary for effective HIV prevention programming.
For more information please visit: WHO
3 by 5 and President's
Emergency Plan for AIDS Relief.
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Top Ten Things to Watch
for in 2004
By Mark Jason McLaurin
Associate Director for Prevention Policy
Gay Men's Health Crisis
1. Presidential Election
No one factor will be more important in the arena of HIV prevention
and treatment than who is elected in November to serve as our President
in the next four years. Activists and advocates have already devised
a comprehensive HIV platform and are using it as a launching point
for discussions with all the candidates, Republican and Democratic.
It is crucial that whoever is elected (or re-elected), that he/she
understand that HIV/AIDS remains a devastatingly lethal disease
both globally and domestically.
2. CDC Prevention Awards
Sometime in the month of April, 2004, CDC will announce which community-based
organizations have been chosen to receive direct support for their
prevention activities. This announcement will play a critical role
in deciding whether communities most hard hit by the virus receive
the support they need to stem the tide. This announcement is even
more crucial as the CDC is, with this announcement, combining what
had heretofore been discrete sources of support. What this means
is that, should an organization (or a community) fail to receive
support under this announcement, there will be very few other opportunities
to compete for other resources with the CDC.
3. YMSM of Color Crisis
We were first made aware nearly two years ago (and subsequent studies
have confirmed) that there is, perhaps, no singularly most disproportionately
impacted demographic with regards to HIV than Young MSM of Color
(especially African Americans and Latinos). Resources are just beginning
to target this community, but the monstrous size of the problem
places into clear relief the need for similarly monstrous sized
efforts and resources to be devoted to this population.
4. The rise of unsafe behaviors among MSM
Recent behavioral data from studies such as the (unsuccessful)
VAXGen Vaccine Trial and the resurgence of syphilis among MSM (a
large proportion of who are co-infected with HIV), clearly point
to a rise in unsafe sexual practices, especially among white urban
MSM. We must be vigilant in re-enforcing that HIV is not an inevitable
part of membership in the gay community and that respect for your
own personal health and the health of your partners is an essential
building block of this community.
5. Crystal Methamphetamine Usage
Anecdotal reports from community health workers on the frontlines
and emerging behavioral science data suggest that substance use,
especially the use of crystal methamphetamine, are playing a large
role in facilitating the transmission of HIV, especially among predominantly
urban, white gay men. While everything about this nexus is not yet
clear, it would appear that crystal misuse inclines one towards
increased appetite for sex and sexual partners, increased stamina
and ability to perform sexually without resting periods and lower
inhibitions around the types of sex and the degree to which such
sex is safer sex. This confluence of factors appears to be a lethal
combination and represents a relatively new (or newly recognized)
chapter and area of specialty for HIV prevention workers.
6. Prevention for Positives
One of the announced goals of CDC's new "Advancing HIV Prevention"
is increased focus on HIV + persons in the context of HIV prevention.
While this is a welcomed and laudable goal (and one long advocated
for by HIV prevention advocates), it is important that resources
remain available for individuals who are at-risk for HIV, that the
prevention environment for positive persons remain one that is absolutely
free of "blaming and shaming" and that we work towards fostering
an environment where people are responsible for and to both themselves
and each other.
7. Rapid Testing
Last year, the FDA finally approved for use OraQuick, a test that
allows preliminary HIV test results in less than thirty minutes.
While this revolutionizes the world of HIV testing and will do wonders
to increase the rate at which persons who test return for their
results, it is important that advocates keep a close eye on ensuring
that rigorous pre and post test counseling requirements be adhered
to and that sufficient resources are placed into the HIV care infrastructure
to allow those who do test positive, to access adequate care services.
8. Ideological Interference with Research
One of the newer developments of the past year, and one that we
anticipate will continue into next year, is the degree to which
ideology has been allowed to influence heretofore sacrosanct scientific
decisions. This has been seen in issues ranging from environmental
protections down to appointments to various executive branch advisory
commissions. Most important, however, are the attacks on NIH funded
behavioral science studies. While they often study subjects of a
controversial nature, it is these very studies which are critical
to developing and implementing effective strategies to address [behavioral
risk among] many populations who are at high risk for both contracting
and transmitting HIV. We must allow the scientific community to
have the widest possible berth in their efforts to help the prevention
community stop the transmission of HIV.
9. Health Education and Risk Reduction Activities
Many community based HIV prevention providers have found themselves
under attack from conservative ideologues on the degree to which
their HIV prevention materials and the HERR activities they engage
in are too explicit. What twenty plus years of HIV prevention has
taught us is that diverse communities and sub- populations call
for similarly diverse interventions which, sometimes, need to be
explicit and talk to people in language and terms with which they
are most familiar. In the face of such a virulent foe, HIV prevention
providers cannot be allowed to be distracted or intimidated by their
federal resource partners (egged on by conservative activists) questioning
proven effective behavioral interventions.
10. Critical Research Gaps among African American MSM
One of the critical needs that must be addressed by researchers
is the devastatingly disproportionate impact HIV has had on African-American
MSM. What little data we have suggests the following paradox: African
American MSM report no more than equal to, and in many cases less,
high risk sexual behavior than white gay men. Yet HIV infection
continues to exact a far greater toll among the former. We must
demand that research into this central question, be started immediately;
we may not have a definitive answer this year, but a failure to
begin the journey towards one, is inexcusable.
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Ten Things to Watch
in 2004
By Steven Tierney, Ed.D.
Director - HIV Prevention
City and County of San Francisco
1. Crystal Methamphetamine
This drug has fueled a sea change in sexual and injection risk
behavior in gay men and other MSMs. Prevention programs should be
designed and delivered that include treatment for drug addiction
and offer harm reduction interventions for recreational drug users.
This dual approach is our best opportunity to reduce risk behavior
across the community.
2. Rapid HIV Testing Technologies
These tests will allow us to engage hard to reach populations more
effectively and get the clients their results and an entree to services.
Pre and post test counseling is being re-designed to meet the needs
of the clients using this testing technology.
3. Testing as Part of Routine Medical Care
San Francisco supports increasing the access to HIV testing by
increasing screening at primary care settings. The ability of physicians
to provide "time-consuming" counseling and referrals is a challenge.
Our new Partner Disclosure Assistance Program will support primary
care providers in delivering a continuum of services. The willingness
of primary care providers to gather client data is also a question
that remains to be answered.
4. PEMS
The introduction of the PEMS and program indicators will provide
important information for federal and local health planning groups
and officers. There is little question that these new systems will
create administrative and clerical demands (as well as the need
for training and technical assistance) on CBOs, local health departments
and the CDC. Level funding of CDC (and by CDC) mean that direct
services will have to be cut to provide the funds for data collection
and analysis.
5. Prevention Services for People Living with HIV/AIDS
San Francisco welcomes the increased attention to these vital services.
These initiatives will naturally serve as bridges between HIV prevention
efforts and HRSA funded care programs. Identifying methods for integrating
these resources will require Solomon's wisdom.
6. African Americans
The African American population in San Francisco (8% of the City's
population) is disproportionably impacted by new HIV infections.
More than 60% of the infections are among African American gay and
other MSMs. Programs must be designed and delivered which understand
and effectively communicate health messages with meaning for this
population. Additionally, despite small actual numbers, African
American women and youth must have access to health and HIV prevention
services which respond to this disproportionate impact.
7. Night Services San Francisco is committed to meeting clients
where they "really are." In recent years many established services
have moved away from late evening and night outreach. Studies (and
common sense) indicate that the community members who are on the
streets between midnight and dawn are at high risk based on drug
and sexual behavior. HIV and STD prevention services must be designed
for these community members. Methods for motivating agencies to
deliver night services will be implemented.
8. Joint HIV-STD Programs
San Francisco has done an excellent job in offering joint HIV-STD
programs and strongly supports efforts to do so nationally. A series
of mutually supportive social marketing campaigns, linked testing
and treatment services and projects and referral networking has
begun to show positive outcome measures. Please refer to the following
websites for more information on these social marketing campaigns:
http://www.magnetsf.org/,
http://www.newcondoms.org,
http://www.hivstopswithme.org/
and http://www.healthypenis2003.org
9. Political and Economic Changes
We have a new Mayor and a new Governor. One is a Democrat and the
other a Republican. HIV prevention resources for the city and county
come from federal, state and city funds. Developing relationships
with our new leaders will be critical. Both the Governor and the
Mayor have stated strong support for HIV/AIDS prevention, care and
research. Their leadership and support in dealing with the federal
bureaucracy will be important. The challenges we face in California
include the roll out of CDC's Advancing HIV Prevention
initiative to identify more HIV positive individuals. A serious
budget cutting proposal in the state capitol calls for capping the
ADAP program. These two initiatives are clearly at odds.
10. Effective HIV Prevention
San Francisco believes that HIV prevention efforts have been successful.
Our evaluation efforts have told that story. We welcome new initiatives
from Washington and Atlanta aimed at improving HIV prevention. We
encourage all health departments and CBOs to embrace evaluation
and research.
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Ten Issues for Communities
of Color
NASTAD spoke with its African American and Latino Advisory Committees
via conference call to identify the following top ten issues impacting
communities of color in 2004. These committees are comprised of
African American and Latino AIDS Directors and senior-level program
staff who have a particular interest in working with NASTAD on specific
communities of color initiatives.
1. Focus on Prevention with Positives
As prevention providers begin to implement Advancing HIV Prevention
and as more focus is being placed on prevention with positives,
there is a potential for increasing stigma, particularly in communities
of color. In many ways, these communities are already undervalued,
seen as vectors of disease and, therefore, ultimately deserving
of poor health outcomes.
2. Moving Towards a Medical Model
The federal government seems to be moving to more of a medical
model to address HIV/AIDS. This is concerning in that many communities
of color continue to be distrustful of traditional medical approaches,
in many cases for good reason. Exacerbating this concern is the
lack of health insurance among many African Americans and Latinos.
3. Rapid Testing/Use of Oraquick
Rapid testing (Oraquick) has the potential to empower people of
color to know their HIV status, seek the appropriate treatment and
protect others. However, implementation of rapid testing is proving
to be complex and many communities of color do not feel this will
be a panacea for addressing the epidemic in communities of color.
4. Access to Services
Access to services continues to be an issue of concern for persons
living with HIV/AIDS. As we move to a medical model of care and
treatment, access to other important care services for communities
of color are dwindling. This continues to be a particular issue
of concern for communities of color who in many ways are already
disenfranchised.
5. Culturally Sensitive Providers
As HIV/AIDS becomes more and more an epidemic of people of color,
it is extremely important to have culturally sensitive providers
who can better understand and address the unique needs, concerns
and challenges faced by persons of color living with HIV/AIDS.
6. Lack of Research, Interventions and Participation in Research
There is a tremendous need for research and proven behavioral interventions
that can effectively address the needs of communities of color.
The development of effective behavioral interventions for communities
of color should be a priority in 2004. Additionally there needs
to be more advocacy around the participation of people of color
in vaccine research to ensure that these studies are appropriate
and ethically sound.
7. Competing Priorities
Many communities of color have to contend with a multitude of challenges
throughout their daily lives. Concerns of health and health status
often become another competing priority rather than a central focus.
How can we bring attention back to this issue and re-energize African
American leadership and other communities of color in 2004?
8. Addressing Both Men and Women
African American women and Latinas constitute a growing number
of new HIV infections among women. Specific strategies need to be
developed targeting heterosexual African American women and Latinas
in particular and there must be increased efforts to support their
representation on community planning bodies and on the development
of targeted prevention interventions. At the same time, given that
African American and Latino gay, bisexual, non gay-identified men
who have sex with men and heterosexual men make up a large percentage
of HIV/AIDS cases in communities of color, prevention interventions
for these populations need to be a focus in 2004.
9. Epidemic in Rural America and the South
There is growing concern around the spread of HIV/AIDS among communities
of color in the south and in rural America. What can we do to address
these populations that too often harbor shame and are afraid to
access services? How much of an impact can we really have with little
financial support going to these communities to address the epidemic
especially the amount of Minority HIV/AIDS Initiative dollars going
to some of these rural populations? Since the largest percentage
of increases in Latino populations occurred in southern states (North
Carolina, Arkansas, Georgia, Tennessee and South Carolina) how will
prevention programs be tailored and targeted to meet the diverse
cultural and linguistic characteristics of Latinos in 2004?
10. Medicare Drug Benefit
How will this drug benefit impact communities of color, who are
the primary users of Ryan White services in the coming year?
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