The Global Engagement in Care Convening: Recommended Actions to Improve Health Outcomes for People Living With HIV.

The National HIV AIDS Strategy (NHAS) calls for a more coordinated response to the HIV epidemic. The Global Engagement in Care Convening created a forum for domestic and international experts to identify best practices in HIV care. This manuscript summarizes the meeting discussions and recommendations from meeting notes and an audio recording of the meeting. Recommendations include: further standardization of performance goals and performance measures; additional research; a more robust system to support competing needs of clients receiving services; electronic information exchanges for HIV-related data; an expansion of the role of other health professionals to extend the capacity of physicians and other members of the care team; and revisions to current financing systems to increase reimbursement for and access to services that promote linkage to and retention in HIV care. The recommendations provide a unique example of "reverse technical assistance" and will inform U.S. program development, research, and policy.

Informational privacy and the public's health: the Model State Public Health Privacy Act.

Protecting public health requires the acquisition, use, and storage of extensive health-related information about individuals. The electronic accumulation and exchange of personal data promises significant public health benefits but also threatens individual privacy; breaches of privacy can lead to individual discrimination in employment, insurance, and government programs. Individuals concerned about privacy invasions may avoid clinical or public health tests, treatments, or research. Although individual privacy protections are critical, comprehensive federal privacy protections do not adequately protect public health data, and existing state privacy laws are inconsistent and fragmented. The Model State Public Health Privacy Act provides strong privacy safeguards for public health data while preserving the ability of state and local public health departments to act for the common good.

The Serostatus Approach to Fighting the HIV Epidemic: prevention strategies for infected individuals.

In the United States, HIV prevention programs have historically tailored activities for specific groups primarily on the basis of behavioral risk factors and demographic characteristics. Through the Serostatus Approach to Fighting the Epidemic (SAFE), the Centers for Disease Control and Prevention is now expanding prevention programs, especially for individuals with HIV, to reduce the risk of transmission as a supplement to current programs that primarily focus on reducing the risk of acquisition of the virus. For individuals with HIV, SAFE comprises action steps that focus on diagnosing all HIV-infected persons, linking them to appropriate high-quality care and prevention services, helping them adhere to treatment regimens, and supporting them in adopting and sustaining HIV risk reduction behavior. SAFE couple a traditional infectious disease control focus on the infected person with behavioral interventions that have been standard for HIV prevention programs.

Are we headed for a resurgence of the HIV epidemic among men who have sex with men?

HIV remains a critical health issue for men who have sex with men (MSM). In the United States, an estimated 365,000 to 535,000 MSM are living with HIV, and 42% of new HIV infections occur in this population. Recent data on sexually transmitted diseases and on sexual behavior indicate the potential for a resurgence in HIV infections among MSM. Outbreaks of gonorrhea and syphilis have been reported in a growing number of cities, and several studies have observed an increase in unprotected anal intercourse among MSM. These increases in HIV risk behavior may be attributed to several factors that have affected the sexual practices of MSM, including changes in beliefs regarding the severity of HIV disease. These emerging data have implications for surveillance and intervention research activities and indicate a need to reevaluate, refocus, and reinvigorate HIV prevention efforts for MSM. Our recommendations for addressing the HIV prevention needs of MSM include the need to consider HIV-related issues within the broader context of the physical, mental, and sexual health of MSM.

Decision-making in HIV prevention community planning: an integrative review.

Since 1994, the Centers for Disease Control and Prevention has required that the 65 health department grantees that receive funding for HIV prevention interventions engage in a community planning process to involve affected communities in local prevention decision making; to increase the use of epidemiological data to target HIV prevention resources; and to ensure that the planning process takes into account scientific information on the effectiveness and efficiency of different HIV interventions. Local community planning groups are charged with identifying and prioritizing unmet HIV prevention needs in their communities, as well as prioritizing prevention interventions designed to address these needs. Their recommendations, in turn, form the basis for the local health department's request for HIV prevention funding from the Centers for Disease Control and Prevention. Given the community planning process's central role in the allocation of federal HIV prevention funds, it is critical that sound decision-making procedures inform this process. In this article, we review the basics of the community planning prioritization process and summarize the decision-making experiences of community planning groups across the US. We then describe several priority-setting tools and decision analytic models that have been developed to assist in HIV community planning prioritization and discuss their strengths and weaknesses. Finally, we offer suggestions for improving the decision-analytic basis for HIV prevention community planning.

The context of HIV/AIDS surveillance.

HIV surveillance and diagnostic testing for HIV infection share elements in common, yet differ notably in context. Clinical testing provides vital information for individual medical and behavioral decisions, whereas surveillance, which focuses on populations, provides information to develop policy, direct resources, and plan services. HIV/AIDS surveillance has evolved over the course of the epidemic, reflecting changes in scientific knowledge, populations affected, and information needs. Likewise, the benefits of early diagnosis of HIV have become increasingly apparent with advances in HIV treatment. This article examines the changing context of HIV/AIDS surveillance and discusses the potential impact of HIV surveillance practices and policies on HIV testing behaviors. Special emphasis is placed on the importance of protecting the confidentiality of HIV/AIDS surveillance data and on the role of health department in monitoring the impact of surveillance policies on test-seeking patterns and behaviors.

Trends in HIV seropositivity in publicly funded HIV counseling and testing programs: implications for prevention policy.

INTRODUCTION: We describe trends in seropositivity among clients attending publicly funded HIV counseling and testing sites across the United States and discuss implications for prevention policy. METHODS: The present analysis used client-level data from 1990 through 1994 for 26 of 65 state, territorial, and local health departments receiving Centers for Disease Control and Prevention funds. Logistic regression was used to predict the proportion of HIV tests that were positive. Curves were created representing adjusted HIV seropositivity trends for 1990 through 1994. RESULTS: HIV seropositivity rates were higher before 1992. Throughout, rates were higher among men, most racial/ethnic minorities tested, and persons 30 years or older. Although rates for men remained higher than those for women, the gap has narrowed in recent years. For both men and women, rates remained low for those reporting heterosexual activity as their only potential risk for HIV. Over time, more high-risk seronegatives are being repeatedly tested. CONCLUSIONS: Lower, stabilized seropositivity rates after 1992 reflect large increases in testing volume, increasing frequency of repeat testing, and fewer asymptomatic-infected persons entering this public system. Various program innovations including enhanced outreach, improved access, rapid testing, and client-centered counseling should be considered as strategies to increase the number of infected persons who learn their serostatus early and enter into medical care.

HIV counseling and testing: its evolving role in HIV prevention.

The development of an enzyme-linked immunosorbent assay (ELISA) for screening blood for antibodies to HIV was a major milestone in the history of AIDS prevention and treatment. Since early 1985, the Centers for Disease Control and Prevention (CDC) has provided public funds to state and local health departments to support a national HIV counseling-and-testing (HIV CT) program directed toward persons at risk of transmitting or becoming infected with HIV. The implementation and ongoing development of this national program has often been marked by intense policy debate, especially in the area of mandatory testing. Furthermore, the lessons learned during its 11-year program history are highly relevant to understanding the challenges that might arise when implementing other new biomedical or behavioral HIV prevention technologies. Using the construct of public health infrastructure, this article describes key features, events, lessons learned, and future challenges of this evolving national prevention program.

Cost-effectiveness of HIV-prevention skills training for men who have sex with men.

OBJECTIVE: A previous study empirically compared the effects of two HIV-prevention interventions for men who have sex with men: (i) a safer sex lecture, and (ii) the same lecture coupled with a 1.5 h skills-training group session. The skills-training intervention led to a significant increase in condom use at 12-month follow-up, compared with the lecture-only condition. The current study retrospectively assesses the incremental cost-effectiveness of skills training to determine whether it is worth the extra cost to add this component to an HIV-prevention intervention that would otherwise consist of a safer sex lecture only. DESIGN: Standard techniques of incremental cost-utility analysis were employed. METHODS: A societal perspective and a 5% discount rate were used. Cost categories assessed included: staff salary, fringe benefits, quality assurance, session materials, client transportation, client time valuation, and costs shared with other programs. A Bernoulli-process model of HIV transmission was used to estimate the number of HIV infections averted by the skills-training intervention component. For each infection averted, the discounted medical costs and quality-adjusted life years (QALY) saved were estimated. One- and multi-way sensitivity analyses were performed to assess the robustness of base-case results to changes in modeling assumptions. RESULTS: Under base-case assumptions, the incremental cost of the skills training was less than $13,000 (or about $40 per person). The discounted medical costs averted by incrementally preventing HIV infections were over $170,000; more than 21 discounted QALY were saved. The cost per QALY saved was negative, indicating cost-savings. These results are robust to changes in most modeling assumptions. However, the model is moderately sensitive to changes in the per-contact risk of HIV transmission. CONCLUSIONS: Under most reasonable assumptions, the incremental costs of the skills training were outweighed by the medical costs saved. Thus, not only is skills training effective in reducing risky behavior, it is also cost-saving.

The acceptability of voluntary HIV antibody testing in the United States: a decade of lessons learned.

OBJECTIVE: As the benefits of early diagnosis of HIV increase, US adults are more likely to be offered HIV counseling and testing in settings where they may not seek testing. Rates and determinants of counseling and testing acceptance in these settings are poorly understood. DESIGN: We reviewed articles and abstracts published from 1985 to 1995 which addressed rates or determinants of counseling and testing acceptance in facilities that provide perinatal, family planning, gynecology, sexually transmitted disease (STD) and drug treatment services, hospitals, and prisons. Data reflected testing experience of more than 240,000 adults. RESULTS: Acceptance rates varied widely (3-100%), even within settings of the same type. Acceptance was generally higher (> 50%) among persons at high risk for acquiring or transmitting the infection (e.g., STD patients, pregnant women at high risk) than among low-risk persons. Factors associated with high acceptance rates included the client's perception of HIV risk, acknowledging risk behaviors; confidentiality protections; presenting counseling and testing as 'routine' rather than optional; and the provider's belief that counseling and testing will benefit the client. Factors associated with low acceptance rates included prior HIV testing, fears about coping with results, and explicit informed consent. CONCLUSIONS: To institute and evaluate counseling and testing programs for persons who do not specifically seek testing, multiple determinants of acceptance must be considered. Practices that protect confidentiality, endorse counseling directed to a client's unique circumstances, and highlight the medical and social benefits of testing are likely to promote acceptance. Acceptance of counseling and testing offered nonroutinely to the numerous Americans who have been previously tested or are at low risk is likely to be low.

Primary care physicians and their HIV prevention practices.

A national random-sample survey of 4011 primary care physicians was conducted to determine the extent to which they are providing HIV prevention and clinical services, and to learn what characteristics and attitudes might impede the provision of such services. Physicians were asked about their history-taking practices for new adult and adolescent patients, including asking about the use of illicit drugs (injection and noninjection), the number of sexual partners, use of condoms and contraceptives, past episodes of sexually transmitted diseases (STDs), sexual orientation, and sexual contact with partner(s) at high risk for HIV. A preliminary analysis was conducted and reported earlier by the Centers for Disease Control and Prevention (CDC), focusing on the HIV-prevention services being provided by primary care physicians. This report provides additional analyses from this study, focusing on characteristics and attitudes that may prevent physicians from providing these services. Male physicians and the physicians' belief that patients would be offended if asked questions about their sex behaviors were strongly predictive of not asking new patients about their sex and drug behaviors. The physician's specialty was also a strong predictor-OB/GYNs were predictive of asking these questions and GP/FPs were predictive of not asking the questions. Physicians who indicated that a majority of their patients were white were less likely to report asking patients about their sex and drug behaviors. The authors conclude that a substantial number of primary care physicians are missing important opportunities to prevent HIV transmission by not adequately assessing patients' risks and not providing necessary risk-reduction counseling during their physician-patient encounters. Physician's attitudes and beliefs about their patients, as well as their level of experience with HIV, may help to explain these observations.

Year one of HIV prevention community planning: a national perspective on accomplishments, challenges, and future directions.

Two of the most important principles for the implementation of successful human immunodeficiency virus (HIV) prevention programs are the following: (a) planning for the programs must be done in conjunction with members of affected communities; and (b) the foundation of the programs should consist of solid behavioral, social, and epidemiological science. In 1994, the Centers for Disease Control and Prevention and its prevention partners formally implemented HIV prevention community planning in order to address these two key factors. The occasion of the one year anniversary of HIV prevention community planning is marked by taking stock of progress-to-date from a national perspective. This article reviews year one accomplishments and difficulties, and describes the trajectory of HIV prevention community planning for year two and beyond.

Community planning: a national strategy to improve HIV prevention programs.

Beginning in fiscal year (FY) 1994, the Centers for Disease Control and Prevention (CDC), in collaboration with health departments and other human immunodeficiency virus (HIV) prevention partners, set in motion a significant innovation in HIV prevention programs: HIV Prevention Community Planning. This process, implemented by all 65 health departments receiving HIV prevention funds from CDC, requires that the identification and prioritization of HIV prevention needs to be a shared responsibility between the health departments administering the funds and representatives of the affected communities for whom the services are intended. Guidance for this planning process strongly embraces the notion that high priority HIV prevention strategies and interventions must have a sound basis in behavioral and social science and that program planning must begin with an accurate assessment of the epidemiology of the current and projected future HIV epidemic. Rather than mandate a single standardized process for all of the 65 jurisdictions, CDC guidance provides flexibility for each jurisdiction to configure a planning process responsive to its own unique circumstances. However, all planning activities must be guided by 13 essential principles. This article will describe the principles and logistics of HIV Prevention Community Planning, identify the potential program benefits of this new undertaking, and describe implementation challenges.

An overview of the effectiveness and efficiency of HIV prevention programs.

Because of the enormity of the HIV-AIDS epidemic and the urgency for preventing transmission, HIV prevention programs are a high priority for careful and timely evaluations. Information on program effectiveness and efficiency is needed for decision-making about future HIV prevention priorities. General characteristics of successful HIV prevention programs, programs empirically evaluated and found to change (or not change) high-risk behaviors or in need of further empirical study, and economic evaluations of certain programs are described and summarized with attention limited to programs that have a behavioral basis. HIV prevention programs have an impact on averting or reducing risk behaviors, particularly when they are delivered with sufficient resources, intensity, and cultural competency and are based on a firm foundation of behavioral and social science theory and past research. Economic evaluations have found that some of these behaviorally based programs yield net economic benefits to society, and others are likely cost-effective (even if not cost-saving) relative to other health programs. Still, specific improvements should be made in certain HIV prevention programs.

An interview with Ronald O. Valdiserri, MD. Interview by Barry Raine.

AIDS: Dr. Ronald O. Valdiserri, deputy director of the Division of STD/HIV Prevention at the Centers for Disease Control and Prevention (CDC) in Atlanta, remembers the reactions he had during the period when his brother Edwin, a psychiatrist, was ill with AIDS. Similar to other periods in the life of these twins, it was a time characterized by intimate and constant communication, frequent phone calls, visits, and voluminous correspondence. For a long period between Edwin's diagnosis and the onset of symptoms, they were the only two persons to know the diagnosis and share its distress. Dr. Valdisseri began writing his book, "Gardening in Clay", during his brother's illness, although most of the book's ideas came right after Edwin's death.^ieng

Clients without health insurance at publicly funded HIV counseling and testing sites: implications for early intervention.

The characteristics of clients reporting no health insurance were compared with those reporting any health insurance at publicly funded human immunodeficiency virus (HIV) counseling and testing sites in the United States during 1992. Thirty of 65 funded health departments collect data on self-reported health insurance status. Data were dichotomized into two groups, clients reporting any health insurance versus those reporting none, and multivariate logistic models were developed to explore independent associations. Of the 885,046 clients studied, 440,416 reported that they lacked health insurance. Clients without health insurance were more likely to be male, members of racial or ethnic minorities, adolescent, and HIV seropositive. Prisoners (odds ratio = 0.26), clients of Hispanic ethnicity (odds ratio = 0.52), and clients receiving testing during field visits (odds ratio = 0.53) in drug treatment centers (odds ratio = 0.55) and in tuberculosis clinics (odds ratio = 0.55) were less likely to have health insurance. Injecting drug users, whether heterosexual (odds ratio = 0.65) or homosexual (odds ratio = 0.67), were less likely to have health insurance compared with other behavioral risk groups. Large numbers of clients receiving publicly funded HIV counseling and testing lack health insurance. Lack of health insurance may interfere with subsequent receipt of needed primary care services among high-risk clients, especially HIV seropositive clients in need of early intervention services.

Preventive services guidelines for primary care clinicians caring for adults and adolescents infected with the human immunodeficiency virus.

Primary care clinicians caring for persons infected with the human immunodeficiency virus greatly contribute to public health efforts to combat the human immunodeficiency virus/acquired immunodeficiency disease epidemic in the United States. Primary care clinicians can assess the prevention needs of persons infected with the human immunodeficiency virus and ensure that needed prevention services are received.