April – December 2003

Overview 

On April 17, the Centers for Disease Control and Prevention (CDC) announced a new initiative, “Advancing HIV Prevention (AHP): New Strategies for a Changing Epidemic.” Its aim is to reduce barriers to early diagnosis of HIV infection and increase access to quality medical care, treatment, and ongoing prevention services for HIV-positive persons and their partners. The AHP initiative represents a multi-agency collaboration within the Department of Health and Human Services (DHHS). As described in the April 18, 2003, issue of the Morbidity and Mortality Weekly Report , the initiative consists of four new strategies for HIV prevention:

• Make HIV testing a routine part of medical care
• Implement new models for diagnosing HIV infections outside medical settings
• Prevent new infections by working with persons diagnosed with HIV and their partners
• Further decrease perinatal HIV transmission

Roll-out

CDC has taken steps to lay the foundation for AHP and to ensure its success. Since announcing the initiative in April 2003, CDC has consulted with various groups on the best ways to implement AHP strategies, including:

• Four community-based organization (CBO) consultations (Miami, San Francisco, New York, and Chicago)
• Full-day consultations with people living with HIV, communities of color, medical provider groups, and experts on stigma prevention
• Four Web conferences with health departments
• Meetings with the Congressional Black Caucus, Federal AIDS Policy Partners, Presidents Advisory Council for HIV/AIDS, and CDC/HRSA AIDS Advisory Committee

2003 Implementation Activities

The AHP initiative was allocated $35 million in FY2003. Those funds were used to launch a wide range of AHP projects and activities. They include:

Demonstration projects

Nine health departments and 16 CBOs have been awarded $23 million over two years to develop models and demonstrate efficacy for implementing the four AHP strategies. The seven projects are:

1. Routine HIV testing in medical care settings serving high HIV-prevalence populations.
2. Partner counseling and referral using rapid HIV tests to increase the number of partners who learn their HIV status.
3. HIV prevention in medical care for persons living with HIV.
4. Rapid HIV testing in jails to increase number of inmates receiving test results.
5. Working with persons living with HIV to reach high-risk persons in their social networks.
6. Rapid HIV testing in non-clinical settings, such as homeless shelters, drug treatment programs, and social events.
7. Prevention case management for people living with HIV who have multiple complex problems.

Monitoring and evaluation

AHP places increased emphasis on monitoring and evaluation. The following projects, tools, and guidance are being developed or are already in place:

• Post-marketing surveillance projects are examining implementation and results of rapid HIV testing, including client satisfaction.
• Evaluation of demonstration projects will include feasibility and cost-effectiveness assessments.
• New performance indicators for funded health departments and community-based organizations will monitor process and outcomes for HIV prevention activities.
• Perinatal chart reviews will assess the level of integration of routine prenatal HIV testing into medical practice.

Creating partnerships

Implementing AHP requires cooperation and coordination among CDC, federal partners, the public health community, and the medical care community. CDC is working with its partners on the following AHP-related projects:

Federal partners

• Health Resources and Services Administration (HRSA) and Centers for Medicaid & Medicare Services (CMS) –established an intra-agency agreement to share information about case management activities funded by the three agencies.
• HRSA –changed its grantee application guidance to emphasize the need to prioritize services outlined in AHP.
• Agency for Healthcare Research and Quality and the U.S. Preventive Services Task Force –reviewing the evidence for routine HIV screening for adults and for pregnant women to ensure appropriate recommendations for testing are in place.
• Substance Abuse and Mental Health Services Agency (SAMHSA), Department of Veterans Affairs, and Indian Health Service –eliminating barriers to HIV testing and prevention services in their jurisdictions.
• SAMHSA –developing a training program for implementing rapid HIV testing in substance abuse treatment facilities.
• HRSA, CMS, and SAMHSA –estimating the need for increased care and treatment services for HIV-infected persons identified through this initiative.

Other partners

• American Hospital Association –developing operational guidance on HIV testing in hospitals.
• National Association of Community Health Centers –creating model protocols and policies for use in community health centers on prevention for persons living with HIV and on encouraging testing for persons with unknown HIV status.
• American College of Obstetricians and Gynecologists –considering the development of clinical guidance for routine rapid HIV testing of women in labor with unknown HIV status, as well as repeat HIV screening during pregnancy in areas of high seroprevalence.
• Purchasers of care –creating a business case that will support reimbursement of HIV prevention services.
• Managed care representatives – studying the cost-effectiveness of early HIV diagnosis in managed care settings.

Rapid HIV testing training for health departments and CBOs

CDC also is working with health departments and community based organizations (CBOs) to ensure they have the skills and resources to incorporate rapid HIV testing. Activities include:

• CDC and OraQuick manufacturer, OraSure Technologies, have conducted 20 regional rapid HIV testing training sessions for health departments and CBOs that plan to conduct rapid HIV testing. An additional 15-20 training sessions on rapid HIV testing are planned in 2004.
• In 2003, approximately 250,000 OraQuick Rapid HIV-1 Antibody Test kits were purchased by CDC and distributed to health departments and funded CBOs around the country. In 2004, a similar number of OraQuick tests were purchased and are being distributed.

Communication

Keeping CDC constituents up to date on AHP developments is a key component of its success. Information has been distributed through multiple channels.

• Publications available online and in print
  • Recommendations for Incorporating HIV Prevention into the Medical Care of Persons Living with HIV (MMWR, July 18, 2003)
  • AHP: Interim Technical Guidance for Selected Interventions
  • Procedural Guidance for Selected Strategies and Interventions for Community-Based Organizations
  • Advancing HIV Prevention: The Science Behind the New Initiative
• AHP Web site (http://www.cdc.gov/hiv/partners/ahp.htm) provides up-to-date guidelines, program news and announcements, questions and answers, slide presentations, and journal articles.
• AHP Speakers Bureau has fulfilled more than 20 AHP presentation requests from local, state, and national organizations.

Research

In addition to its demonstration projects, AHP is funding research that will inform and guide the initiative as it moves forward. Research projects planned or underway include:

• Development of effective prevention messages for persons living with HIV.
• Validation of the use of oral fluid Western Blot testing to confirm preliminary positive rapid HIV tests.
• Analysis of financial and organizational factors related to integrating HIV prevention into care settings.

Plans for 2004

As the initiative enters its second year, CDC is providing funds for a wide range of programs and activities to move AHP strategies into high gear. Next steps include:

Prevention Programs

• Require all health departments receiving CDC funds to make people living with HIV the highest priority population targeted for HIV prevention services.
• Fund CBOs to implement interventions for prevention with positives and their HIV-infected partners, testing in community settings, and working with high-risk seronegative persons.
• Maintain CBO support for health-education and risk-reduction activities targeting populations at risk.

Technical assistance and guidance

• Guide CBOs on how to adapt, tailor, and implement procedures and protocols for their target populations and communities.
• Work with federal partners to develop guidelines for prevention case management and patient referral.
• Train clinicians and outreach workers to implement rapid HIV testing in clinical care and outreach settings and prevention with positive persons in care settings.
• Create materials and guidelines for conducting rapid HIV testing during routine prenatal screening and labor and delivery.

Evaluation

• Conduct post-marketing surveillance on the extent to which rapid HIV testing has been used in health department and other CDC-funded programs.
• Develop and implement a new software system for collecting data on counseling, testing, referral, and for process and outcome monitoring of funded interventions.
• Review medical records of pregnant women to determine progress toward the goal of universal screening to prevent mother-to-child HIV transmission.

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Last Updated: February 10, 2004
Centers for Disease Control & Prevention
National Center for HIV, STD, and TB Prevention
Divisions of HIV/AIDS Prevention
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