Trussell and colleagues call for better HIV prevention
Yvonne Chiu Hays
The United States is not doing enough to thwart the spread of HIV, according to a recent report issued by a national committee co-chaired by James Trussell, associate dean of the Woodrow Wilson School of Public and International Affairs.
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James Trussell
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The Centers for Disease Control and Prevention asked the institute to review current HIV prevention efforts and develop a framework for a national prevention strategy as one of several steps the CDC is taking to refine its approach to reducing the virus' spread.
"This report will be invaluable as we move forward toward our goals," said Helene Gayle, director of CDC's National Center for HIV, STD and TB Prevention. "Ultimately, we hope this report will propel the nation into action."
Two decades after the first case of AIDS was identified in this country, an estimated 40,000 Americans still become infected with HIV each year and the number of new AIDS cases among women, minorities and adolescents has increased significantly, the report states.
Trussell, an expert on public health issues, and his colleagues are urging health officials and legislators to develop a better system to track the disease and direct funds to programs that effectively prevent the spread of HIV, which causes AIDS.
The country currently does not have a surveillance system tracking the epidemic, Trussell said in a recent interview. The current system follows reported AIDS cases. The incidence and prevalence of HIV are estimated using statistical methods that calculate backward according to well-established patterns of disease progression.
"We do not know where the epidemic is," Trussell said. "We know where the epidemic was."
He noted that recent potent AIDS therapies further complicate the process. "From the time of infection to AIDS used to be, on average, about 10 years," he said. "So at most, you knew where it was 10 years ago. However, that link has become completely broken because treatment is now delaying the onset of AIDS."
The committee proposes that the CDC establish sites at facilities such as clinics specializing in sexually transmitted diseases, tuberculosis, substance-abuse treatment and family planning to draw random blood samples and test for the virus anonymously. From a statistically valid sample, the number of new infections could be estimated.
"The impetus for this has gotten stronger because, for the first time, there is a test that can tell patients if they have been recently infected or not. Up until that point, all we could tell is if they tested positive, with no information on when they actually got infected. So now we can get an idea of who is currently being infected the incidence as opposed to the prevalence of HIV," Trussell said.
For the committee, however, the key is the management of federal funds for HIV prevention. "The committee believes that decisions regarding the allocation of public HIV prevention funds represent the single most important set of HIV prevention decisions made," the report states.
Currently, social forces strongly dictate how prevention dollars are spent, a process that has impeded the implementation of proven strategies. The committee believes that prevention funds should instead be guided by principles of cost-effectiveness.
As an example, it points to the $250 million in federal funds spent on abstinence-only sex education when there is no evidence that this approach is effective. The committee suggests the same money could be spent to support comprehensive sex education programs and condom availability, which have been shown to reduce the risk of sexually transmitted diseases without promoting sexual activity.
The committee also recommends lifting restrictions against needle exchange programs, since there is evidence that these programs avert new HIV infections without increasing injection drug use.
"The clash here, I think, is between those who take a social conservative moral approach and those of us who take a public health, harm-reduction approach," Trussell said. "We take it as a given that there are people who use injection drugs. Therefore, we think two things ought to be done. One is treatment ought to be available to anyone who requests it. There are not nearly enough treatment spots. And secondly, if people decide they are going to keep using drugs, then it makes sense for them to use them safely so that they don't infect themselves or others."
The report, "No Time To Lose," also recommends delivering more public health messages to combat complacency; developing prevention programs at the community level; spending more money on research and technology; and calling upon health insurers to provide doctors with incentives to deliver prevention messages. In addition, the committee suggests making better use of the opportunities presented by clinics. Facilities that are treating high-risk or already infected individuals should routinely take drug and sex histories, provide counseling and behavior modification and offer HIV tests.
"First and foremost, the report makes it clear that HIV prevention works," Gayle said. "The CDC applauds the central finding providing further support that scientifically based prevention is at the core of efforts to win our nation's fight against HIV/AIDS. The report also makes clear how urgent the need is more than ever for innovative, cost-effective prevention programs targeted to at-risk communities."
A copy of the report is available at <http://books.nap.edu/books/0309071372/html/index.html>.
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October 23, 2000 Contents • Neuroscientists
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depression • Trussell and colleagues call for better HIV prevention • Alumnus
wins Nobel in economics • Committee
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