WASHINGTONTwo decades after the first case of AIDS was
recognized in the United States, the nation does not have a
comprehensive, effective, and efficient strategy for preventing the
spread of HIV, the Institute of Medicine (IOM) said in a new report.
national strategy focused on better tracking of HIV infections and
funding of the most cost-effective prevention programs could
significantly cut new infections, the IOM said. The report was
sponsored by the Centers for Disease Control and Prevention (CDC).
Thousands of new HIV infections could be avoided each year if
we gave greater emphasis to prevention and were smarter in the way we
spent our prevention dollars, said Harvey Fineberg, MD, PhD,
provost of Harvard University, and co-chair of the committee that
wrote the report.
Current epidemiologic surveillance focuses mainly on AIDS cases,
where diagnosis lags behind HIV infection by 10 years or longer.
While this approach may be useful for allocating funds for treatment,
it is an inappropriate basis for allocating prevention services, the
report said. This is because the AIDS epidemic is shifting, with the
number of new AIDS cases declining dramatically among homosexual men
and increasing considerably among women, minorities, and adolescents.
The current epidemiological surveillance system does not
provide a complete or accurate picture of the incidence of HIV
infection, said James Trussell, PhD, associate dean, Woodrow
Wilson School of Public and International Affairs, Princeton
University, and co-chair of the study committee. Todays
surveillance system looks at the past rather than to the future and
tracks where the epidemic has been rather than where it is
Rather than trying to count every newly infected person, the
committees approach to surveillance would estimate the number
of new infections by testing a statistically valid sample of those at
the highest risk.
These individuals would be drawn from sentinel sites,
including health care facilitiessuch as clinics specializing in
sexually transmitted diseases, tuberculosis, substance abuse
treatment, and family planningwhere at-risk people are likely
to seek care.
Overcoming Social Barriers
Social and political pressures have led to policy and legal obstacles
that block the use of proven prevention strategies. These laws and
policies should be abolished, the committee said, including
elimination of federal, state, and local requirements that public
funds be used for abstinence-only sex education. The federal
government has appropriated $250 million to be spent over 5 years for
abstinence-only programs without any evidence that this
approach is effective. Yet, the report said, comprehensive sex
education and condom availability have been shown to reduce the risk
of HIV and other sexually transmitted diseases without promoting
Federal and state barriers to the adoption of clean needle programs
for drug users also should be lifted, the committee said. There is
clear evidence that these programs avert new HIV infections without
increasing the level of substance abuse.
Routine evaluations of the cost-effectiveness of HIV prevention
interventions are needed so that interventions that do not work or
that are very expensive in relation to the number of infections they
prevent could be abandoned, the committee said.
Another important step is to make better use of the opportunities
presented by clinics and doctors offices to deliver prevention
messages. Medical facilities that treat patients who are at high risk
or are already infected should routinely take sexual and drug
histories, provide counseling and behavior modification, and offer
HIV tests, the committee said.
Federal agencies also should increase research funding to develop new
or enhanced prevention technologies, especially female condoms,
microbicides, new antiretroviral drugs, vaccines, and rapid testing
methods for detection of HIV antibodies.