The CDC and the President should direct the Secretary of HHS to produce an annual estimate of HIV incidence based on seroprevalence studies and to work to ensure a reasonable relationship between epidemiological trends and CDC prevention funding. This report should specifically examine the demographic characteristics and geographic distribution of populations that experience disproportionate increases in new infections. The CDC should issue to the President an annual estimate of HIV incidence based on seroprevalence studies that provides a geographic and demographic analysis of the populations where there is a continuing disproportionate increase in new HIV infections. The President should direct the Secretary of HHS to ensure that resources are allocated to accomplish this task. The President should ensure that funding is adequate and responsive to the epidemiological trends, needs, and prevention infrastructure of affected communities.
Administration's Response
It should be noted that CDC's prevention programs have been flat-funded by the Congress, despite the President's efforts to obtain significant increases. Therefore, decisions to invest additional resources in one area often result in difficult decisions to cut back in others.
CDC is working to derive annual HIV incidence estimates in selected subpopulations, including injection drug users (IDUs) and clients of sexually transmitted disease (STD) clinics. However, current methods have not succeeded in producing reliable HIV incidence estimates for the country as a whole.
As part of the community planning process, State and local health departments are expected to document that programming for HIV prevention reflects the local epidemiology. Grant applications are being reviewed with this in mind, and States and localities not following this portion of the guidance will be provided technical assistance. When necessary, CDC can and will require revisions in State plans.
Assessment of the Response
The Council is pleased that the CDC has determined that HIV incidence estimates within subpopulations must play a central role in the development of HIV prevention and education programs.
Followup Action Recommended
The Council recommends that the CDC continue to pursue means to achieve reliable national incidence estimates using data from surveillance systems and special studies, as needed, and that the Council be periodically updated on the progress in this area.
Furthermore, we recommend that the CDC report to the Council on its efforts to develop HIV seroincidence estimates, including adequacy, effectiveness, and efficiency of funding such efforts.
Finally, the Council supports the requirement for State and local health departments to document that programming for HIV prevention reflects the local epidemiology. We urge strong enforcement of this policy as well as the provision of relevant technical assistance.
The President should direct the CDC to develop a behavioral surveillance mechanism that will provide an analysis of patterns in risk-taking behavior. The President should direct the CDC to join with the National Institute on Drug Abuse (NIDA) and other relevant agencies to institute surveillance methods for detecting patterns of risk-taking behaviors in populations that show a continuing disproportionate increase in AIDS cases. He should direct the Secretary of HHS to coordinate the planning of an early warning system and ensure its ongoing use.
Administration's Response
CDC agrees with the Council's recommendation to develop a behavioral surveillance mechanism to monitor patterns of risk-taking behavior. In addition, behavioral surveillance can monitor the adoption of protective behaviors that decrease the risk of HIV transmission. CDC is in the process of integrating standard HIV data elements in ongoing behavioral surveillance mechanisms, coordinating surveillance approaches for HIV with those for other STDs, and continuing expanded surveillance of persons reported with HIV infection and AIDS. CDC will soon solicit proposals for behavioral surveillance of subpopulations at particular risk for HIV infection, to be initiated in FY 1997. While surveillance does not fall within the mission of the NIH, program staff of NIDA will consult with CDC program staff to develop a better method to detect patterns of risk behavior.
In addition, the Substance Abuse and Mental Health Services Administration (SAMHSA) and CDC's National Center for Health Statistics (NCHS) are collaborating on an interagency agreement that would use SAMHSA's National Household Survey on Drug Abuse to collect new data. This includes incorporating NCHS's HIV/AIDS Risk Behaviors Module into the National Household Survey. CDC will also encourage local areas to use HIV surveillance or prevention funds for surveys of sexual behavior in the general population. As indicated above, State and local prevention partners are expected to direct their programs (and funds) in response to the epidemiology of the epidemic in their localities.
Assessment of the Response
The Council commends the Administration's efforts toward fulfilling this recommendation. It is our understanding that the Administration has made progress toward this goal. We acknowledge that developing an effective behavioral surveillance mechanism presents difficult scientific challenges. Furthermore, once developed, efficient dissemination of the findings as a part of an "early warning system"—although critical—will require extensive planning.
Followup Action Recommended
The Council requests that we be briefed at our next full Council meeting on the Administration's efforts to date and plans for future efforts in this area and that appropriate members of the Council be included in the ongoing development of this necessary prevention tool.
The Administration should pursue a comprehensive strategy to decrease HIV transmission related to injection drug use, which accounts for at least 50 percent of new HIV infections. In addition, high-risk sexual behavior while under the influence of drugs and/or alcohol accounts for another significant percentage of new cases of HIV disease. Strategies must explicitly address the sharing of injection drug use paraphernalia, as well as the high-risk sexual behavior associated with drug and/or alcohol use.
Administration's Response
The need for a comprehensive approach to substance abuse and HIV transmission was recognized by the President in his remarks at the White House Conference on HIV/AIDS on December 6, 1995. In that speech, he directed the CDC to convene a meeting designed to develop a cross-governmental strategy. This meeting is scheduled for this summer. In addition, the White House Office of National AIDS Policy has convened a working group of the Interdepartmental Task Force on HIV/AIDS to consider these issues.
Assessment of the Response
See Recommendation II.C.3a-c.
Followup Action Recommended
See Recommendation II.C.3a-c.
Recommendation II.C.3.a.
Increase access to effective substance abuse prevention and treatment research programs by: • Opposing congressional efforts to cut SAMHSA and other Federal funding for drug abuse treatment and prevention programs in FY 1996 appropriations. • Restoring budget requests for SAMHSA and other Federal funding for drug abuse treatment and prevention programs to at least the FY 1995 levels. • Supporting the continuation of specific funding for NIDA's AIDS demonstration projects.
Administration's Response
The President has fought for increased funding for substance abuse treatment and has opposed Congressional efforts to cut back dramatically on substance abuse funding. For FY 1997, the President has requested $1.272 billion for the Substance Abuse Performance Partnerships, the principal source of Federal funding for substance abuse treatment. This is $32 million above the FY 1995 spending level. The President's FY 1997 AIDS research budget request is contained in a consolidated account for the NIH OAR. The final level for projects proposed by NIDA will be determined by the Director of OAR in accordance with the priorities and objectives of the NIH Plan for HIV-Related Research.
Assessment of the Response
The Council commends the President for his support for expanded access to effective substance abuse prevention and treatment programs and the Administration's support of the Substance Abuse Performance Partnerships.
Followup Action Recommended
The Council recommends that the Administration actively support the reauthorization of SAMHSA programs and that the Director of the Office of National Drug Control Policy be engaged in communicating the importance of SAMHSA programs in our Nation's effort to reduce illicit drug use.
Representatives of the Council would like the opportunity to meet with the Director of the Office of National Drug Control Policy.
Revise the Department of Justice Model Drug Paraphernalia Act, which serves as a model for State drug paraphernalia laws, to make it consistent with current reports, studies, and data relating to the access to sterile syringes as an effective intervention to counter HIV transmission among IDUs.
Administration's Response
CDC and a variety of Federal and nongovernmental agencies sponsored a "Consultation on Recommendations for Model Laws and Regulations Related to the Sale, Possession, and Distribution of Syringes," held at the Carter Presidential Center in Atlanta, Georgia, on Thursday and Friday, May 16-17, 1996. Leaders from the fields of public health, substance abuse treatment, pharmacy, medicine, ethics, and criminal justice participated. Sponsors included the Task Force for Child Survival and Development, the Kaiser Family Foundation, CDC, and the Georgetown/Johns Hopkins University Program on Law and Public Health. This meeting included a review of the Model Drug Paraphernalia Act. The Department of Justice will assess any changes in the model law based on the recommendations of the Secretary of HHS.
Assessment of the Response
We strongly commend the CDC for its leadership in convening this important meeting. We welcome the opportunity to engage in a dialogue with other public health, substance abuse treatment, pharmacy, medicine, ethics, and criminal justice professionals, as well as with State and Federal lawmakers to ensure that Federal and State laws regarding drug paraphernalia are consistent with current scientific knowledge.
Followup Action Recommended
The Council requests that it be briefed on what specific steps have been taken and those planned for the future.
The President should direct the Secretary of HHS to provide a recommendation (within 90 days) regarding the impact of needle-exchange programs on HIV infection and substance abuse. The recommendation should be based upon current reports, studies, and data on needle-exchange programs, and should include specific recommendations for programs and demonstration projects to implement needle exchange. The Secretary should develop and execute a plan to carry out the recommendations and indicate what programs and demonstration projects will be started or expanded.
Administration's Response
No action has been taken.
Assessment of the Response
The Council continues to have grave concerns that Federal policy regarding needle-exchange programs is not consistent with current knowledge and understanding regarding the impact of such programs on HIV prevention efforts.
Followup Action Recommended
Council representatives intend to meet with the Secretary of HHS and the Assistant to the President for Domestic Policy as soon as possible to explore steps to bring Federal policy in line with current scientific knowledge.
The President should reaffirm his support for community-based planning for prevention activities.
Direct the CDC to maintain HIV prevention programs independent of any consolidated grant programs, including the currently proposed Performance Partnerships Grants.
Administration's Response
CDC will continue to support community-based planning for HIV prevention efforts and will work to coordinate HIV prevention programs with other prevention services and activities serving the same populations. The Administration has decided to keep the HIV prevention programs separate from the new Performance Partnerships Grant structure.
Assessment of the Response/Followup Action Recommended
The Council is pleased that the Administration has decided to maintain the strategically important approach of community-based planning for HIV prevention efforts, as focused and distinct efforts from other health planning needs. We urge the Administration to continue this policy. The Council supports the Administration's efforts to find ways to increase the coordination of HIV prevention efforts with related health concerns and facilitate effective and efficient health planning by State and local health departments.
Direct the CDC to continue direct funding to community-based organizations.
Administration's Response
CDC has worked closely with community-based organizations over the past six years and views them as valuable partners in HIV prevention. CDC has extended the cooperative agreement for direct funding of HIV community-based organizations through March 1997. CDC will continue discussions with governmental and nongovernmental partners to determine the best ways to ensure that the HIV prevention needs of at-risk populations, currently addressed by community-based organizations, will continue to be met beyond April 1997.
Assessment of the Response
The Council supports the CDC decision to extend direct funding to community-based organizations through March 1997. We believe that this will allow for a natural transition and integration of these programs and organizations into the broad prevention efforts being developed in the HIV prevention planning process.
Followup Action Recommended
The Council recommends that this extension period be used to develop a strategic plan by which the communities, subpopulations, and programs that these organizations represent will continue to be served beyond 1997. The Council recommends that the direct funding of community-based organizations be maintained. Further, we recommend that the CDC clarify the relationships between directly funded community-based organizations and State/local health departments; develop clear guidance to ensure coordination between local planning groups, health departments, and community-based applicants for CDC funds; and provide support for program evaluation and accessible technical assistance.
Direct the CDC, with the assistance of existing national minority organizations and other appropriate partners, to structure its technical assistance programs to address the prevention program development and infrastructure needs of populations that are currently experiencing a continued disproportionate increase in new infections.
Administration's Response
CDC will continue to work through the National/Regional Minority Organizations (NRMOs) Grant Program to strengthen the capacity of existing NRMOs to work in partnership with CDC in the development of culturally competent HIV prevention programs for communities of color that are at increased risk for HIV infection. Beginning in FY 1994, activities for this program were refocused to concentrate on providing culturally competent and relevant technical assistance and training in organizational capacity building and programmatic development to organizations and agencies (primarily State and local health departments and minority community-based organizations) that offer HIV/STD prevention services to racial/ethnic minority populations. National organizations also provide tools and consultation to project areas to help assess technical assistance needs and priorities in support of HIV prevention community planning.
Assessment of the Response
The Council supports the CDC decision to continue its support of the NRMO Grant Program.
Followup Action Recommended
The Council requests that it be given an overview of what other partnerships the CDC has made in the effort to reach populations and subpopulations that are experiencing disproportionate increases in HIV infection rates (e.g., rural populations, young gay men, gay men of color, women, and IDUs). Additionally, we request that the CDC provide the Council with its assessment of the current NRMO technical assistance program and, if any changes or alterations are planned, ensure that the program is responsive to the current capacity-building and programmatic development needs of organizations serving the most highly impacted populations and subpopulations.
Direct the Director of the Indian Health Service (IHS) to develop a comprehensive AIDS prevention and care plan for Indian Country (within 90 days) with the input from consumers of IHS services.
Administration's Response
A review of the IHS AIDS prevention program is completed and will be available for the Council at its April meeting.
Assessment of the Response
We acknowledge the receipt of IHS's HIV/AIDS Prevention Program Report.
Followup Action Recommended
The Council requests an update on the implementation of the Summary of Findings and appendices contained in the IHS's HIV/AIDS Prevention Program Report, along with supporting documentation of consumers' input.