1. Muck, Kelly L. MPH

Article Content

As we move into the third decade of the human immunodeficiency virus (HIV) epidemic, the disease continues to challenge the patience and flexibility of public health professionals. While there have been successes in slowing the epidemic and improving survival of those infected, the epidemic lingers with a disturbing ability to adapt to and overcome our defenses. Both the rise of HIV resistance to current anti-retroviral therapies and the resurgence of risk among homosexual men testify to this ability. The public health infrastructure must be quick and flexible to respond to changes in trends and behaviors reported by HIV/acquired immune deficiency syndrome (AIDS) epidemiologists and prevention specialists. Four articles in this issue demonstrate public health professionals responding to an issue posed by the evolving epidemic, guiding their peers on how to proceed based on lessons learned and requiring a higher standard of collaboration and accountability among the public health community.


The effect of the introduction of highly active anti-retroviral treatment therapy in the mid-1990s has slowed the progression to AIDS, thus increasing the time between HIV infection and AIDS diagnosis. With a growing proportion of those living with HIV/AIDS being pre-AIDS, HIV data have become increasingly important in appropriately planning prevention services and allocating resources to areas of greatest need. Some states in the United States have yet to implement HIV surveillance systems and, among states that have, there is no broad consensus on how to report HIV cases. In an article by Wood and coauthors, the contentious issue of confidential HIV reporting by name versus reporting by some form of unique identifier is explored. An important consideration in adopting a particular HIV reporting system includes maintaining the accuracy of the HIV case reporting while being sensitive to confidentiality fears among the HIV/AIDS affected community. Wood and colleagues describe the process of developing a system in Washington State where HIV cases are reported by name to local health departments and later converted to a non-named code prior to reporting to the state health department.


Among those states tracking HIV either by name or a form of unique identifier, counseling and testing service sites (CTSs) serve as important sources of identifying persons infected with HIV. The documented success of treatment, when started early on in HIV infection, underscores the importance of identifying HIV positives early in the course of disease progression and ensuring prompt access to HIV care services. Many CTS sites offer both confidential and anonymous testing. No identifying information is collected from clients testing anonymously; thus, necessary follow-up cannot be provided to clients who test positive but fail to return for their results. An article by Castrucci and associates discusses the surrounding debate and impact of eliminating the option of anonymous testing and offering only confidential testing in North Carolina. Conflicting findings in the literature as to the possible benefits and detriments of restricting anonymous testing options require that public health professionals continue to debate this controversial issue.


The importance of prevention was established early on in the epidemic when treatment was not yet available. Over the last two decades, numerous prevention efforts have been implemented to respond to the changing faces of the epidemic. For example, there has been a recent shift to expand prevention to positives (population infected) in addition to continuing prevention in the uninfected population. Over the past few years, the Centers for Disease Control and Prevention (CDC) has required more accountability among prevention specialists in terms of the comprehensiveness of their prevention work and appropriateness of prevention resource allocation. The article by Holtgrave presents a useful framework to guide governmental agencies on assessing the comprehensiveness and quality of their HIV prevention activities.


Because the epidemic is becoming more complex as it matures, collaboration among the public health disciplines responding to HIV and AIDS is all the more important. Epidemiologists report varied distributions of high-risk populations and highly affected populations over time and between regions. The current and predicted epidemiological distributions must be communicated promptly and effectively to prevention and service personnel for proper allocation of human and fiscal resources. In addition, as discussed in the article "Integrating HIV Prevention and Care Services: The Seattle 'Collaboration Project'", prevention and health services workers need to ensure a continuum of care for clients in need of both HIV-related prevention and care services. This collaboration between prevention and health service workers is increasingly important as the CDC continues to emphasize the need for prevention with positives.