1. Valdiserri, Ronald O. MD, MPH

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Commenting on the future of public health in the twenty-first century, the Institute of Medicine (IOM)1 identified 6 complementary areas of "action and change" to ensure their vision of healthy people living in healthy communities. Briefly stated, the 6 areas are: (1) consider the multiple determinants of health, (2) strengthen the public health infrastructure, (3) build new partnerships, (4) develop systems of accountability, (5) support evidence-based decision making, and (6) enhance communication. Pointedly, the IOM defined a healthy community as one in which "essential public health services, including quality care, are available."(p179)


Does this future vision of healthy communities change in any way-and, if so, how-when we look through the lens of HIV prevention? In the US, we have set an ambitious goal of reducing the number of new HIV infections from its current plateau of an estimated 40,000 annual cases to no more than 20,000 by the year 2005.2 But looking at recent trends in HIV diagnoses,3 and other surrogate measures of HIV incidence, it is evident that there remain major challenges to reducing incident HIV infections by half.


Granted, it may be easier to identify impediments to the successful achievement of a goal than it is to enumerate solutions to minimize or nullify those same impediments. But sound program management requires that we recognize what stands in the way of our ability to achieve healthy communities, so that we can develop informed strategies to surmount these obstacles. Absent a major breakthrough in vaccine technology, how can we move closer toward our goal of significantly reducing the spread of HIV in the United States?


As Lurie4 points out, research is urgently needed to understand how "nonmedical determinants of health," including social circumstances, intervene and influence the course of an individual's or a community's health. This is especially true in the field of HIV prevention, where both general public and risk-group perceptions and attitudes about the consequences of HIV infection have changed over time, coincident with improved treatments and decreased mortality.5 A recent meta-analysis of 25 studies conducted between 1996 and 2001 revealed that "the likelihood of unprotected sexual behavior was significantly higher in people who believed that HAART (highly active antiretroviral therapy) reduces HIV transmission or who were less concerned about engaging in unsafe sex given the availability of HAART."6 Enabling HIV-free communities will require not only a societal commitment to develop a safe and effective vaccine, but also the continued support of research on behavioral and risk determinants in this era of improved HIV treatments.


The mantra "strengthen public health infrastructure" is neither new nor unique to HIV prevention. But it is nonetheless critical for success. Although non-governmental organizations have been prominent in many historically important public health initiatives,7 the degree to which they are involved in the development and delivery of HIV prevention services is arguably exceptional. In many US communities, nongovernmental organizations, whether service oriented, faith-based, or social in nature, are in routine contact with persons who are at high risk for HIV infection or who are already infected-both diagnosed and not. This circumstance provides a tremendous opportunity for organized public health. But, as with all opportunities, there are costs involved.


Because HIV prevention services are neither homogeneous nor typically standardized, their successful delivery requires that organizations possess substantial expertise in program design, implementation, and evaluation-among other competencies.8 Yet organizations, like individuals, are at different stages of maturity and capability. Without ongoing support, many of those organizations best poised to reach vulnerable populations will simply not have adequate skills to succeed in addressing their clients/members' HIV prevention needs. This observation is not intended to indict community-based organizations, but to recognize that the domain of HIV prevention is complex and is formulated on an evolving science base that requires both knowledge and skill to translate into practice. Although strides have been made in increasing resources to communities at risk for HIV infection,9 much work remains to be done in the development of systems to support sustainable program capacity.


As suggested by the IOM, building new partnerships is certainly an important way to strengthen national HIV prevention efforts. But to achieve our desired goal of reducing HIV transmission, it may be best to think in terms of new "styles" of partnership rather than "new" partners, per se. For example, health care providers have always been critical partners in HIV prevention efforts. Nothing new there. Yet, various constraints continue to result in physicians providing "less than optimal" HIV prevention counseling to patients with HIV, at a time when more people than ever are living with HIV in the United States-and there is evidence of increases in risk behavior among persons living with HIV.10 The essential question for our partners is this: What changes have to take place in systems of medical education, provider reimbursement, and quality assurance, to ensure that physicians have the skill, time and motivation to adequately counsel their HIV infected patients about the importance of preventing the spread of virus to others? And how can the public health community help to bring about those changes?


Enhancing accountability among all of us engaged in efforts to prevent the spread of HIV is a broadly endorsed goal. At a federal level, the Centers for Disease Control and Prevention (CDC) has reprioritized funds to promote early diagnosis of HIV infection and has placed a greater emphasis on preventing transmission from persons who are infected with HIV11-two tangible responses to an expert recommendation calling for "prevention resources (to) be allocated to prevent as many new infections as possible."12(p6) Another significant example of increased accountability can be found among state and local health departments receiving federal HIV prevention funds. They are being required to adopt standardized and more detailed reporting measures so as to better monitor their HIV prevention grant performance.13 Both examples underscore the profound responsibility of ensuring that public resources allocated to preventing the spread of HIV are being used in the most effective manner possible.


Yet, even as we embrace improved targeting of resources and better systems to measure program performance, we must be careful not to limit our sense of accountability to a narrow managerial construct. Equally important is public health's responsibility to "make evidence the foundation of decision making."1 This, too, is an important dimension of accountability-especially when the resultant decision or action taken is not popular or uniformly acclaimed.


Finally, we must be able and willing to communicate both our successes and our failures in the domain of HIV prevention. Otherwise, how can we move the field forward? Recognizing that we have not reached our goal of halving new HIV infections in the United States is not an admission of failure, but a recognition that we must redouble our efforts-not just by improving program targeting and performance, but also by investing in the types of research and stable systems of program support that underpin successful HIV prevention efforts. In the prescient words of Barbara Ward, the British economist who died the year AIDS was first described, "There is no human failure greater than to launch a profoundly important endeavor and then leave it half done."14




1. Institute of Medicine. The Future of the Public's Health in the 21st Century. Washington, DC: National Academy Press; 2003. [Context Link]


2. Valdiserri RO, Ogden L, Janssen RS, Onorato I, Martin T. Aligning budget with US national HIV prevention priorities. Journal of Public Health Management Practice. 2004;10(2):140-147. [Context Link]


3. Centers for Disease Control and Prevention (CDC). HIV/AIDS Surveillance Report 14. Atlanta, GA: CDC; 2002:1-40. [Context Link]


4. Lurie N. What the Federal Government can do about the nonmedical determinants of health. Health Affairs. 2002;21(2):94-106. [Context Link]


5. Valdiserri RO. Mapping the roots of HIV/AIDS complacency: implications for program and policy development. AIDS Education and Prevention. 2004;16(5):426-439. [Context Link]


6. Crepaz N, Hart TA, Marks G. Highly active antiretroviral therapy and sexual risk behavior: a meta-analytic review. Journal of the American Medical Association. 2004;292(2):224-236. [Context Link]


7. Centers for Disease Control and Prevention. Changes in the public health system. Morbidity and Mortality Weekly Report. 1999;48(50):1141-1147. [Context Link]


8. Miller RL, Bedney BJ, Guenther-Grey C. Assessing organizational capacity to deliver HIV prevention services collaboratively: tales from the field. Health Education and Behavior. 2003;30(5):582-600. [Context Link]


9. Valdiserri RO. HIV/AIDS in historical profile. In: Valdiserri RO, ed. Dawning Answers: How the HIV/AIDS Epidemic Has Helped to Strengthen Public Health. New York: Oxford University Press; 2003. [Context Link]


10. Metsch LR, et al. Delivery of HIV prevention counseling by physicians at HIV medical care settings in 4 US cities. American Journal of Public Health. 2004;94(7):1186-1192. [Context Link]


11. Centers for Disease Control and Prevention. Advancing HIV prevention: new strategies for a changing epidemic-United States, 2003. Morbidity and Mortality Weekly Report. 2003;52(15):329-332. [Context Link]


12. Institute of Medicine. No Time to Lose: Getting More from HIV Prevention. Washington, DC: National Academy Press; 2001. [Context Link]


13. National Alliance of State and Territorial AIDS Directors (NASTAD). NASTAD's Top Ten: HIV Prevention Bulletin. Washington, DC: NASTAD; January 2004. [Context Link]


14. Ward B. The Rich Nations and the Poor Nations. New York, NY: W.W. Norton & Co; 1962. [Context Link]