No time to lose

Last year, a committee of 16 scientists and academics began evaluating the nation’s efforts to prevent the spread of AIDS and HIV. What it found was unsettling: a lack of coordination among federal agencies, funding of interventions that showed no evidence of success, reliance on political rather than scientific criteria for funding and, perhaps most startling, no clear goal for prevention.

“Despite the fact that we know so much about how to prevent HIV,” said Michael H. Merson, M.D., dean of public health and one of two Yale faculty members on the panel, “we can’t get the job done.”

The Committee on HIV Prevention Strategies in the United States concluded that the nation’s public health system needs to set the obvious yet previously unstated goal of averting as many new HIV infections as possible with the resources available. Under current funding, the committee estimated that a reallocation of resources could reduce new infections by 30 percent. And interventions currently denied federal funding, such as needle exchange programs and comprehensive sex education, could prevent even more infections. “That is probably the most important thing to realize,” said the other Yale faculty member on the committee, Edward H. Kaplan, Ph.D., a professor of both management sciences and public health. “You can get better results not only by increasing the budget, but also by changing the allocation.”

The committee was established by the Institute of Medicine at the request of the Centers for Disease Control and Prevention, which wanted to have a prevention framework in place before the 2000 presidential election, Merson said.

One of the national effort’s main failures, the report said, is in the allocation of HIV prevention resources. Money for prevention follows reports of AIDS cases, but because HIV incubates for 10 years, this approach yields old data. “It rewards people for counting cases of AIDS instead of preventing HIV infections,” Kaplan said.

The report proposed a six-pronged prevention strategy. Allocation of resources should target not reported AIDS cases, but estimates of new HIV infections through anonymous testing of “sentinel groups,” such as drug users in treatment. Evaluations of existing programs should determine whether interventions work. HIV prevention counseling should reinforce prevention messages among those already infected. Research and interventions should strengthen local capacity to implement effective programs. Federal agencies should continue to invest in HIV prevention. Finally, the committee recommended overcoming social barriers to HIV prevention, such as opposition to syringe exchanges, comprehensive sex education and condom availability in schools, and facilitation of prevention efforts in prisons.

“This is the greatest public health crisis the world has faced since the bubonic plague pandemic of the Middle Ages,” Merson said, adding that years from now people will ask a simple question: “How did a country that had all the knowledge it needed about the virus and the resources required to prevent its spread allow such a tragedy to occur, killing so many people?”