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HIV Prevention in the United States at a Critical Crossroads

August 2009

The Status of HIV Prevention in the United States

The science is clear: HIV prevention can and does save lives.1-4 Scores of scientific studies have identified effective prevention interventions for numerous populations,5-10 and it is estimated that prevention efforts have averted more than 350,000* HIV infections in the United States to date.4 In addition to the lives saved from HIV, it is estimated that more than $125 billion in medical costs alone have been averted.11,12

But the HIV crisis in America is far from over. CDC's latest estimates suggest that more than 56,000 Americans become infected each year13 -- one person every 9? minutes -- and that more than one million people in this country are now living with HIV.14 Far too many Americans remain at risk for HIV, especially African Americans, Latinos, and gay and bisexual men of all races. CDC estimates that roughly 1 in 5 people infected with HIV in the United States is unaware of his or her infection and may be unknowingly transmitting the virus to others.14

The heavy burden of HIV in the United States is neither inevitable nor acceptable. It is possible to end the U.S. epidemic, but such an achievement will require that we dramatically expand access to proven HIV prevention programs, make tough choices about directing available resources, and effectively integrate new HIV prevention approaches into existing programs.

Estimated Number of New HIV Infections and Persons Living with HIV/AIDS, 1977-2006

Despite continued increases in the number of people living with HIV/AIDS over time, and more opportunities for transmission, HIV prevention efforts have helped to keep the number of new infections stable.

HIV Prevention in the United States at a Critical Crossroads
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*A conservative estimate examining the period 1991 to 2006.

HIV Prevention Works

"It's imperative that we confront a serious threat to the health of our nation. And that threat is complacency -- a false sense of security, a false sense of calm that hides what remains a serious epidemic. The fact is that, right here in the United States, every 9½ minutes someone's mother, someone's daughter, someone's son, someone's father, or friend, becomes infected with HIV."

Dr. Kevin Fenton
Director, CDC's National Center for HIV/AIDS, Viral Hepatitis,
STD, and TB Prevention

After almost three decades of experience with HIV in the United States, we know that prevention works.

Our national investment in HIV prevention has contributed to dramatic reductions in the annual number of new infections since the peak of the epidemic in the mid 1980s, and an overall stabilization of new infections over the past decade.13 Given continued increases in the number of people living with HIV, this stabilization is in itself a sign of progress (see box, "Measuring the Success of Prevention"). Other important signs of progress include dramatic declines in mother-to-child HIV transmission and reductions in new infections among injection drug users and heterosexuals over time.

HIV prevention has also generated substantial economic benefits. For every HIV infection that is prevented, an estimated $355,000 is saved in the cost of providing lifetime HIV treatment,12 resulting in significant cost-savings for the health care system.4

CDC's Prevention Efforts

While significant progress has been made, much more must be done. CDC pursues three major strategies to reduce the toll of HIV in the United States:

Proven HIV Prevention Interventions

We know more than ever before about what works to prevent HIV. Research has led to a growing number of proven, cost-effective approaches to reduce the risk of HIV infection. In the United States, proven strategies include:

*The term men who have sex with men is used in CDC surveillance systems because it indicates the behaviors that transmit HIV infection, rather than how individuals self-identify in terms of their sexuality.

Measuring the Success of Prevention: How Do You Count What Doesn't Occur?

"The harsh mathematics of this epidemic proves that prevention is essential to expanding treatment. Treatment without prevention is simply unsustainable."

Bill Gates
Co-chair, Bill & Melinda Gates Foundation

Trying to measure what does not occur -- the number of infections prevented, illness avoided, and lives saved -- is a difficult challenge in HIV prevention. Three key indicators can be used to gauge the impact of HIV prevention efforts on the U.S. epidemic:

Too Many Americans Are Still at Risk for HIV

Despite substantial knowledge of how to effectively prevent HIV, there is evidence that populations at greatest risk are not being sufficiently reached by proven prevention interventions and that Americans are becoming complacent about the threat of HIV:

Estimates of New Infections, 2006, By Race/Ethnicity, Risk Group, and Gender, for the Most Affected U.S. Subpopulations*

Gay and bisexual men of all races and black heterosexuals account for the greatest number of new HIV infections in the United States.

HIV Prevention in the United States at a Critical Crossroads
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*Subpopulations representing 2 percent or less of the overall U.S. epidemic are not reflected in this chart.

**The term men who have sex with men is used in CDC surveillance systems because it indicates the behaviors that transmit HIV infection, rather than how individuals self-identify in terms of their sexuality.

Populations at Greatest Risk

Gay and bisexual men of all races and racial/ethnic minorities are disproportionately affected by HIV, comprising the largest number of new HIV infections, HIV and AIDS diagnoses, and deaths among people with AIDS in the United States. Injection drug users also remain at considerable risk, but new HIV infections have been declining in this group.13

Men Who Have Sex with Men

While HIV now affects a more diverse population than ever before, gay and bisexual men of all races remain the group most severely and disproportionately impacted by this epidemic.

African Americans

In addition to disparities by risk group, there are also severe racial/ethnic disparities in the U.S. HIV epidemic, with blacks bearing the heaviest burden. While prevention efforts have helped maintain stability in the level of HIV infection among blacks overall since the early 1990s,13 the ongoing toll in many black communities across the nation is staggering:


While not as severely impacted as blacks, Hispanics are also disproportionately affected by HIV.

What Will Determine the Future Course of the U.S. HIV Epidemic

"We need to be able to talk about HIV as we talk about jobs, as we talk about housing, as we talk about civil rights. We all have a responsibility to break the silence about this disease."

Dr. Dorothy Height
Chair and President Emerita, National Council of Negro Women

Dramatically reducing HIV infection rates in the United States will require a major new commitment to HIV prevention. The future course of the U.S. HIV epidemic will be determined by the scale of our response, and by how effectively we utilize proven and emerging approaches to preventing HIV.

1. Scale of the Response

Research suggests that the size of the nation's investment in HIV prevention predicts future infection rates. Historically, increases in federal investment in HIV prevention have been followed by declines in infection rates.41 In recent years, federal resources have not been able to keep pace with the epidemic. Since 2002, CDC's HIV prevention budget (approximately $750 million in FY09) has declined by almost 20 percent in real dollars (adjusted for inflation), and prevention currently accounts for 4 percent of all federal HIV/AIDS spending on the domestic epidemic.4,42,43

At the request of Congress, CDC recently estimated the impact of additional investment on the epidemic. These estimates projected that with an additional $877 million in annual HIV prevention funding, the reach of prevention programs could be significantly expanded and transmission rates could be cut in half in just over a decade, resulting in dramatic cost-savings and lives saved.44 It will take our collective investment -- across all levels of government and the private sector -- to address the substantial unmet HIV prevention need that has mounted in this country.

2. Making Tough Choices About Directing Available Resources

As the population in need of prevention services has continued to grow in the United States, CDC and the state and local partners it funds have been forced to do more with less. This has resulted in a "triage approach" to public health, in which only the most urgent priorities can be addressed.

The nation has been and will increasingly be required to make difficult choices to ensure that available funds are having the greatest impact on infection rates. Resources must be directed to the populations at highest risk and to the strategies that are most cost-effective in reducing HIV transmission. As a nation, we must commit to using the best available science and knowledge to guide decision-making at the national, state, and local levels.

CDC is developing new tools to help determine the most effective combination of HIV prevention interventions for specific populations. These tools include:

3. Integrating New HIV Prevention Tools into Existing Programs

While existing prevention tools have had a significant impact on the epidemic, there remains an urgent need for new prevention options to reduce the burden of HIV in the United States. CDC, the National Institutes of Health (NIH), and other research partners are evaluating promising new biomedical and behavioral approaches to HIV prevention.

As new prevention interventions become available, it will be critical to use them not in isolation, but in combination with other proven interventions, especially since no single behavioral or biomedical intervention is likely to be 100 percent effective against HIV infection. Biomedical and behavioral interventions will need to be delivered in tandem to ensure that all tools are maximized and avoid migration away from more effective approaches.

A number of promising clinical trials focusing on biomedical strategies are likely to report results in the near future. These include:

"As a nation, now is the time to determine the direction we will take in fighting this serious -- yet preventable -- disease. One direction leads to complacency and the injustice of an HIV epidemic that affects the most vulnerable of Americans. The other turns toward a re-energized, science-driven effort to reduce the spread of HIV. Public health and our national conscience require we make the right choice."

Dr. Jonathan Mermin
Director, CDC's Division of HIV/AIDS Prevention

CDC is also currently evaluating the potential role of adult male circumcision in slowing the U.S. epidemic. This tool was recently proven to reduce female-to-male transmission in African settings. While there are important differences in the routes of transmission and rates of circumcision in the United States and Africa, there may be some subpopulations for whom this could offer additional protection.

Moving forward, it will also be critical to identify effective interventions to address the root societal factors facilitating HIV transmission, including poverty, racism, and stigma. Finally, we must maximize opportunities to address other serious threats to health in those living with and at risk for HIV, including viral hepatitis, other STDs, and tuberculosis.

In the fight to conquer HIV, we stand at a critical crossroads. Significant reductions in HIV are possible with a stronger response to the HIV epidemic in the United States. Unfortunately, without such a response, increases in new infections are also possible. The future of the HIV epidemic will depend on the choices we make today.


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