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Written Presentation to the
Institute of Medicine

By
Sandra Thurman
Director
White House Office of National AIDS Policy

January 25, 2000

"The IOM Study: An Opportunity for Vision and Direction"

Good afternoon. To the Chair and Vice-Chair, the IOM committee, liaison panel and other guests, I am glad to have this opportunity to speak with you today. I have a lot to cover in a few minutes - points and issues that I hope you will keep in mind as you go forward with your important work - the work of reviewing the CDC's HIV prevention efforts within the context of our overall effort to prevent HIV infection and its consequences. As written in the statement of task for this study, such a review of CDC and the resulting framework for future prevention activities will need to be done within the context of the respective roles and missions of other DHHS agencies, as well as, other public and private agencies and organizations. This is no small task - in fact, it's huge - but it is one that is timely and one which has the potential of providing us with invaluable guidance as we take on this next phase of our battle against HIV and AIDS, with all of its challenges and increasingly, new opportunities.

What does this mean to the Committee and its work? I know that yesterday you were briefed by CDC AIDS Advisory Council members on areas of HIV prevention research, policy and service delivery programs - that Drs. Koplan and Gayle gave you an overview of CDC's effort and Drs. Nathanson and Auerbach presented on NIH's prevention research strategy and program. Today you have heard background points from other key organizations that will be important as you consider CDC's enormous potential and central role in our HIV prevention efforts. Let me see if I can add to these perspectives and the knowledge base you are gathering, and possibly tie together a few of the major points that have been expressed at this meeting over the last two days.

We all know that the news about HIV and AIDS on the home front continues to be mixed. The good news is that new and better drugs are allowing many people infected with HIV or who have AIDS to live longer and healthier lives. The bad news is that the epidemic continues to shift dramatically to women, people of color, and young people. More than 50% of all new infections in this country are in people under 25 1 in 4 of those are teenagers. And while we have seen a dramatic decline in AIDS cases and AIDS deaths we have seen virtually no decline in the number of new infections. A point that some, claiming that the worst is over, seem not acknowledge. In other words, there is still a tremendous amount of work to do.

Everyday, in your work and in mine, we must remember that HIV infection and AIDS are preventable. But today, we are confronted with an estimated 200,000 - 300,000 HIV-infected Americans who do not know their status. Without medical care, treatment and support these individuals are at increased risk for an early death and continue to put others in jeopardy of transmission. In addition, issues such as incomplete adherence to AIDS medications, reports of increased HIV risk behaviors among young gay men, and policies that continue to restrict maximal effectiveness of public health measures to prevent HIV, continue to underscore the challenges we face. These are hard issues - issues that require a new level of clear leadership - leadership that is able to assimilate the data, establish workable action plans, and then determine, empower and partner with the best mix of change agents and/or delivery systems to get the job done.

Getting the job done. Today there are more testing options than ever before. Getting tested for HIV is easier and quicker. We have blood tests, oral tests, urine tests - tests that can be available to anyone in any kind of setting. We must encourage people across the country to take control of their health by getting tested for HIV and knowing their serostatus. But all of us here are aware that knowing about HIV, even knowing about one's own status, whether positive or not, is not enough. We now have a growing wealth of HIV prevention science research - research that addresses key prevention issues and dynamics at the individual, interpersonal, community, and societal levels. This is research that we should now be taking advantage of in our efforts to prevent new HIV infections, as well as, to minimize the health consequences for those who are already infected. Proper utilization and dissemination of these proven prevention strategies and programs, both here at home and in the global community, can give people the skills and opportunities they need to stay safe and remain healthy. This often requires providing the "hands-on" technical assistance to those who need it the most. From the policymakers in Washington to the directors of the local CBOs, we are all in need of understandable, usable translations of the prevention science and the availability of clear guidance and tutelage on how best to apply them to our particular prevention needs and goals.

It is in this spirit that I ask that as you move forward in your work, especially in developing a framework of how best to implement and sustain successful HIV prevention efforts, you consider what research and program experience have taught us. Namely, that we need to:

  • base our prevention efforts on sound scientific principles and evidence;

  • integrate behavioral and biomedical prevention strategies;

  • embrace proven prevention technologies and implement the strategies that will get them into appropriate widespread practice;

  • adapt prevention strategies to changing circumstances;

  • view recipients of prevention efforts as "change agents" rather than targets;

  • deliver our interventions in a complimentary fashion at multiple levels;

  • consider the behaviors, practices and attitudes of the individual within the context of the group and society he or she is living in;

  • have strong and multifaceted partnerships among government agencies, as well as, other public and private agencies and organizations; and,

  • continually evaluate, translate and disseminate the information on what works, where, with who, and why.

And as this expert Committee proceeds in its analysis and deliberations, I would encourage you to emphasize that aspect of your charge which asks you to specifically examine CDC's efforts with respect to HIV prevention. Why? Because the CDC's mission places it central to the many components of our overall HIV prevention effort. It is the primary funder of HIV prevention at the State and community levels. From utilizing the growing body of HIV prevention science research, to the assessment of the changing patterns and distribution of infection, to ensuring linkages and follow through referrals to prevention case management or HIV treatment services, the CDC has a critical role to play in our effort to overcome HIV. Consistent with recommendations we have heard from the OMB, the Presidential Advisory Council on HIV and AIDS, and other community leaders, an examination of CDC's programs, funding and administrative mechanisms is timely and warranted to ensure its ability to implement its responsibilities in the most effective ways possible.

As this Committee moves forward it will be important to consider how the CDC might best develop:

  • an agency-wide HIV prevention plan with measurable outcomes;
  • a process for allocating it's budget in furtherance of this strategic plan; and
  • systems for insuring that HIV prevention funds are used only for HIV-focused prevention activities (including HIV prevention FTEs).

In addition, the committee should consider how CDC might best determine and forge:

  • the optimal mix of funding strategies to achieve targeted prevention goals, particularly within marginalized communities; and,
  • enhanced collaborations and partnerships with other key agencies, organizations and community groups involved in the varied aspects of HIV prevention.

All of which should take into account and help delineate the key areas of responsibility under its mission including:

  • Epidemiological research and surveillance;
  • Field implementation and evaluation of evidence-based interventions;
  • Public education;
  • Technical assistance and,
  • Policy.

So, in your work, as you identify and acknowledge the important role that other agencies have in the area of HIV prevention, it will remain vital that this study specifically considers how best to maximize the effectiveness of CDC's functions and programs in setting and realizing its own prevention goals. For example, we are now seeing new relationships of HIV prevention and treatment. It will be useful to consider how CDC can best synthesize and integrate research and treatment advances into its prevention mission and programs in a way that builds upon what has been learned and improves what is being implemented. This will most likely require creative, possibly unconventional partnerships with health care and health care-related service delivery systems, as well as organizations working in non-traditional settings where people at high risk are found.

As the committee moves to articulate its vision of a comprehensive prevention effort, these and other points will be important to consider in determining a framework that is able to effectively:

  • influence individual choices;
  • ease social and economic constraints to safe behavior;
  • set government priorities (both process and content);
  • institutionalize and sustain programs that work;
  • invest in new knowledge and technology; and,
  • build a comprehensive public health infrastructure in this country that adequately supports HIV prevention, and promotes the same elsewhere.

HIV/AIDS is a story that unfortunately is not slowly nearing its end but rather a huge tragedy just beginning to unfold. Together, we must find ways in which the struggle against AIDS in our nation can be addressed effectively, and be joined with the larger struggle against AIDS across our world. We must remember that the many dimensions of HIV prevention provide multiple opportunities for intervention. It is our challenge to identify and harness those opportunities in the most effective and timely ways.

CDC is an agency that has the obligation and the capacity to play a central leadership role in this effort. But to do so, it must re-evaluate and determine what is working, what is not, and what its appropriate role is relative to other agencies and organizations. From where I sit, I continue to hear from community groups and others across this country, that to do this, it is important to have an external, independent and objective perspective. This is the task that I see the CDC and its advisory council asking you, as an experienced and thoughtful committee of experts, to assist them in doing. I am aware that it has been emphasized that internally CDC is working on ways to address issues that relate to the charge of this committee. That is positive and I am sure the outcomes of these efforts will be helpful to the committee as CDC provides you with this information as it becomes available throughout the course of this important IOM study. But I continue to feel that there are important benefits to be gained by being able to bring your perspective and expertise to bear on many of these same issues as they impact the CDC and as they relate to the challenges facing the design of our Federal prevention efforts. And it is this solid grounding that will allow us to go forward and make the effective argument for an increased Federal investment in HIV prevention.

I wish you the best in your endeavor here and I look forward to your conclusions. My office stands ready to assist you in whatever manner we can.

Thank you for your time today. I will be glad to answer questions in the time remaining.

 

 

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