High Impact Community Based Strategy

In the High-Impact Prevention approach, HIV prevention efforts are guided by five major considerations:

Effectiveness and cost. While all proven interventions may have a place in HIV prevention programs, High-Impact Prevention prioritizes those that are most cost-effective at reducing overall HIV infections. Available cost-effectiveness data strongly supports interventions such as HIV testing and condom distribution, as well as many others. Programs to help people living with HIV avoid transmitting HIV to others are also cost-effective, since this group can be more efficiently served than the much larger population of people at risk for becoming infected.

Feasibility of full-scale implementation: To make a substantial difference in new infections, priority should be placed on interventions that are practical to implement on a large scale, at reasonable cost. More time- and resource-intensive interventions, such as one-on-one or group counseling, should be reserved for people at the very highest risk of transmitting or becoming infected with HIV.

Coverage in the target populations: Prevention planners should select interventions based in part on how many people can be reached once the intervention is fully implemented. For example, CDC recommends routine, opt-out HIV testing in health care settings for people regardless of risk, as research has shown that this approach can identify many people with undiagnosed HIV infection. Additionally, CDC supports targeted HIV testing in non-health care settings among people at higher risk, as this is a cost-effective tool for helping those individuals learn their HIV status.

Interaction and targeting: It is also important to consider how different interventions interact, and how they can most effectively be combined to reach the most-affected populations in a given area. For example, expanding HIV testing can amplify the impact of efforts to increase adherence to treatment, particularly in areas where large numbers of people remain undiagnosed.

Prioritization: To put the above considerations into practice, prevention planners need to rigorously assess the potential impact on HIV infections of combining different interventions for specific populations. This will allow for prioritizing the interventions that will have the greatest overall potential to reduce infections.

At the national level, CDC has recently taken important steps to establish clear priorities for directing resources to the geographic areas and interventions that could have the greatest impact on HIV rates and health equity. These include a new approach to health department funding, expanded HIV testing efforts, and combination prevention demonstration projects in the areas and populations most heavily affected by HIV. (For examples, see boxes below.)

High-Impact Prevention in Practice

Real-world examples of CDC's approach to HIV prevention

Health Department Funding

CDC funding: $359 million annually, FY2012-FY2016 (assumes level funding)

A new approach to health department funding that better matches prevention dollars to the HIV burden in every state, territory, and heavily affected city, focusing on high-impact interventions.

Expanded Testing Initiative

CDC funding: $111 million total, FY2007-FY2010

Targeted funding for HIV testing in communities at risk. Between 2007 and 2010, provided 2.8 million tests; resulted in more than 18,000 new HIV diagnoses; and helped avert $1.2 billion in direct medical costs.

Enhanced Comprehensive HIV Prevention Planning (ECHPP)

CDC funding: $34.8 million anticipated total, FY2010-FY2012

Innovative demonstration projects implementing combination prevention in 12 cities with the highest AIDS burden. For example, the Houston ECHPP project brought together a diverse range of government agencies to create new links between prevention, care, substance abuse, and other services that can reduce new HIV infections.

Community-Based HIV Prevention for Young MSM and Transgender Persons of Color

CDC funding: $50 million total, FY2012-FY2016 (assumes level funding)

Support for local HIV prevention efforts to reach young MSM and transgender people of color with HIV testing and linkages to care, support, and prevention services, as well as targeted behavioral interventions and other effective approaches.

On April 1, 2014, the Centers for Disease Control and Prevention (CDC) plans to award $115 million over 5 years to train and strengthen 21 capacity-building organizations and ensure on-the-ground prevention programs and their staff have the skills, information, and organizational support they need to best serve individuals living with, and at high risk for, HIV in their communities

With an estimated 50,000 new HIV infections each year, more must be done with existing resources to maximize the impact of every federal prevention dollar and achieve the goals of the National HIV/AIDS Strategy (NHAS). The new capacity building assistance (CBA) program aligns with the goals of the NHAS and CDC’s High-Impact Prevention (HIP) and Community High-Impact Prevention (CHIP) approaches by supporting a defined set of scalable, cost-effective activities and placing new emphasis on the delivery of high-quality prevention and care services for persons living with HIV; effective new prevention strategies for those at high-risk for HIV; policy change to advance HIV prevention goals among health departments; and collecting and using care continuum data for policy planning and program prioritization. The program also continues to emphasize key activities with demonstrated potential to reduce new infections such as HIV testing, condom distribution, and use of surveillance data to improve program efficiency and effectiveness.

Individual level - Community capacity-building on an individual level requires the development of conditions that allow individual participants to build and enhance existing knowledge and skills. It also calls for the establishment of conditions that will allow individuals to engage in the "process of learning and adapting to change."

(1) Identify multi-level factors (individual, familial, societal, economic and legislative) which underlie those social determinants that are associated with risk for HIV acquisition or negative HIV care and treatment outcomes at the individual or population levels. Research that focuses on modifiable factors beyond the individual-level is encouraged.

Institutional level - Community capacity building on an institutional level should involve aiding pre-existing institutions in developing communities. It should not involve creating new institutions, rather modernizing existing institutions and supporting them in forming sound policies, organizational structures, and effective methods of management and revenue control.

(2) Identify individual and/or community-level mechanisms (e.g., coping, social networks) associated with desired HIV prevention or HIV disease outcomes despite exposure to negative social, economic and/or legal conditions. Research that operationalized resilience as distinct from risk factors is particularly encouraged.

Societal level - Community capacity building at the societal level should support the establishment of a more "interactive public administration that learns equally from its actions and from feedback it receives from the population at large." Community capacity building must be used to develop public administrators that are responsive and accountable

(3) Design multi-level, structural interventions to intervene upon specified social determinants or sets of social determinants to minimize the negative effects of those social determinants; attempt to reduce the social and structural barriers that negatively impact HIV risk, care and treatment and go beyond influencing individual knowledge, attitudes, and beliefs. Evidence-based justification (e.g., modeling data) for the design of the structural intervention is encouraged prior to proposing to test its impact on HIV prevention, care and/or treatment outcomes