Detailed Information on the
National Center for HIV/AIDS, Viral Hepatitis, Sexually Transmitted Diseases, and Tuberculosis Prevention Assessment

Explicitly tie budget requests to the accomplishment of annual and long-term goals and presenting resource needs in a complete and transparent manner.

Establish baselines and targets for those HIV/AIDS long-term and annual measures lacking such data.

Monitor and report on program's progress in achieving its performance goals and efficiency measures annually.

Measure: Increase the efficiency of core HIV/AIDS surveillance as measured by the cost per estimated case of HIV/AIDS diagnosed each year.

Explanation:CDC provides financial and technical support to all state health departments, which have legal authority for mandating and defining processes for reporting of medical conditions and to produce HIV and AIDS surveillance data. States use the data to guide their prevention programs. At the national level, data are used to guide allocations of funding for HRSA-funded care and treatment programs and the Housing Opportunities for People with AIDS program supported by HUD. CDC uses HIV/AIDS surveillance data to identify populations most at risk and to guide prevention efforts. However, while national data are available for AIDS cases, national data are not yet available on HIV infections. This is because, unlike AIDS and other infectious diseases, for which standard methods of disease reporting are employed, states have historically used several different methods for collecting data on HIV infection: name-based, code-based, or name-to-code. Today, potent antiretroviral therapies which delay or prevent the development of AIDS for many HIV-infected persons make imperative the need for HIV data to monitor trends in the epidemic. CDC has found that rapid implementation of a scientifically accurate and reliable system of national HIV reporting can only occur with the adoption of a standard system of patient identification used by all states. In order to achieve the goal of nationwide, high-quality HIV data, in 2005, CDC recommended that all states and territories adopt confidential, name-based surveillance systems to report HIV infections. To monitor trends in the epidemic at a national level, CDC analyzes data from states with mature, confidential, name-based HIV reporting systems. The number of states included in this analysis has risen over the years, as additional states adopt confidential, name-based HIV reporting methods, and as those systems are implemented and stabilize. This measure reflects efficiencies that are being achieved in HIV surveillance nationally. Because CDC provides technical and financial support to HIV and AIDS reporting systems regardless of the type of reporting used, funds allocated to states to conduct core case surveillance are not anticipated to rise dramatically with the adoption and maturation of confidential, name-based surveillance in more states. Additional efficiencies might also be achieved as surveillance systems work with existing resources to accommodate increased reports of HIV resulting from widespread implementation of HIV screening.

Measure: Decrease the annual HIV incidence.

Explanation:The target population for this measure is adults and adolescents (>13 years of age). The ability to monitor trends in new HIV infections (i.e. HIV incidence) is a fundamental indicator of the impact of HIV prevention activities in the U.S. However, until this time, CDC has not had the ability to monitor trends in HIV incidence. Surveillance for HIV has relied primarily on reporting of diagnosed cases of HIV infection. Since individuals may be infected for years before being diagnosed, reports of HIV diagnoses may not provide information on recent infections. In the past, CDC has used several proxies to monitor trends in the epidemic. AIDS case surveillance was used until the late 1990s to monitor trends in the epidemic; however, the advent of effective, life-prolonging treatments has rendered AIDS surveillance less useful in monitoring trends in HIV infection. More recently, CDC has used HIV transmission among persons less than 25 years old as a proxy for HIV incidence, since most HIV infections among persons less than 25 years old are recent. However, since an estimated one quarter of HIV infections are currently undiagnosed, this measure is subject to confounding with changes in HIV testing behaviors. Initiatives to increase HIV testing are likely to increase the number of diagnosed HIV infections, and may do so without actual increases in the total number of infections. CDC is now using newly available laboratory methods in a national HIV incidence surveillance system. CDC provides funding and technical assistance to selected state and local health departments to conduct HIV incidence surveillance. This complex surveillance system uses the Serologic Testing Algorithm for Recent HIV Seroconversion (STARHS) methodology, a testing algorithm developed by CDC staff to assess HIV incidence. Using residual serum specimens from standard HIV antibody testing, STARHS uses a less sensitive Enzyme-Linked Immunoassay (EIA) to determine whether the person has been infected with HIV for less than six months (recent infection or longer than six months (long-standing infection). Ongoing population-based data from the funded areas are adjusted to impute annual national HIV incidence estimates. The first data from this new surveillance system will be available in the latter part of 2007.

Measure: Decrease the number of pediatric AIDS cases.

Explanation:This measure addresses children <13 years of age who have developed AIDS. Among this population, AIDS has declined from nearly 1,000 per year in the early 1990s to 58 in 2005. This decline was strongly associated with increased HIV testing and treatment of infected pregnant women. Effective treatments for pregnant women have been shown to greatly reduce, but not eliminate, perinatal transmission (transmission can be reduced from an estimated 25% to <2% among HIV-infected women in the U.S.) More recently, some decline is likely associated with improved treatments which delay the onset of AIDS for HIV-infected children. Further declines in AIDS cases among children <13 years old will be difficult to achieve. Prevention programs for this age group have been extraordinarily successful and further declines are contingent upon continued delay of development of AIDS among those children under 13 who are already infected; reductions in the perinatal transmission rate among pregnant women; and reducing the prevalence of HIV infection among women. Given the growing population of women living with HIV and the existing number of children who are already infected, decreases in the number of children developing AIDS are unlikely. CDC provides funding and technical assistance to 65 state and local health departments to conduct HIV/AIDS prevention programs, including perinatal transmission prevention. CDC also produces guidelines, provides technical assistance, and provider education to reduce perinatal HIV.

Measure: Reduce the Hispanic: white rate ratio of HIV/AIDS diagnoses.

Explanation:Hispanics are disproportionately affected by the HIV/AIDS epidemic. This measure compares the HIV/AIDS rates per 100,000 population between Hispanics and whites. CDC provides funding and technical assistance to 65 state and local health departments to conduct HIV/AIDS prevention programs, including evidence-based prevention interventions for Hispanic communities. CDC also produces guidelines, provides technical assistance, and provider education to reduce racial and ethnic disparities in HIV/AIDS rates.

Measure: Reduce the black:white rate ratio of HIV/AIDS diagnoses.

Explanation:African-Americans are disproportionately affected by the HIV/AIDS epidemic. This measure compares the HIV/AIDS rates per 100,000 population between African-Americans and whites. CDC provides funding and technical assistance to 65 state and local health departments to conduct HIV/AIDS prevention programs, including evidence-based prevention interventions for African-American communities. CDC also produces guidelines, provides technical assistance, and provider education to reduce racial and ethnic disparities in HIV/AIDS rates.

Measure: Decrease the rate of HIV transmission by HIV-infected persons.

Explanation:The target population for this measure is adults and adolescents (>13 years of age). The ability to monitor the national HIV transmission rate is a fundamental indicator of the impact of HIV prevention activities in the U.S. Until recently, CDC was not able to monitor transmission rates because no means were available to accurately monitor trends in new HIV infections. However, new laboratory methods now enable CDC to conduct HIV incidence surveillance. Today, CDC provides funding and technical assistance to selected state and local health departments to conduct HIV incidence surveillance. This surveillance system uses the Serologic Testing Algorithm for Recent HIV Seroconversion (STARHS) methodology, a methodology developed by CDC staff to measure HIV incidence. Using residual serum specimens from standard HIV antibody testing, STARHS uses a less sensitive Enzyme-Linked Immunoassay (EIA) to determine whether the person has been infected with HIV for less than six months (recent infection) or longer than six months (long-standing infection). Ongoing population-based data from the funded areas are adjusted to impute annual national HIV incidence estimates. The first data from this new surveillance system will be available in the latter part of 2007. In the era of more effective therapies for HIV, Americans with HIV are living longer and the total number of Americans living with HIV is increasing. For example, from 2001-2005 the number of persons living with HIV/AIDS in the 33 areas with longstanding name-based HIV surveillance increased from an estimated 384,553 to 476,749. This measure takes into account the increasing number of persons who are living with HIV, and therefore at risk of transmitting the virus, as a result of the new, live-prolonging treatments. CDC is working to decrease transmission rates by increasing the number of people who know they are infected and providing prevention services to those living with HIV.

Measure: Decrease risky sexual and drug using behaviors among persons at risk for transmitting HIV.

Explanation:CDC provides a variety of evidence-based prevention services for persons who are HIV infected to help reduce their risk of transmitting the virus to their partners. CDC will be able to monitor changes in risk behaviors among persons living with HIV through the Medical Monitoring Project, a second generation surveillance system which has been developed and piloted and will be implemented in the field in 2007. When fully implemented, MMP will be a nationally representative, population-based surveillance system assessing clinical outcomes, behaviors, and quality of care among HIV infected persons who are in medical care. HIV-infected persons are interviewed about sexual and drug-using behaviors that may put them at risk for transmitting HIV. MMP replaces CDC's Supplemental HIV/AIDS Surveillance (SHAS), a convenience sample surveillance system which had provided data on HIV infected persons in care in 16 areas. MMP is being conducted in 19 states, 1 US territory and 6 cities. MMP uses a 3-stage sampling design which will result in annual cross-sectional probability samples of adults in medical care for HIV infection in the United States. During the first stage of sampling (state sampling), 20 geographic primary sampling units (PSUs) were selected from the 50 US states and Puerto Rico using probability proportional to size (PPS) sampling based on AIDS prevalence at the end of 2002. During the second stage (provider sampling), a sample of facilities providing HIV care in each of the project areas was selected. The measure of size for PPS sampling of facilities was the number of HIV-infected patients who received care at the facility during the most recent reporting year for which measure of size data were complete. During the third stage of sampling (patient sampling), participants will be randomly selected from among all eligible patients. The sample size will be greater than 10,000 persons per year.

Measure: Decrease risky sexual and drug using behaviors among persons at risk for acquiring HIV.

Explanation:This measure addresses persons who are at increased risk of acquiring HIV infection due to risky sexual or drug using behaviors. CDC supports prevention activities for persons who are uninfected and at behavioral risk of infection. NHBS is a nationally representative behavioral surveillance system that collects risk behavior data from three populations at-risk for acquiring HIV infection: men who have sex with men (MSM), injection drug users (IDU), and high risk heterosexuals in areas where HIV is prevalent (HRH). It utilizes survey sampling techniques developed in the past few years to reach representative samples of at risk populations. NHBS replaces the HIV Testing Survey (HITS), a convience sample survey of persons at risk for HIV that had been done in rotating states around the country. NHBS was initiated in 2004, is conducted on an annual basis, and is limited during each cycle to one of these three study groups. Because of the survey cycle, different targets are set for the respective populations surveyed for the different years. The first NHBS cycle included approximately 10,000 MSM; the second NHBS cycle included approximately 13,000 IDU; and the third NHBS cycle will include approximately 18,750 heterosexuals. MSM data and targets have been established. New, effective treatments for HIV have resulted in increased risk taking behavior among MSM. This is reflected in increased self-reported risk behavior, STD infections, and increased HIV diagnoses. Other factors have also combined to increase risk among MSM; such as methamphetamine use, use of the Internet to meet new sexual partners and beliefs regarding the severity of HIV disease. Because of the difficulties in changing behaviors on a population-wide basis, and in the face of countervening trends, only modest decreases in this measure can be expected over the next several years without substantial infusion of new resources.

Measure: Increase the proportion of persons at risk for HIV who received HIV prevention interventions.

Explanation:This measure addresses the extent to which at-risk individuals have received intensive HIV prevention interventions (participation in an individual or small group prevention intervention). CDC supports prevention activities for persons who are at risk of infection. The National HIV Behavioral Surveillance (NHBS) System is a nationally representative behavioral surveillance system that collects risk behavior data from three populations at-risk for acquiring HIV infection: men who have sex with men (MSM), injection drug users (IDU), and high risk heterosexuals in areas where HIV is prevalent (HRH). It utilizes survey sampling techniques developed in the past few years to reach representative samples of at-risk populations. NHBS replaces the HIV Testing Survey (HITS), a convience sample survey of persons at risk for HIV that had been done in rotating states around the country. NHBS was initiated in 2004, is conducted on an annual basis, and is limited during each cycle to one of these three study groups. Because of the survey cycle, different targets are set for the respective populations surveyed for the different years. The first NHBS cycle included approximately 10,000 MSM; the second NHBS cycle included approximately 13,000 IDU; and the third NHBS cycle will include approximately 18,750 heterosexuals. MSM data and targets have been established. Individual and group level interventions are targeted at persons at highest risk of HIV transmission. This measure addresses persons who had recently (within the past 12 months) received an intervention and does not measure the cumulative effect of evidence-based HIV prevention efforts. Only modest increases in this measure can be expected without substantial infusion of new resources.

Measure: Increase the proportion of HIV-infected people in the United States who know they are infected.

Explanation:Decreasing the prevalence of undiagnosed HIV infection has been a key prevention priority for CDC. CDC has facilitated HIV testing through publicly funded HIV counseling and testing, targeted distribution of rapid HIV tests, social marketing campaigns and revised recommendations promoting routine HIV screening in medical settings. CDC estimates that approximately 75% of the approximately 1,000,000 persons living with HIV are aware that they are infected. However, increasing the proportion of people who know their HIV status is an ongoing prevention challenge for CDC. Some persons with undiagnosed HIV infection (particularly those with recent infection) may not seek testing because they do not believe that they are at risk for HIV infection. Others are aware that they may be at risk, but they avoid testing (or being re-tested) because they are afraid of learning that they are HIV infected. HIV-infected persons who are unaware of their HIV status are more likely to transmit HIV and are estimated to account for more than ?? of HIV transmissions in the US. In September, 2006, CDC issued Revised Recommendations for HIV Screening of Adults, Adolescents, and Pregnant Women in Health-Care Settings. CDC is addressing challenges to implementation of HIV screening in health-care settings through a multidisciplinary approach that includes: policy diffusion strategies; partnerships with organizations of health care professionals; coordination with other federal agencies; implementation guidance; professional education materials; monitoring and evaluation strategies; social marketing; and strategies to ensure follow up care for HIV-infected persons.

Measure: Increase the proportion of persons with HIV-positive test results from publicly funded counseling and testing sites who receive their test results.

Explanation:This measure addresses persons tested for HIV in publicly-funded HIV testing and counseling sites. Historically, a large proportion (up to 50% in some settings) of persons who got tested for HIV did not return to the clinic to receive their HIV test results. This represented considerable lost opportunities for HIV prevention. Consequently, emphasis is placed on providing test results to those persons with HIV positive test results. These data were captured by CTR, and are now being incorporated into PEMS. CDC developed PEMS in response to the need to strengthen the monitoring and evaluation of HIV prevention programs nationwide. When fully implemented PEMS will be used by all health departments and CBOs funded through CDC HIV prevention cooperative agreements and will provide quantitative data to show program progress toward meeting implementation goals and program effectiveness. PEMS is a secure Internet browser-based software program for data entry and reporting.

Measure: Increase the proportion of people with HIV diagnosed before progression to AIDS.

Explanation:Since the mid-1990s, effective medical therapies for HIV infection and associated opportunistic infections have dramatically reduced death rates associated with HIV infection. Age-adjusted mortality due to HIV disease has declined from approximately 17 per 100,000 population in 1995 to less than 6 per 100,000 population in 2002. In order to take advantage of more effective therapies and prevent transmission to others, individuals should be aware of their infection early in the course of the disease. CDC provides funding and technical assistance to 65 state and local health departments to conduct HIV/AIDS prevention programs aimed at increasing early diagnosis. Data are from a system which includes both the HIV diagnosis and AIDS diagnosis dates. Data are from 33 states with mature, confidential name-based reporting.

Measure: Increase the percentage of HIV-infected persons in publicly funded counseling and testing sites who were referred to PCRS.

Explanation:This measure addresses persons who were tested for HIV in publicly-funded HIV testing and counseling sites. Prevention Counseling and Referral Services (PCRS) is a key component of CDC's HIV prevention activities. Through PCRS, infected persons are counseled about the importance of notifying their partners and provided skills for doing so. Through this strategy, notified partners can choose whether to be tested, and receive relevant counseling and prevention services. Data for this measure will come from PEMS. CDC developed PEMS in response to the need to strengthen the monitoring and evaluation of HIV prevention programs nationwide. Currently, more than 1,250 agencies, including health departments and community-based organizations across the country, have access to PEMS. CDC has considered the needs and capacities of these widely differing organizations in developing and refining PEMS. To this end, CDC has held several stakeholder meetings and is currently piloting PEMS in both state and local health departments and among community-based organizations. When fully implemented PEMS will be used by all health departments and CBOs funded through CDC HIV prevention cooperative agreements and will provide quantitative data to show program progress toward meeting implementation goals and program effectiveness. PEMS is a secure Internet browser-based software program for data entry and reporting.

Measure: Increase the percentage of HIV-infected persons in publicly funded counseling and testing sites who were referred to medical care and attended their first appointment.

Explanation:This measure addresses persons who were tested for HIV in publicly-funded HIV testing and counseling sites and who were found to be HIV-infected. Referral to appropriate medical care is a key HIV prevention activity. Early medical intervention can reduce the likelihood of developing AIDS and offers an important opportunity for HIV prevention. Data for this measure come from PEMS. CDC developed PEMS in response to the need to strengthen the monitoring and evaluation of HIV prevention programs nationwide. Currently, more than 1,250 agencies, including health departments and community-based organizations across the country, have access to PEMS. CDC has considered the needs and capacities of these widely differing organizations in developing and refining PEMS. To this end, CDC has held several stakeholder meetings and is currently piloting PEMS in both state and local health departments and among community-based organizations. When fully implemented PEMS will be used by all health departments and CBOs funded through CDC HIV prevention cooperative agreements and will provide quantitative data to show program progress toward meeting implementation goals and program effectiveness. PEMS is a secure Internet browser-based software program for data entry and reporting.

Measure: Increase the percentage of HIV-infected persons in publicly funded counseling and testing sites who were referred to HIV prevention services.

Explanation:This measure addresses persons tested for HIV in publicly-funded HIV testing and counseling sites and who were found to be HIV-infected. CDC supports prevention services among HIV-infected individuals to reduce risk of transmission. These services are not necessarily offered at the testing and counseling facility. Therefore, HIV-infected individuals may need referral to another organization or facility. Data for this measure come from PEMS. CDC developed PEMS in response to the need to strengthen the monitoring and evaluation of HIV prevention programs nationwide. Currently, more than 1,250 agencies, including health departments and community-based organizations across the country, have access to PEMS. CDC has considered the needs and capacities of these widely differing organizations in developing and refining PEMS. To this end, CDC has held several stakeholder meetings and is currently piloting PEMS in both state and local health departments and among community-based organizations. When fully implemented PEMS will be used by all health departments and CBOs funded through CDC HIV prevention cooperative agreements and will provide quantitative data to show program progress toward meeting implementation goals and program effectiveness. PEMS is a secure Internet browser-based software program for data entry and reporting.

Measure: Increase the percentage of HIV-infected persons in medical care who initiated medical care within three months of diagnosis.

Explanation:CDC provides a variety of evidence-based prevention services for persons who are HIV infected to help reduce their risk of transmitting the virus to their partners. CDC will be able to monitor changes in risk behaviors among persons living with HIV through the Medical Monitoring Project, a second generation surveillance system which has been developed and piloted and will be implemented in the field in 2007. When fully implemented, MMP will be a nationally representative, population-based surveillance system assessing clinical outcomes, behaviors, and quality of care among HIV infected persons who are in medical care. HIV-infected persons are interviewed about sexual and drug-using behaviors that may put them at risk for transmitting HIV. MMP replaces CDC's Supplemental HIV/AIDS Surveillance (SHAS), a convenience sample surveillance system which had provided data on HIV infected persons in care in 16 areas. MMP is being conducted in 19 states, 1 U.S. territory and 6 cities. MMP uses a 3-stage sampling design which will result in annual cross-sectional probability samples of adults in medical care for HIV infection in the U.S. During the first stage of sampling (state sampling), 20 geographic primary sampling units (PSUs) were selected from the 50 U.S. states and Puerto Rico using probability proportional to size (PPS) sampling based on AIDS prevalence at the end of 2002. During the second stage (provider sampling), a sample of facilities providing HIV care in each of the project areas was selected. The measure of size for PPS sampling of facilities was the number of HIV-infected patients who received care at the facility during the most recent reporting year for which measure of size data were complete. During the third stage of sampling (patient sampling), participants will be randomly selected from among all eligible patients. The sample size will be greater than 10,000 persons per year.

Measure: Increase the number of states with mature, name-based HIV surveillance systems.

Explanation:The target population for this measure is the HIV surveillance systems in the 50 United States. Since 1985, all states and territories have conducted AIDS surveillance using the same standardized name-based methods as all other infectious diseases. Implementation of HIV surveillance has been less consistently implemented, and some states have used code-based methods of HIV surveillance. Based on CDC recommendations and requirements in the Ryan White Treatment Modernization Act of 2006, more states have adopted name-based HIV surveillance systems. However, after a state implements name-based HIV surveillance, it takes a number of years for the system to "mature" (establish statewide surveillance standards, train reporting entities, eliminate backlogs of prevalent cases, eliminate interstate and intrastate duplicates, etc.). For purposes of conducting statistical analyses of trends etc., CDC does not include data from states until the HIV surveillance system is identified as being "mature."

Measure: Increase the percentage of HIV prevention program grantees using PEMS to monitor program implementation.

Explanation:This measure addresses all CDC-funded prevention program grantees. CDC has developed PEMS to strengthen monitoring and evaluation of HIV prevention programs. PEMS is to be used by health departments and CBOs funded through CDC HIV prevention cooperative agreements. Data for this measure come from PEMS. CDC developed PEMS in response to the need to strengthen the monitoring and evaluation of HIV prevention programs nationwide. Currently, more than 1,250 agencies, including health departments and community-based organizations across the country, have access to PEMS. CDC has considered the needs and capacities of these widely differing organizations in developing and refining PEMS. To this end, CDC has held several stakeholder meetings and is currently piloting PEMS in both state and local health departments and among community-based organizations. When fully implemented, PEMS will be used by all health departments and CBOs funded through CDC HIV prevention cooperative agreements and will provide quantitative data to show program progress toward meeting implementation goals and program effectiveness. PEMS is a secure Internet browser-based software program for data entry and reporting.

Measure: Increase the number of evidence-based prevention interventions that are packaged and available for use in the field by prevention program grantees.

Explanation:The target for this measure is the number of evidence-based prevention interventions available for use by CDC-funded prevention programs. CDC conducts systematic reviews to identify efficacious HIV prevention behavioral interventions based on rigorous efficacy criteria. After an intervention has been identified to be effective, CDC "packages" the intervention through the Replicating Effective Programs (REP) Project. CDC then provides technical assistance and training to move effective HIV interventions into program practice.

Measure: Increase the number of Agencies trained each year to implement DEBIs.

Explanation:The target population for this measure is CBOs funded by CDC. The Diffusion of Effective Behavioral Interventions (DEBI) project was designed to bring evidence-based, community-and group-level HIV prevention interventions to community-based service providers and state and local health departments. The goal is to enhance the capacity to implement effective interventions at the state and local levels, to reduce the spread of HIV and STDs, and to promote healthy behaviors. CDC supports training for CBO staff nationwide to help CBOs implement effective prevention interventions for their local populations. By 2005, most CBOs funded by CDC had been trained on one or more DEBIS. Training is now focused on training replacement staff, newly funded CBOs and on newly available DEBIs. CDC expects to maintain its current level of training activities assuming level funding for these efforts.

Measure: Reduce the rate of new cases of hepatitis A (per 100,000 population).

Explanation:In the United States, viral hepatitis, a liver disease, is most often caused by infection with hepatitis A virus (HAV), hepatitis B virus (HBV), or hepatitis C virus (HCV). One in three Americans has been infected with one of these viruses at some point in their lives. Many don't know it. Approximately 100,000 new infections occur each year. HAV is spread by close contact with infected persons or ingestion of contaminated food. Vaccination, outbreak response, and food safety programs are the primary interventions used to prevent hepatitis A. As one of the nationally notifiable diseases, it is mandated that any case of diagnosed hepatitis A should be reported to local health authorities. The overall rate of hepatitis A is determined based on reports of acute disease received by state health departments and reported to CDC. Because it incorporates data from all 50 states and the District of Columbia, this measure, which is also included in the Healthy People 2010 initiative, provides a representative method to assess national trends in this disease.

Measure: Reduce the rate of new cases of hepatitis B (per 100,000 population).

Explanation:In the United States, viral hepatitis, a liver disease, is most often caused by infection with hepatitis A virus (HAV), hepatitis B virus (HBV), or hepatitis C virus (HCV). One in three Americans have been infected with one of these viruses at some point in their lives. Many don't know it. Approximately 100,000 new infections occur each year. HBV is spread by exposure to infectious blood or body fluids or through sexual contact. HBV infection can become chronic in some persons and lead to death from cirrhosis or liver cancer. In the United States, approximately 1-1.25 million persons have chronic hepatitis B, and 3,000-5,000 die each year. Key components of CDC efforts to prevent HBV-related morbidity and mortality are 1) vaccination of newborns, infants, and children and of adults at increased risk of infection and 2) identification and referral of HBV-infected persons for public health management and treatment, with a focus on persons from HBV-endemic countries and others with high prevalence of chronic HBV infection. As one of the nationally notifiable diseases, it is mandated that any case of diagnosed hepatitis B should be reported to local health authorities. The overall rate of hepatitis B is determined based on reports of acute disease received by state health departments and reported to CDC. Because it incorporates data from all 50 states and the District of Columbia, this measure provides a representative method to assess national trends in this disease and track the progress toward elimination of HBV transmission in the U.S.

Measure: Increase the proportion of individuals knowing their hepatitis C virus infection status.

Explanation:Hepatitis C is the most common bloodborne viral infection and a leading cause of death from liver cancer. Approximately 3 million persons in the United States have chronic hepatitis C, many of whom were infected in the past through injection-drug use. Most HCV-infected persons are unaware of their infection, increasing the risk that they will transmit the virus to others and suffer poor health outcomes themselves. In the absence of a hepatitis C vaccine, the goals of HCV prevention are early identification of infection, behavior modification to avoid HCV exposure, and referral for treatment. Knowledge of chronic hepatitis C infection status is a critical determinant of whether or not patients receive treatment and adopt preventative health behaviors. Data collected from NHANES can be used to estimate the proportion of HCV-infected persons in the United States who know there HCV status. Because of the ongoing nature of NHANES, we can assess trends in this knowledge over time.

Measure: Increase the number of areas reporting chronic hepatitis C virus infections to CDC to 50 states and New York City and District of Columbia.

Explanation:Because surveillance for chronic hepatitis C infection is critical for planning public health prevention activities, determining unmet health care needs and evaluating ongoing prevention programs, chronic Hepatitis C became a nationally notifiable disease in 2003. Despite this, national surveillance for chronic hepatitis C infection remains incomplete, in large part due to a high volume of reports and inadequate staff resources at the state and local levels. Efforts to increase jurisdictions that report cases of chronic hepatitis C infection to CDC will substantially improve our ability to accurately describe the epidemiologic characteristics of these cases nationally.

Measure: Reduce pelvic inflammatory disease in the United States.

Explanation:More than 50% of all preventable infertility among women is a result of STDs, primarily chlamydial infection and gonorrhea. Because most infected women, and at least one half of infected men, have no symptoms or have such mild symptoms that they do not seek medical care, many infections go undetected and are not reported or counted. Untreated chlamydia and gonorrhea infections can cause severe and costly reproductive and other adverse health consequences, including pelvic inflammatory disease (PID), which can lead to infertility. An estimated 10%-40% of women with untreated chlamydia or gonorrhea will develop PID which can result in ectopic pregnancy, chronic pelvic pain and infertility. NDTI provides a single, national estimate of the number of women diagnosed with this important condition each year.

Measure: Reduce the prevalence of chlamydia among high-risk women under age 25.

Explanation:This measure reflects the prevalence of chlamydia infection in a population of high-risk young women who are not seeking health care. They are routinely screened as part of their enrollment in the program. Because the nature of the population and the type of test used has not changed over time, the data are especially useful to follow trends in prevalence among young, relatively high-risk women. More than 50% of all preventable infertility among women is a result of sexually transmitted diseases (STDs), primarily chlamydial infection and gonorrhea. Because most infected women, and at least one half of infected men, have no symptoms or have such mild symptoms that they do not seek medical care, many infections go undetected and are not reported or counted. In fact, it is estimated that 2.8 million new chlamydial infections occur each year in the United States. Untreated chlamydia can cause severe and costly reproductive and other adverse health consequences, including pelvic inflammatory disease (PID), which can lead to infertility, ectopic pregnancy, and chronic pelvic pain. An estimated 10%-40% of women with untreated chlamydia will develop PID.

Measure: Reduce the prevalence of chlamydia among women under age 25, in publicly funded family planning clinics.

Explanation:This measure reflects prevalence of Chlamydia in a population of young sexually active women seeking reproductive health care. More than 50% of all preventable infertility among women is a result of STDs, primarily chlamydial infection and gonorrhea. Because most infected women, and at least one half of infected men, have no symptoms or have such mild symptoms that they do not seek medical care, many infections go undetected and are not reported or counted. In fact, it is estimated that 2.8 million new chlamydial infections occur each year in the United States. Untreated chlamydia can cause severe and costly reproductive and other adverse health consequences, including pelvic inflammatory disease (PID), which can lead to infertility, ectopic pregnancy, and chronic pelvic pain. An estimated 10%-40% of women with untreated chlamydia will develop PID. CDC's Infertility Prevention Program (IPP) provides funding to Title X Family Planning Clinics to screen women for chlamydia in accordance with CDC's recommendation that all sexually-active women under age 26 be screened annually for chlamydia. The targets are realistic, but ambitious, given the resources available and factors that impact infections. Reported chlamydial infections have increased, reflecting the expansion of screening activities, increased use of the most sensitive diagnostic tests, an emphasis on case reporting from providers and laboratories, and improvements in reporting systems. Increases in reported chlamydial infections are likely to continue as screening expands to more public and private medical settings. In 2000, the Health Plan Employer Data and Information Set (HEDIS) introduced a measure for chlamydia screening of sexually active women, 16 through 25 years of age, who receive their medical care through managed care organizations. The promulgation of and adherence to this measure are also likely to increase screening and reporting practices in the private sector. Because of these expected increases, the target for flat prevalence rates is ambitious, though realistic within the current resource context.

Measure: Reduce the incidence of gonorrhea in women aged 15 to 44 (per 100,000 population).

Explanation:This measure provides our best national data on gonorrhea incidence among women of reproductive age. More than 50% of all preventable infertility among women is a result of STDs, primarily chlamydial infection and gonorrhea. Because most infected women, and at least one half of infected men, have no symptoms or have such mild symptoms that they do not seek medical care, many infections go undetected and are not reported or counted. In fact, it is estimated that 2.8 million new chlamydial infections and 700,000 gonorrheal infections occur each year in the United States. In women, untreated gonorrhea can cause severe and costly reproductive and other adverse health consequences, including pelvic inflammatory disease (PID), which can lead to infertility, ectopic pregnancy, and chronic pelvic pain.

Measure: Eliminate syphilis in the United States. Data Source: STD Morbidity Surveillance System, CDC.

Explanation:Persistence of syphilis is a sentinel public health event with important social and historical significance. Syphilis is preventable and curable. Syphilis increases efficiency of HIV transmission 2 to 5-fold and is associated with serious morbidity on its own (e.g., serious illness in babies, strokes and other neurologic disease). This data provides the best national data on the incidence of the early, symptomatic stages of syphilis (i.e., primary and secondary syphilis). CDC will work to achieve interim indicators progressing toward the long-term goal of elimination.

Measure: Reduce the incidence of P&S syphilis in men (per 100,000 population). Data Source: STD Morbidity Surveillance System, CDC.

Explanation:Beginning in 2001, syphilis rates among men began to rise, after declining since 1991. Data suggested and additional studies confirmed that the great majority of cases in men were attributable to transmission among men who have sex with men (MSM), many of whom are at high-risk for transmitting or acquiring HIV infection. Traditional approaches to syphilis prevention are less-effective in this population and reducing syphilis among MSM requires different approaches from those used with women. With this measure CDC monitors its progress in addressing this newly-emerged epidemic.

Measure: Reduce the incidence of P&S syphilis in women (per 100,000 population).

Explanation:Beginning in 2001, syphilis rates among men began to rise, after declining since 1991. Rates among women continued to decline until 2005. As mentioned above, the prevention approaches used with women are different from those used with MSM and the complications of infection are also different (risk of transmission to babies). With this measure CDC monitors its progress in addressing syphilis among women.

Measure: Reduce the incidence of congenital syphilis per 100,000 live births. Data Source: STD Morbidity Surveillance System, CDC.

Explanation:When a woman has a syphilis infection during pregnancy, she may transmit the infection to the fetus in utero. This often results in fetal death or an infant born with physical and mental developmental disabilities. Most cases of congenital syphilis are easily preventable if women are screened for syphilis and treated early during prenatal care, as is recommended by CDC and other professional health organizations and as is required in all 50 states. There is also a World Health Organization (WHO) Initiative to Eliminate Congenital Syphilis, and CDC is an active engaged partner in this endeavor.

Measure: Reduce the racial disparity of P&S syphilis (reported ratio is black:white). Data Source: STD Morbidity Surveillance System, CDC.

Explanation:Syphilis is an example of a racial disparity in health with historical and sociological significance that is important to be addressed. In 1997, prior to initiation of the National Plan to Eliminate Syphilis from the United States, the B:W rate ratio was 43:1 and by 2005 has dropped to 5.4:1. With this measure CDC monitors its progress in reducing this important historic disparity while addressing the new epidemic in syphilis among MSM.

Measure: Decrease the rate of cases of TB among US-born persons (per 100,000 population).

Explanation:Despite the global epidemic, rates of TB have been declining for 13 years in the U.S. due to successful control measures begun in the early 1990s. Most of this decline is attributable to declines among U.S.-born persons. An estimated 9 to 14 million U.S. citizens have latent TB infection, and about 10% of these individuals will develop TB at some point in their lives. Those who are infected with HIV have a greater chance of developing TB. CDC works with state partners to identify and control TB in the U.S. However, persons born outside the U.S. account for 54% of all U.S. TB cases, constituting a majority of cases for the third year in a row. Ensuring future declines in TB in the U.S. is dependent upon reducing TB among foreign-born persons that enter the U.S. In the absence of any planned budget increases, resulting in a real decrease in spending power, coupled with increasing cases among the foreign-born in this country (who may transmit TB to U.S. born persons), rates among U.S. born person are likely to stabilize over the next several years, and increase by 2015.

Measure: Increase the percentage of TB patients who complete a course of curative TB treatment within 12 months of initiation of treatment (some patients require more than 12 months).

Explanation:Because completion of TB treatment is the most effective way to reduce the spread of TB and prevent its complications, this objective is the highest priority for CDC's TB program. Its achievement is vital to reduce TB cases and to eventually eliminate TB. Patients who do not complete therapy within 12 months are often difficult to treat and require numerous interventions. CDC supports outreach workers, hired from language, cultural, and ethnic groups with high TB incidence to help meet this objective. Outreach workers help patients complete treatment through directly observed therapy incentives and other adherence strategies. CDC and the CDC-funded Model TB Centers also design and implement training and educational aids for health department and healthcare providers to improve the skills they need to help achieve this objective.

Measure: Increase the percentage of TB patients with initial positive cultures who also have drug susceptibility results.

Explanation:Healthcare providers must know if a newly diagnosed infectious patient is infected with drug-sensitive or drug-resistant organisms so that appropriate drug therapy can be initiated. If this information is unknown, patients may receive inadequate treatment leading to the spread of drug-resistant organisms, additional morbidity, and mortality. Progress towards this measure is attributable to increased efforts of state and local health departments and hospital infection-control practitioners to address the resurgence of TB and increased funding for health department laboratories to purchase state-of-the-art equipment needed to perform more accurate and rapid laboratory testing and confirmation for TB and multi-drug resistant TB.

Measure: Increase the percentage of contacts of infectious (Acid-Fast Bacillus (AFB) smear-positive) cases that are placed on treatment for latent TB infection and complete a treatment regimen.

Explanation:Completion of treatment for latent TB infection among contacts of infectious TB cases is a cornerstone of U.S. efforts to reduce TB and eliminate the disease, second only to ensuring that those with active TB complete treatment with appropriate drugs. Contacts of smear-positive TB patients are at high risk of developing TB and therefore must be screened for infection. If infected, these contacts should be offered complete treatment for latent infection. Through cooperative agreements with state and local health departments, CDC supports identifying and examining contacts of persons with active TB, as well as completing treatment for contacts who have latent TB infection.

Is the program purpose clear?

Explanation: The program has a clear an unambiguous mission. While the areas covered by the Center are fairly broad, the program has a succinct mission statement, and does not have conflicting purposes. NCHHSTP achieves its mission through prevention programs for HIV, viral hepatitis, STDs, and TB; strengthening and promoting public health surveillance activities, and by translating relevant research findings into prevention policy and programs.

Evidence: Evidence includes the program's mission statement: "The National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention (NCHHSTP), Centers for Disease Control and Prevention (CDC), maximizes public health and safety nationally and internationally through the elimination, prevention, and control of disease, disability, and death caused by Human Immuno-deficiency Virus Infection (HIV)/Acquired Immunodeficiency Syndrome (AIDS), Non-HIV Retroviruses, Viral Hepatitis, other Sexually Transmitted Diseases (STDs), Tuberculosis (TB), and Non-Tuberculosis Mycobacteria." The Public Health Service Act authorizes the program to design, implement, and evaluate comprehensive STD and TB prevention programs, including the prevention of STD-related infertility. Specific authorities also exist for Hepatitis C prevention and aspects of the HIV prevention program.

Does the program address a specific and existing problem, interest, or need?

Explanation: The program addresses a clear public health problem in the United States. HIV/AIDS, viral hepatitis, other STDs, and TB are among the most prevalent infectious diseases in the U.S. and have a substantial impact globally. Further, HIV/AIDS, TB, and Hepatitis B and C are among the ten leading causes of infectious disease deaths worldwide. The program purpose is still relevant given the prevalence of these infectious diseases both in the United States and internationally.

Evidence: The program surveillance data for HIV and other sexually transmitted diseases (STDs), tuberculosis (TB), and hepatitis (available though the Centers for Disease Control and Prevention website at www.cdc.gov) indicates a clear need for the existence of this program. For example, the HIV epidemic continues to have a disproportionate impact on racial and ethnic minorities. In 2002, (the most recent year for which data are available), HIV infection was the leading cause of death for African American women aged 25-34 years. Studies of incarcerated persons have found that this group is often disproportionately impacted by a variety of health problems, including HIV, viral hepatitis, other STDs and TB. Trend data on STDs can be accessed through at http://www.cdc.gov/std/stats/trends2005.htm.

Is the program designed so that it is not redundant or duplicative of any other Federal, state, local or private effort?

Explanation: The program does not excessively overlap with other Federal and non-Federal efforts to prevent HIV, STDs, TB, and hepatitis. The program is the lead federal agency responsible for public health surveillance, prevention research, and interventions to prevent and control HIV/AIDS, viral hepatitis, other STDs, and TB in the United States. The program carries out this responsibility by providing national direction and coordinating the prevention efforts of public and private sector partners. The program fulfills a unique Federal role in prevention program implementation by providing guidance, grants, and technical assistance to state, local, territorial, and community-based organizations (CBOs) agencies to conduct prevention activities, including counseling, testing, laboratory support, referral services, behavioral interventions, and community mobilization.

Evidence: There are no other programs at the Federal level intended to carry out a mission similar to CDC's National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention (NCHHSTP). Given the prevalence of these conditions in the United States, the program is uniquely positioned to conduct public health surveillance and research, much of which is available to the public at the program's website (http://www.cdc.gov/nchstp/od/nchstp.html). The program also develops guidelines for local health organizations to use to ensure effective implementation of NCHHSTP programs at the local level. The purpose of these guidelines is to further STD prevention by providing a resource to assist in the design, implementation, and evaluation of STD prevention and control programs. The complete guidelines can be accessed from the NCHHSTP website: http://www.cdc.gov/std/program/.

Is the program design free of major flaws that would limit the program's effectiveness or efficiency?

Explanation: There is no evidence that another approach or mechanism would be more efficient or effective to achieve the intended program purpose. NCHHSTP utilizes a public health approach to disease prevention. The public health approach is widely regarded as the approach that is mostly likely to produce significant and sustained reductions disease transmission in the most effective manner. It uses four basic evidence-based steps in a systematic way: 1) Problem definition (surveillance); 2) Identify causes (risk factor research) and develop and test interventions; 3) Implement interventions; and 4) Assessing effectiveness. These steps are applicable to the health problems addressed by NCHHSTP.

Evidence: A program assessment including essential components of a comprehensive strategy to prevent domestic HIV can be accessed from NCHHSTP's website at http://www.cdc.gov/hiv/resources/reports/comp_hiv_prev/comprehensive.htm. Each of the four evidence-based steps support the program's effectiveness. Disease surveillance activities help to better define and understand the epidemics across the nation, and inform the targeting and development of prevention strategies. The program's prevention research is peer reviewed, consistent with OMB guidelines. The program's Diffusion of Effective Behavioral Interventions (DEBI) Project, Prevention Research Synthesis Project (PRS), and Replicating Effective Programs (REP) Project within NCHHSTP's Division of HIV/AIDS Prevention work together to move effective HIV interventions into program practice. Information on each of these projects can be found online at http://www.effectiveinterventions.org/, http://www.cdc.gov/hiv/topics/research/prs/index.htm, and http://www.cdc.gov/hiv/projects/rep/default.htm. A cost-effectiveness study published in the American Journal of Public Health showed that lowering the number of cases of syphilis could reduce HIV incidence among African Americans by 3% to 5%, and avert as much as $113 million or more annually in lifetime HIV-related medical care costs (http://www.ajph.org/cgi/content/full/93/6/943).

Is the program design effectively targeted so that resources will address the program's purpose directly and will reach intended beneficiaries?

Explanation: The program achieves its prevention goals through cooperative agreements and grants with state, territorial, and local health departments and other prevention partners. Where appropriate, NCHHSTP programs target their interventions where they will be most effective and will have the greatest impact. The program has plans which assist in the prioritization of interventions. NCHHSTP uses surveillance data, which identifies patterns of disease and risk factors, to develop evidence-based national guidelines and recommendations to inform how and where interventions are targeted. For example, the CDC HIV Strategic Plan; the Syphilis elimination plan; the Hepatitis B elimination strategy; and the TB elimination plan all guide the targeting of prevention resources so that they reach clients in greatest need. The program produces evidence-based national guidelines and recommendations to inform how and where interventions are targeted. Recent guidelines have been produced on targeting HIV/AIDS, viral hepatitis, STD, and TB, prevention interventions at population subgroups, settings, or jurisdictions to most efficiently reach those at risk, including: racial/ethnic minorities; correctional institutions; and healthcare settings. Funding is not being replicated for activities that would have occurred without the program.

Evidence: NCHHSTP currently funds comprehensive STD prevention and control activities in 65 areas, and NCHHSTP requires grant recipients to annually report their STD prevention needs and STD morbidity trends. Grantees are also required to describe significant behavioral characteristics of groups affected by STDs, trends in local health service delivery, and other information that may affect STD morbidity. Budgets and activities must address specific prevention needs of the community, with special emphasis on populations at greater risk for STDs due to health disparities and high-risk sexual behaviors. The HIV Prevention Program requires grantees to incorporate community planning in funded projects and NCHHSTP provides support to build the capacity of community planning groups to function effectively and efficiently. These groups identify the priority HIV prevention needs for their community, including priority target populations and interventions for each identified target population, based on the local epidemiology of HIV. The Tuberculosis Elimination agreements identify the priority population for grantees as all cases of active TB and their contacts who have developed active or latent TB infections, and direct completion of therapy efforts to these populations. In 2004, NCHHSTP's Division of TB Elimination (DTBE) developed a new funding formula in an effort to use available federal funds most efficiently and effectively. Through this new funding formula, DTBE redistributed a portion of funds starting in FY 2005 through its TB prevention and control cooperative agreements. This funding formula aligns a portion of available resources to address TB in populations hardest hit and areas of urgent need. NCHHSTP's HIV prevention program for directly-funded CBOs awards grants based on the quality of each application, local disease burden, the geographic distribution of potential awardees, and the needs of populations at highest risk for contracting HIV. The program also provides support to build capacity of community advisory planning groups to function effectively and efficiently in prioritizing prevention interventions based on the local epidemiology of HIV. The national leadership provided by the program is critical for the prevention of the diseases addressed by the program. Cooperative agreements with States allow the program to review activities to ensure that funds are being administered appropriately, and provide the program with the ability to make adjustments should funding be unwarranted.

Does the program have a limited number of specific long-term performance measures that focus on outcomes and meaningfully reflect the purpose of the program?

Explanation: The program has established a wide range of long-term measures that focus on domestic health outcomes and reflect the mission of the program. This program has established more long-term measures than most other programs due to the broad mission and responsibilities of the program. These measures cover over 98% of the NCHHSTP domestic budget. The long-term measures aim to reduce rates of new HIV infections, viral hepatitis, non-HIV STDs, and tuberculosis in the United States. These goals are critical to achieving the disease prevention mission of the program. The proposed long-term measures update the goals listed in CDC's current performance budget. Timeframes for long-term measures generally extend to 2015.

Evidence: Complete information on long-term performance measures can be found in the measures tab of this PART assessment.

Does the program have ambitious targets and timeframes for its long-term measures?

Explanation: The program has proposed long-term measures that focus on outcomes and reflect the purpose and mission of the program. Each of the major areas of the program are addressed with long-term goals and measures, with baselines and ambitious targets. For the majority of the program's measures, clear baselines exist from which to assess targets and changes in performance. The baselines are based on historical and trend data which also assist in the setting of targets. In a few cases, baselines and targets will be established in the Fall of 2007 because data systems by which these measures are assessed are currently being deployed. As a result of new technologies and methodologies, these new data systems will lead to more robust data and provide a better reflection of trends in disease morbidity and mortality and the effectiveness of prevention and control efforts. The program plans to meet these measures by FY 2015.

Evidence: Complete information on the targets and timeframes established for achievement of the long-term performance goals can be found in the measures tab attached to this PART assessment.

Does the program have a limited number of specific annual performance measures that can demonstrate progress toward achieving the program's long-term goals?

Explanation: The program has developed a set of annual performance measures to assess progress toward achieving its long-term outcome goals of reducing HIV, viral hepatitis, STDs, and TB. While the list of measures is relatively long, the measures are relevant to policy objectives, and reflect the broad public health mission of the program. The annual performance measures directly link to and demonstrate progress toward achieving the corresponding long-term measure. For example, the program has established an annual measure to reduce the rate of gonorrhea in women ages 15 to 44. This annual measure directly supports a long-term measure to reduce rates of pelvic inflammatory disease in the United States by 2015. Like the long-term measures, the annual measures selected are meaningful in the context of the NCHHSTP mission, purpose, priorities and budget. These measures are a refinement of those in CDC's current performance budget.

Evidence: Complete information of the annual performance goals can be found in the measures tab accompanying this PART analysis.

Does the program have baselines and ambitious targets for its annual measures?

Explanation: The program has established baselines and targets for its annual performance measures. The program has attempted to establish ambitious targets, taking projected disease trends and externalities into account when appropriate. As a res