Limitations of Counseling and Testing in CDC's HIV Prevention Efforts


To the Editor: We were delighted to see that our colleagues at the Centers for Disease Control and Prevention (CDC) had read our article (Darrow et al., 1998a) and responded (Wolitski and Doll, 1999). Their criticisms of our cross-sectional study of 51 HIV-infected men who have sex with men (MSM) and live in South Beach are welcomed and appreciated. In this brief reply, we continue the dialogue by addressing their concerns and recommending an appropriate course of action. Their methodological concerns are twofold: (1) our analysis did not assess pre-post changes in risk behavior and (2) it did not compare risk practices of men who had previously received counseling and testing (CT) with those who had not. They continue by identifying three limitations of our findings and end with a rhetorical question, "Is this a reasonable standard for any single prevention program to be held to?" To which we answer, "Why not?" Let us begin with their phrase, "single prevention program." Three books—all with the same title—have now been published which can be used to trace the evolution in social scientific thinking about "preventing AIDS" in the United States. Valdiserri (1989) clearly points out that CT has its roots in the paternalistic model of a medical provider conducting a "risk assessment," diagnosing a patient's "behavioral problem," and remedying "the problem" by telling the complacent patient what to do about "his or her problem." DiClemente and Peterson (1994) open up HIV prevention possibilities to a wide array of more promising, theoretically based intrapersonal, interpersonal, community-level, and societal interventions. Kalichman (1998) begins the process of rigorously examining the empirical evidence for the efficacy, effectiveness, and cost-effectiveness of these interventions in a variety of settings. One immediately apparent problem with "CDC's HIV prevention efforts" is its determination to promulgate and support with $253 million a year a "single prevention program" anchored in the medical model of Counseling and Testing, Referral, and Partner Notification (CTRPN). If CDC does not intend to prevent HIV transmission through behavioral changes prompted and maintained by CTRPN, then what is the purpose of this program? Now let us turn to their argument that "CDC does not require state and local health departments to provide a specific level of support [for CTRPN]" and "local HIV community planning groups" have been responsible for allocating funds for prevention activities since 1994. From the outset, CDC (1993, p. 1) defined CTRPN as an "essential" component that must be included in every HIV prevention program. In program announcements published subsequently to 1994, CDC instructs state and local health departments to include funding for CTRPN "unless prohibited by State law or regulation" (Department of Health and Human Services, 1997, p. 7). In a paper recently published through CDC sponsorship, Valdiserri (1997, p. 11) maintains that—even in the absence of convincing evidence—"HIV CT will continue to be an essential component of a comprehensive national HIV prevention strategy." To our knowledge, no local community planning group is responsible for allocating funds for HIV prevention activities anywhere in the United States. Planning groups are advisory. They make recommendations. They are allowed to express their "concurrence" with health department decisions about how to spend the money awarded to the health department through a cooperative agreement between the health department and CDC. Usually, they "concur" (Division of HIV/AIDS Prevention, 1996). We were pleased to be able to conduct the South Beach Health Survey on behalf of the Florida Department of Health and the Miami-Dade County HIV Prevention Community Planning Group (DCPG), 1 of 17 community planning groups in the state that reports, through three representatives (one each from the local health department, Ryan White Title II consortia, and community, respectively), to the Florida HIV/AIDS Community Planning Group (FCPG). In turn, the 64-member FCPG reports to the Bureau of HIV/AIDS in Tallahassee (Florida Department of Health, 1998a). Of the $631 million

DOI: 10.1023/A:1025464829663

Cite this paper

@article{Darrow2004LimitationsOC, title={Limitations of Counseling and Testing in CDC's HIV Prevention Efforts}, author={William W. Darrow and Robert D. Webster and Steven P. Kurtz and Abraham K. Buckley and Robert R. Stempel}, journal={AIDS and Behavior}, year={2004}, volume={3}, pages={253-255} }