Robert S. Janssen, MD, David R. Holtgrave, PhD, Ronald O. Valdiserri, MD, MPH,
Melissa Shepherd, ABJ, Helene D. Gayle, MD, MPH,
and Kevin M. De Cock, MD, FRCP, DTM&H
A B S T R A C T
In the United States, HIV preven-
tion programs have historically tailored
activities for specific groups primarily
on the basis of behavioral risk factors and
demographic characteristics. Through the
Serostatus Approach to Fighting the Epi-
demic (SAFE), the Centers for Disease
Control and Prevention is now expand-
ing prevention programs, especially for
individuals with HIV , to reduce the risk of
transmission as a supplement to current
programs that primarily focus on reduc-
ing the risk of acquisition of the virus.
For individuals with HIV, SAFE
comprises action steps that focus on di-
agnosing all HIV-infected persons, link-
ing them to appropriate high-quality care
and prevention services, helping them ad-
here to treatment regimens, and support-
ing them in adopting and sustaining HIV
risk reduction behavior. SAFE couples a
traditional infectious disease control focus
on the infected person with behavioral in-
terventions that have been standard for
HIV prevention programs. (Am J Public
July 2001, Vol. 91, No. 7American Journal of Public Health 1019
The AIDS epidemic, although first rec-
ognized only 20 years ago, has had a pro-
found impact in communities throughout the
United States. By mid-2000, more than
750000 Americans with AIDS had been re-
ported and more than 430000 Americans
had died.1After peaking in the mid-1980s,
HIV incidence in the United States stabi-
lized in the late 1980s and early 1990s.2The
Centers for Disease Control and Prevention
(CDC) estimates that the number of new in-
fections has remained stable at approxi-
mately 40000 per year since 1992.3An es-
timated 800000 to 900000 Americans were
infected with HIV at the end of 1998; of
these, as many as 300000 were unaware of
their infection status.3
Additional approaches are required to
break the grip of HIV in the United States.
With as many as 5 million people at behav-
ioral risk for HIV through unsafe sex and
drug use,4HIV prevention programs have
historically been based on behavioral risk
been tailored to meet the needs of specific
ciated morbidity and mortality are naturally
focused on individuals with HIV, specific
primary prevention efforts to reduce trans-
uninfected have been limited. The CDC is
include new and enhanced activities based
on HIV serostatus, particularly targeting in-
rent steady state of HIV transmission.
Prevention Strategies for
Individuals With HIV
The CDC has launched a new strategy
proach to Fighting the Epidemic (SAFE)
(Figure 1). SAFE is aimed at those who are
infected with HIV—including those cur-
rently unaware of their serostatus—as well
as those who have been tested and found to
be uninfected but are at continued high be-
sents the CDC’s strategies for individuals
focus on diagnosing HIV infection in all in-
ate high-quality care and prevention serv-
ices, and supporting them in adhering to
must use accurate surveillance data, includ-
ing HIV incidence and prevalence; HIV,
AIDS, and sexually transmitted disease
care and prevention efforts on the commu-
is most intense.
Essential Components of SAFE
The 5 SAFE steps are as follows: (1) In-
crease the number of HIV-infected persons
who know their serostatus. (2) Increase the
use of health care and preventive services.
(3) Increase high-quality care and treatment.
(4) Increase adherence to therapy by indi-
viduals with HIV . (5) Increase the number of
The Serostatus Approach to Fighting the
HIV Epidemic: Prevention Strategies for
The authors are with the National Center for HIV,
STD, and TB Prevention, Centers for Disease Con-
trol and Prevention, Atlanta, Ga.
Requests for reprints should be sent to Robert
S. Janssen, MD, Division of HIV/AIDS Prevention,
Centers for Disease Control and Prevention, 1600
Clifton Rd (Mail Stop D-21), Atlanta, GA 30333
This commentary was accepted February 2,
July 2001, Vol. 91, No. 7 1020American Journal of Public Health
Note. Shaded boxes indicate activities for which the Centers for Disease Control and
Prevention does not have the lead government role.
FIGURE 1—Blueprint for a serostatus approach to fighting the HIV/AIDS
TABLE 1—Serostatus-Specific HIV Prevention Interventions
Population HIV Prevention Interventions
Unaware of serostatus; behavioral risk of infection Provide current, essential HIV-related information
Encourage voluntary HIV counseling and testing among those at increased
risk, including anonymous testing
Reduce stigma of HIV disease and services
Educate to provide HIV prevention messages to family, friends, partners Recently tested HIV negative; no apparent
behavioral risk of infection
Recently tested HIV negative; behavioral risk of infection Offer intensive individual or small-group counseling
Develop community-level interventions
Establish linkages to STD, substance abuse, mental health, hepatitis, and
social services as needed
Provide prevention case management for those at highest risk
Develop structural interventions (e.g., sterile syringe access)
Provide intensive prevention services
Offer partner counseling and referral services
Establish linkages to STD, substance abuse, mental health, hepatitis, and
social services as needed
Provide prevention case management
Develop structural interventions (e.g., decrease discrimination)
Tested HIV positive
Note. STD=sexually transmitted disease.
individuals with HIV who adopt and sustain
HIV–STD risk reduction behavior.
1. Increase the number of HIV-infected
persons who know their serostatus
There are both medical and public health
benefits to increasing knowledge of HIV sta-
tus as early after infection as possible.
Medical benefits of HIV diagnosis. Indi-
viduals who have early knowledge of their HIV
infection can benefit from prophylaxis for op-
portunistic infections; treatment of STDs, sub-
stance abuse, and mental health conditions; ac-
cess to social services; and, when appropriate,
use of combination antiretroviral therapy
(ART).5Prophylaxis of opportunistic infec-
tions has been important in reducing HIV-
related morbidity6; treatment of STDs can re-
duce the risk of HIV transmission; treatment of
substance abuse and mental health problems
can reduce HIV risk behavior.7It is ART,
though, that has had the most dramatic effect
on morbidity and mortality. HIV-infected in-
dividuals in care are now living longer than be-
fore the advent of highly active antiretroviral
agents,8and one study suggests that some HIV-
infected individuals receiving ART may have
a normal life expectancy.9AIDS is no longer 1
of the 15 leading causes of death in the United
States.10Quality of life for individuals with
HIV has improved substantially, although the
drugs’side effects can be troublesome and even
life threatening. Recent information about side
effects has resulted in a recommendation to
delay the initiation of ART.5
Public health benefits of HIV diagnosis.
sexually active after they learn they are in-
fected,11,12it is clear that when people know
they are HIV infected, they are significantly
more likely to take steps to protect their part-
by people unaware of their HIV status. The
only data that address this issue directly are
from the Options Project in San Francisco,
Another important public health reason
population for HIV prevention programs is
that ART may reduce infectiousness. If low
viral load is associated with a lower risk of
mately 2.5-fold for every 10-fold increase in
plasma viral load.23,24Several studies have
demonstrated a correlation between plasma
HIV RNA and concentration of HIV RNA in
reduces both plasma and genital fluid viral
load; persons with the greatest decline in
plasma HIV RNA concentration are most
likely to show undetectable genital fluid HIV
RNA.26–28Although cell-associated virus is
July 2001, Vol. 91, No. 7 American Journal of Public Health1021
TABLE 2—Examples of Essential Components of Centers for Disease Control
and Prevention Programs Focusing on Individuals With HIV
1. Increase number of HIV-infected persons who know their serostatus.
Create campaigns to emphasize benefits of early diagnosis of HIV.
Educate to reduce fear of knowledge of serostatus.
Create campaigns to diminish discrimination against HIV-infected persons.
Create campaigns to reduce stigma associated with HIV infection.
Train providers of high-risk persons on benefits and strategies of early HIV diagnosis.
Create campaigns to encourage voluntary HIV testing.
Continue to support anonymous testing.
Make testing venues more responsive to client needs.
Facilitate use of rapid tests.
Increase voluntary testing in health care facilities.
Increase voluntary testing of pregnant women.
Increase voluntary testing in prisons and jails.
Increase voluntary testing among sex and needle-sharing partners of HIV-infected
Increase availability of home collection kits and testing through outreach programs.
2. Increase use of services.
Increase links between prevention and care programs.
Improve access to HIV/AIDS care through community-based organizations.
Upon discharge, link prisoners to care and prevention services.
Increase proportion of pregnant women receiving antenatal care.
3. Increase quality care and treatment.
Increase proportion of HIV-infected pregnant women receiving ART.
Educate health care workers and HIV-infected persons about HIV/AIDS treatment.
Monitor and evaluate quality of HIV/AIDS care.
Institute surveillance for effectiveness and side effects of ART.
4. Increase adherence to therapy by individuals with HIV.
Evaluate and implement strategies for increasing adherence, including directly
Monitor adherence to therapy.
Monitor antiretroviral drug resistance.
5. Increase number of individuals with HIV who adopt and sustain HIV–STD risk reduction
Increase availability of prevention services for individuals with HIV (e.g., counseling,
prevention case management, peer opinion leader, small-group interventions).
Develop, implement, and evaluate specific risk reduction strategies for individuals with HIV.
Monitor behaviors and outcomes in individuals with HIV.
Teach health care providers to perform HIV and STD risk assessment for their HIV-
Increase STD screening, diagnosis, and treatment for individuals with HIV.
Increase delivery of prevention messages to HIV-positive patients by health care workers.
Provide adequate and appropriate substance abuse treatment.
Note. ART=antiretroviral therapy; STD=sexually transmitted disease.
transmission by cell-associated virus may be
less efficient than transmission by cell-free
virus.30,31The reduction of HIV transmission
through the use of antiretroviral treatment is
most clearly seen in the reduction of mother-
gest that ART probably reduces the infec-
exposures, although the evidence is still indi-
change, the agent’s transmissibility, and the
as well as the degree of infectiousness and
ulation level, provided that partner change,
condom use, and sexual practices remain un-
Because of these individual and public
health benefits of HIV diagnoses, the CDC is
giving additional emphasis to encouraging
those at high risk for infection to seek testing
courage testing through raising individual
ple forms of media to address motivation for
and psychologic barriers to testing.37Such
sociated with testing and a diagnosis of HIV
An important method for making HIV
testing more accessible is use of simple, rapid
tests. These can be performed without labora-
tory support and offer the possibility of pro-
viding preliminary results within minutes after
blood or oral secretions are collected. No such
tests are currently available in the United States,
although they are available in most other parts
of the world. Studies have shown that when
used in combination, rapid tests can provide
results equal in predictive value to Western
blot–based testing strategies.38When available
in the United States, they will provide oppor-
tunities to dramatically increase the availabil-
ity of HIV testing in a variety of settings and
thus increase the number of people who know
their HIV status.39Simple, rapid tests can be
used for outreach by community-based or-
ganizations at social events such as commu-
nity health fairs or gay pride festivals, or at
bars, clubs, or street corners where large num-
bers of people at risk for HIV infection may
congregate. In addition, rapid tests can be used
for routine voluntary testing in emergency
rooms or other medical settings where HIV
prevalence may be elevated. Routinely offering
HIV tests to all patients aged 15 to 54 years in
high-HIV-prevalence acute care hospital set-
tings,40and in other high-prevalence settings
such as drug detoxification units and STD clin-
ics, should increase the number of people who
are aware of their serostatus. Through revised
guidelines for HIV counseling and testing, the
CDC is encouraging the routine offering of
voluntary HIV testing in medical settings where
large numbers of HIV-infected people may seek
care for non-HIV-related illnesses.41Expan-
sion of voluntary HIV testing is also needed
in nonmedical facilities such as correctional
institutions where HIV-infected injection drug
users are likely to be found.
2. Increase the use of health care and
Although three quarters of individuals
dividuals, for a variety of personal, social,
economic, or other reasons, delay seeking
on the use of prevention services by individ-
uals with HIV. Better information is also
needed on the performance of current refer-
partners to improve its programs that link
tings to care and prevention services,44
providers in other settings in which testing
occurs will need to develop feasible links to
care and prevention service providers. State
based organizations can create better links
between prevention and care programs, in-
creasing access to both. Case management
related to clinical care and social services or
July 2001, Vol. 91, No. 7 1022 American Journal of Public Health
prevention case management (case manage-
ment with risk reduction counseling)45can
3. Increase high-quality care and
In 1996, one third to two thirds of indi-
viduals with HIV were not receiving appro-
priate HIV/AIDS care, either because they were
unaware that they were infected with HIV or
because care services had not been accessed
or delivered.46While the Health Resources Ser-
vices Administration (HRSA) and the Health
Care Financing Administration (HCFA) are the
leading federal agencies in providing support
for HIV care, the CDC will continue to be a
part of Public Health Service efforts to con-
tinually update guidelines for optimal ART5
and for prophylaxis of opportunistic infection.6
In addition to HIV and AIDS surveillance, the
CDC is developing population-based studies
to monitor the quality, use, and impact of care.
4. Increase adherence to therapy by
individuals with HIV
Toxicity, poor adherence to HIV treatment
regimens, and pharmacologic problems such as
poor drug absorption can cause failure to
achieve viral suppression and development of
drug resistance. Patients’failure to adhere to
the complicated dosage requirements of ART
may be the most important reason for these
negative outcomes of treatment.47,48In addi-
tion, drug-resistant viruses can be transmitted
to uninfected individuals.49,50Improving ther-
apeutic adherence can reduce the frequency of
drug resistance, but it will not eliminate it.
eral agencies, is conducting research on more
effective interventions to increase adherence,
including evaluating the feasibility of directly
observed therapy. Directly observed therapy
regimens of fixed duration,51but because ad-
5. Increase the number of individuals
with HIV who adopt and sustain
HIV–STD risk reduction behavior
Many individuals with HIV feel healthier
when undergoing ART than they did before
such treatments became available. In addition,
the impression that HIV is a treatable chronic
disease, and that ART reduces infectiousness,
may be leading to increases in risk behavior
among HIV-infected individuals and those at
highest risk for HIV infection.52In a number of
cities in the United States, increasing rates of
gonorrhea among men who have sex with men
suggest that unsafe sexual behavior may be
reemerging in this community.53While most
individuals who learn that they are infected re-
duce their risk behavior, a considerable frac-
tion continue to have unprotected sex.54In a
recent outbreak of primary and secondary
syphilis in King County, Washington, among
men who have sex with men, nearly three quar-
ters of whom were HIV infected.55
In 1997, a National Institutes of Health
consensus conference on HIV prevention in-
terventions called for increased research to
identify interventions to support infected in-
dividuals in adopting and sustaining risk re-
duction behavior,56and several studies have
been subsequently initiated by the National
Institute of Mental Health and by the CDC.
The CDC will strongly encourage health de-
partments, HIV prevention community plan-
ning groups, and community-based organiza-
tions to include people with HIV among
priority populations for prevention programs.
In addition, simple risk assessment tools are
needed for physicians to assess the risk be-
havior of their HIV-infected patients and to
provide referral for those needing prevention
interventions. Preliminary information sug-
gests that even when they are enrolled in pri-
mary care, sexually active individuals with
HIV are not receiving adequate HIV preven-
tion counseling or adequate diagnosis and
treatment of other STDs.57The CDC is col-
laborating with the Infectious Diseases Soci-
ety of America and federal agencies to develop
recommendations for prevention activities in
care settings. With the vast majority of pre-
scriptions for ART being written by a few thou-
sand physicians across the country, it is feasi-
ble to offer training to these caregivers to
recognize ongoing risk behavior and refer peo-
ple appropriately for prevention services. Be-
cause many individuals with HIV are already
in publicly financed systems of care,46the
CDC will work closely with HCFA and HRSA
to increase prevention services in those set-
tings. However, new resources are needed to
increase the availability to all individuals with
HIV infection of current prevention services,
such as risk reduction counseling, peer group
support, peer-based prevention case manage-
ment, STD treatment, substance abuse treat-
ment, and mental health services.
Some mathematical models suggest
that much HIV transmission occurs from in-
dividuals who are recently infected and
whose plasma viral loads are therefore
high.58If preventing transmission from such
individuals is essential for controlling the
epidemic, partner counseling and referral
services are crucial, because, in combina-
tion with serologic methods that detect re-
cently acquired HIV infection, they enable
the identification of persons with early HIV
infection.59Using such methods for rapid
assessment of sexual or injection-drug-use
networks can lead to the interruption of
chains of active transmission by helping net-
work members adopt and sustain risk re-
Potential Impact and Resource
The CDC has established the goal of re-
year the number of infected people who be-
tional public investment of $300 million per
year.These additional resources would be di-
comprehensive HIV prevention services for
each seropositive person whose ongoing be-
HIV prevention services such as counseling
for high-risk HIV-seronegative clients identi-
particularly current partners of HIV-infected
uals with HIV who know their status will in-
crease the number in care and will require in-
creases in public financing for care through
Such an investment will save not only
lives but money. Given that in 1997 each
averted HIV infection saved society approxi-
mately $154000 in discounted lifetime treat-
ment costs of HIV disease,60an additional
$300 million would have to avert only about
ings. Preliminary modeling analyses, based
intervention, suggest that SAFE programs
might actually avert approximately 20% of
HIV infections (8000 cases) per year (CDC,
unpublished data, 2000). Thus, maintaining
infected persons and fully implementing the
CDC’s SAFE initiative could reduce HIV in-
people with unknown serostatus by 80% in 4
July 2001, Vol. 91, No. 7 American Journal of Public Health1023
An important aspect of SAFE activities
for those with HIV is developing new part-
nerships with organizations that historically
have not been involved in HIV prevention and
expanding traditional public health partners.
The CDC has mobilized a public–private part-
nership, “X-AIDS ACT NOW! National Part-
nership Council,” to fight the epidemic. More
than 50 organizations, including medical care
organizations, the pharmaceutical industry,
private industry, and the media, as well as na-
tional and community-based HIV prevention
organizations, make up the core of the part-
nership. These organizations are creating al-
liances that will motivate, coordinate, and di-
rect private sector resources to address the
specific needs of SAFE.
Historically, HIV prevention programs
have focused primarily on developing risk
reduction interventions for those at high risk
for becoming infected with HIV . In 1999, a
CDC for funds for HIV prevention programs
demonstrated that only 18 (32.7%) listed
HIV-infected individuals as a priority popu-
lation for HIV prevention programs. Al-
though there are millions of people in the
United States at “behavioral risk” for HIV
infection, transmission can occur only from
people who are infected with the virus. As
the number of individuals with HIV contin-
ues to increase because ofART, so does the
tomized for them. The 1996 International
AIDS conference in Vancouver, British Co-
ment era in the AIDS epidemic, making
knowledge of serostatus and linkage to pre-
vention and treatment services more impor-
tant than ever before.
communities with high HIV prevalence and
proach couples a traditional infectious disease
era, for individual as well as public health rea-
In combination with current programs
focusing on HIV-negative individuals, SAFE
offers an unprecedented opportunity for sig-
nificantly reducing HIV transmission and
HIV-associated morbidity and mortality.
R.S. Janssen, D.R. Hotgrave, and K.M. De Cock
led the writing of this commentary. R.O. Valdiserri,
M. Shepherd, and H.D. Gayle contributed ideas and
helped with writing and reviewing the manuscript.
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