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 result, in some cases, annual measures may not appear to reflect dramatic improvement over current baselines. For instance, recent outbreaks of syphilis among men who have sex with men have slowed progress towards syphilis elimination. These outbreaks have been linked to increases in high-risk sexual behavior driven by factors such as safer sex fatigue, recreational drug use (especially crystal methamphetamine) and HIV treatment optimism. As a result of these new challenges to syphilis control, it is likely that we will see increases in syphilis rates as we redirect existing resources to deal with this emerging problem. Whenever possible, targets are in place for 2007, 2008 and 2009. In some cases where surveillance data are not gathered every year, targets are established for those years when data are available. For most measures, clear baselines exist from which to project targets and assess 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 have yet to be determined 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.

Evidence: Complete information on the baselines and annual targets for measures can be found in the measures tab accompanying this PART assessment.

Do all partners (including grantees, sub-grantees, contractors, cost-sharing partners, and other government partners) commit to and work toward the annual and/or long-term goals of the program?

Explanation: Program partners support the overall goals of the program. All partners commit to and work towards NCHHSTP's goals and objectives. NCHHSTP involves partners and holds consultations to define problems, identify and prioritize relevant strategies to address these problems, and establish meaningful goals and objectives. After program goals are identified, NCHHSTP funds partners to implement activities to meet these goals. The program specifies goals and performance measures in every announcement for available funding, and partners are held accountable to meeting these goals and measures. These measures are consistent with the goals and proposed long-term and annual measures from this PART response and NCHHSTP's goals and measures outlined in its performance budget. Partners set baselines and targets for each performance measure based on the local epidemiology of the disease. Partners funded to implement activities related to NCHHSTP's goals are required to report on these measures in their annual and interim progress reports. Data from progress reports, site visits, and epidemiologic data (including surveillance data) are used to monitor partner progress as well as to assess NCHHSTP's progress in meeting its goals.

Evidence: Funding opportunity announcement for grants and cooperative agreements include information regarding relevant performance goals. Cooperative agreements with grantees include clear discussion of performance goals and targets. The program uses the measures included in these cooperative agreements to monitor grantee progress to ensure that program partners are working to achieve the program's performance objectives.

Are independent evaluations of sufficient scope and quality conducted on a regular basis or as needed to support program improvements and evaluate effectiveness and relevance to the problem, interest, or need?

Explanation: The program receives evaluations on a regular basis to evaluate effectiveness. These evaluations are of high quality, sufficient scope (particularly given the broad mission of NCHHSTP), and independent. Program strategies are developed based on sound research, predominantly randomized control trials. These program strategies, based in research, are then implemented and rigorously reviewed and evaluated for effectiveness, including papers published in peer-reviewed journals. Several peer reviewed articles in published journals have evaluated the effectiveness of NCHHSTP program strategies. In addition, NCHHSTP has conducted and commissioned evaluation activities to measure the effectiveness and relevance of its programs and the programs and strategies of its grantees. External regular and routine monitoring is accomplished by several independent, federally chartered advisory committees which routinely review the Center's work and make recommendations for further action. It is also accomplished through NCHHSTP-sponsored consultations which are used to solicit input and recommendations from external experts to address evolving factors in disease and available prevention strategies. Finally, research and guidelines development are subject to peer review. Findings are published in major peer reviewed journals.

Evidence: Evaluations have been conducted for each of the program's main focus areas. These evaluations were rigorous, and have been published by journals such as the New England Journal of Medicine and the American Journal of Public Health. Evaluations focus on the outcomes of the program, proving effectiveness. The activities of NCHHSTP have been evaluated on a regular basis by many well-regarded external organizations. Between 1997 and 2001, the Institute of Medicine reviewed NCHHSTP's HIV prevention, STD Prevention, and TB Elimination Programs, assessed their effectiveness, and made recommendations for continued achievements. Independent evaluation efforts have been integral in evaluating effectiveness of NCHHSTP's syphilis prevention efforts and supporting program improvements. An NCHHSTP-funded program, with research carried out by independent investigators, evaluated and reported on promising programmatic changes that might enhance reductions in syphilis, especially among African Americans. These evaluations were supplemented by an independent evaluation by the Batelle Institute. These evaluation efforts led to the development and launch of a National Plan to Eliminate Syphilis. In addition, program performance evaluations included a syphilis elimination program assessment by LTG Associates in 2004 that identified lessons learned and best practices. An evaluation by Batelle of the extent and quality of screening services for syphilis and other STDs among HIV-infected MSM is currently occurring. Such evaluation efforts led to a reconsideration of the National Syphilis Elimination Plan through a large external consultation of public health experts and resulted in a revised Plan, issued in 2006.

Are Budget requests explicitly tied to accomplishment of the annual and long-term performance goals, and are the resource needs presented in a complete and transparent manner in the program's budget?

Explanation: While the program and CDC in general do an admirable job at strategic planning and displaying performance information in budget documents, the budget documents do not include the information needed to achieve a Yes answer for Question 2.7. Budget documents do not make a clear link between resources and the achievement of performance goals. Budget documents do not clearly indicate the full costs of achieving performance goals.

Evidence: CDC's performance budget to Congress detailing programmatic activities, funding, and performance information. The full document can be accessed from: http://www.cdc.gov/fmo/PDFs/FY08_CDC_CJ_Final.pdf.

Has the program taken meaningful steps to correct its strategic planning deficiencies?

Explanation: The program is working to address strategic planning deficiencies identified through the PART process. The primary strategic planning deficiency identified through the PART assessments is related to Question 2.7 regarding budget display and performance information. CDC (as part of a broader HHS-wide effort) is implementing a new Unified Financial Management System. This system will allow improved tracking of agency obligations, and should allow for improved linkages between performance and budgeting in the future. In addition to the steps taken across CDC, NCHHSTP has taken significant steps to improve its strategic planning efforts.

Evidence: CDC is currently implementing goals-based planning. This starts with a focus on the organization's mission (and vision and/or values), goals to work toward the mission, strategies to achieve the goals, and action planning (who will do what and by when). To date the agency has identified four goal areas, 24 strategic goals, and 86 core objectives. These objectives will drive budget requests for agency programs that will accomplish them. The goal action plans include 1) an assessment of current agency activities, funding and performance measures, 2) a review of the burden of disease and the known effective interventions, 3) analytic work on the most effective areas for research and intervention, 4) a gap analysis, and 5) the strategic objectives and actions that have the greatest potential for accelerating health impact. NCHHSTP also employs both issues-based and organic strategic planning activities. Where employed, NCHHSTP's issues-based strategic planning often starts by examining issues facing the organization, and developing strategies to address those issues, and action plans. NCHHSTP's organic strategic planning starts by articulating the organization's vision and values and then action plans to achieve the vision while adhering to those values. NCHHSTP's efforts to refine its measures benefit from new data systems used to track progress in meeting the targets set for these measures. For most measures, clear baselines exist from which to assess targets and changes in performance. Historical and trend data assist in the setting of targets. In a few cases, baselines and targets have yet to be determined because data systems used to report on these measures are currently being deployed. These new data systems will provide more robust data and a better reflection of trends in disease morbidity and mortality, the effectiveness of prevention and control efforts, and NCHHSTP's success in achieving its goals.

Does the agency regularly collect timely and credible performance information, including information from key program partners, and use it to manage the program and improve performance?

Explanation: The program collects performance data from grantees and uses performance data to manage grantees, determine resource allocations, and shift program priorities, if necessary. There are several systems through which NCHHSTP collects different types of data that reflect performance and provide baseline and target data for goals and measures. NCHHSTP grantees are funded to collect HIV/AIDS, viral hepatitis, STD, and TB surveillance data. These data enable NCHHSTP and its grantees to monitor disease burden, respond promptly to changes in disease epidemiology, and inform national and local prevention interventions and health policies. Reports of surveillance data include not only national level data, but also state level data as well, often on these same measures. Findings from these analyses are published in reports and peer-reviewed journals and shared with grantees as well as other prevention partners. Grantees funded to carry out other prevention programs through NCHHSTP's grants and cooperative agreements submit interim and annual progress reports and report on a core set of performance measures identified by NCHHSTP. Grantees define baselines and set annual target levels for their own performance. Project officers conduct routine site visits and reverse site visits to review grantee programs and discuss successes and challenges. All funding opportunity announcements for cooperative agreements and grants state that programs are accountable for achieving the target levels of performance established in their plans. If a program fails to achieve its targets or if concerns related to performance are identified during site visits, NCHHSTP works with the grantee to determine steps that can be taken to improve performance.

Evidence: Evidence includes public health surveillance data, available through the agency website (www.cdc.gov). Evidence also includes progress reports files by grantees documenting performance, cooperative agreements and funding opportunity announcements that detail performance expectations of grantees, and site visit reports filed by program staff following visits and interviews with grantees.

Are Federal managers and program partners (including grantees, sub-grantees, contractors, cost-sharing partners, and other government partners) held accountable for cost, schedule and performance results?

Explanation: The program identifies managers responsible for program results, and establishes standards of accountability for these managers. Both Federal managers and program partners are held accountable for program performance and achieving results. For senior executive staff, NCHHSTP uses the Department of Health and Human Services' (HHS) Senior Executive Service (SES) and Organizational Performance Management System to link agency performance plans to HHS and CDC mission and objectives. NCHHSTP partners are held accountable for cost, schedule and performance results through a system of proactive monitoring and collaborative working relationships. Program staff conducts technical reviews of applications to assure compliance with the intent of the funding announcement and to ascertain the level of technical assistance required for success should the applicant be funded. Using this information, staff conduct pre-decisional site visits to assess the applicant's ability to effectively implement the proposed prevention programs, including reviewing their protocols and procedures, staff and administrative capacity, target levels of performance, how well the prevention programs address the needs of the applicant's jurisdiction. Through consultations, NCHHSTP staff clearly define expectations of performance for a federal grantee, and this process of review and accountability is clearly stated in every funding opportunity announcement. Concerns about performance are addressed proactively before they become unmanageable and affect the desired performance. Once funded, grantees commit to and are held accountable to meeting program goals and performance measures as outlined in all funding announcements for cooperative agreements and grants.

Evidence: Evidence includes sample performance plans for several key program managers. Evidence also case studies of grantees and site visit evaluations completed by program staff to assess performance of grantees.

Are funds (Federal and partners') obligated in a timely manner, spent for the intended purpose and accurately reported?

Explanation: Funds are obligated in a timely manner and spent for the intended purposes. In FY 2006, the program obligated 99.82 percent of its funds. CDC's Financial Management Office (FMO) ensures that appropriated funds are properly obligated in a timely manner and that mechanisms are in place to ensure that funds are spent for the purpose for which they are intended. The program has mechanisms in place to ensure that program partners spend their funding for the intended purpose. NCHHSTP Project Officers are responsible for managing grantee implementation of funded-programs to ensure that activities are directed toward program goals and meet the intended purpose of the program. Project Officers monitor performance of program and fiscal activities through interim and annual progress and financial reports, routine data reporting, site visits, and conference calls, ensuring compliance with federally mandated requirements as outlined in every funding announcement. After the program's Extramural Program Offices and CDC budget execution staff approve the details of awards, CDC's Procurement and Grants Office provides a notice of grant award to the recipient both electronically and through the U.S. mail, approximately a month in advance of the availability of funds. The notice explains when the grantee can expect to be able to draw down funds for obligation. Generally, the entire amount of the award is made available to the grantee, who then draws down funds as necessary according to their approved spend plan. Aligned to these efforts are the execution spending plans. The spending plans provide CDC with a detailed sketch of CDC estimated resources needed for the fiscal year by quarter. Each plan is then used to control the incurrence of obligations and is subject to strict fund control procedures. Through the Integrated Resources Information System (IRIS), CDC tracks obligations on a daily basis, but typically, the status of funds is monitored on either a monthly or quarterly basis, according to the needs of the program. Reviews indicate that the agency successfully prevents erroneous payments. The program collaborates with its partners during the application phase of the award process to determine a proposed spend plan (schedule) reflecting grantee activities to be undertaken in support of the program's goals/objectives. Cooperative agreements and grants are then awarded based on the grantee's satisfaction of requirements which are validated and monitored by project officers.

Evidence: Evidence includes standard operating procedures of the budget execution branch at CDC, which explains efforts to ensure that spending plans are executes properly and support agency goals. Spending plans developed at the program level also serve as evidence. The spending plans are used to certify and monitor the status of funds at the program and agency level. Status of funds reports display the funds allotted to the program, and list obligations, commitments, and unobligated balances. CDC uses this information to monitor obligation rates and potential variances. Risk assessments were completed to determine whether they were susceptible to improper payments exceeding $10 million and a 2.5 percent error rate and required to estimate improper payments under the Improper Payments Information Act of 2002 (IPIA) and the related OMB Guidance.

Does the program have procedures (e.g. competitive sourcing/cost comparisons, IT improvements, appropriate incentives) to measure and achieve efficiencies and cost effectiveness in program execution?

Explanation: The program has regular procedures in place to achieve efficiencies and cost effectiveness. The program has conducted several competitive sourcing actions, and also established a High Performing Organization within the CDC IT services office. The program also has established efficiency measures with baselines and targets.

Evidence: Major efforts include competitive sourcing studies to meet requirements of the President's Management Agenda and review and reorganization of organizational and reporting structures across the agency. Since beginning the A-76 program (OMB Circular, No. A-76, Performance of Commercial Activities) in FY 2003, CDC has completed 14 competitions, and the program continues to consider additional competitions. Thus far, A-76 studies have resulted in the contracting out of only the Printing Services functional area. CDC completed five studies of its Facilities Planning and Management Office in FY 2003 and prevailed in all five studies, indicating that through rigorous and complex analysis of work, CDC was performing at a cost to the taxpayers less than that of comparable service providers. In FY 2004, six A-76 competitions were conducted including: Animal Care; Laboratory, Glassware and Associated Laundry services; Office Automation; Printing; Materials Management; and Library Services. In FY 2005, three new standard competitions were announced for Computer Clerk Support, Statistical Support, and Writer and Editor Services. In addition to the standard competitions, the CDC Information Technology Services Office Restructuring Initiative was submitted to OMB as a High Performing Organization (HPO) and was the first HPO approved by OMB as a restructuring alternative to A-76. NCHHSTP currently has two active efficiency measures. These measures reflect both programmatic and administrative endeavors to improve the quality of surveillance information for public health use and to improve the timeliness of awarding carryover funds for use in public health activities, respectively.

Does the program collaborate and coordinate effectively with related programs?

Explanation: The program partners with other federal health agencies; state, local, tribal and territorial health departments; international and national health organizations; academic institutions; and professional, voluntary and community organizations. NCHHSTP works closely with several federal government agencies to optimize resources and knowledge and realize the greatest positive impact on the health of all people. NCHHSTP provides leadership, guidance, technical and financial assistance to state, local and territorial health departments, and community-based organizations to implement prevention and control programs. The program works effectively with national associations such as the National TB Controllers Association, Hepatitis B and C Coordinators, National Coalition of STD Directors, the National Alliance of State/Territorial AIDS Directors, the National Viral Hepatitis Roundtable, the Association of Public Health Laboratories, and the Council of State and Territorial Epidemiologists. NCHHSTP provides national guidance, financial assistance, and technical support to these partners for a range of prevention and control programs.

Evidence: Evidence includes public health documents prepared in collaboration with other Federal agencies on a wide range of issues, including HIV prevention, and the use of rapid HIV antibody diagnostic tests. Evidence also includes interagency agreements between the program and the Indian Health Service to support viral hepatitis, STDs, and HIV/AIDS prevention and control programs among American Indians and Alaska Natives.

Does the program use strong financial management practices?

Explanation: While the most recent independent audit for the Department of Health and Human Services identified two material weaknesses, these material weaknesses do not relate to the specific activities of this program. The program's financial management practices are strong enough to warrant a "Yes" response for this question. A new financial management system will provide timely and accurate financial statements in support of operations. Procedures are in place to minimize improper payments.

Evidence: In 2005, CDC implemented the new Unified Financial Management System (UFMS). UFMS is an integrated, Department-wide financial system that produces financial information to support decision-making and cost-effective business operations at all levels throughout the Department. UFMS replaced the legacy mainframe-based financial system, which was over 15 years old. Some of the direct benefits of implementing UFMS include providing programs with more real time data, streamlining processes to free up program resources to do more value-added work, and producing accurate, timely, and reliable financial reports, enabling CDC to make fact-based operational decisions. Program staff, contract and grant management personnel, and financial management personnel perform activities on a continuous basis to identify and manage improper payments. These activities include grant and contract oversight functions, site visits, prepayment reviews, voucher reviews, and quality control reviews. Furthermore, system controls were designed to reduce the risk of impropriety. System controls include limited access to data files and programs, required authorizations, and reconciliation checks. In addition to these on-going activities, CDC has performed a risk assessment of significant programs as required by the Improper Payment Information Act of 2002. Based on results of the FY 2006 risk assessment, the agency concluded that none of the programs reviewed were susceptible to significant improper payments.

Has the program taken meaningful steps to address its management deficiencies?

Explanation: The program has taken steps to correct management deficiencies noted in prior PART reviews. These steps include: improving data for program monitoring and oversight, making data publicly available, improving efficiency, assuring funds are spent for intended purposes, and holding mangers accountable for performance.

Evidence: Since its last PART review, the program has included performance measures in all of its funding opportunity announcements and grantees report on these measures. NCHHSTP makes data on key program and health outcome indicators available to the public. Indicators such as pediatric AIDS cases and racial disparities in AIDS; Chlamydia, syphilis and gonorrhea rates; TB rates; and viral hepatitis rates are available in surveillance reports and other public documents. Improving cost-effectiveness and efficiency in program execution have been addressed in a number of ways. In 2005, NCHHSTP consolidated six HIV/AIDS prevention programs for CBOs into a single program to implement outreach, counseling, testing and prevention case management strategies. This consolidation was done to improve efficiency and integration of effective program strategies. Further, this consolidation resulted in reduced staff time required to develop individual program announcements and to establish separate panels for reviewing and scoring each application. Further, this action reduced the burden on CDC's Procurement and Grants Office (PGO) staff by consolidating the number of applications they reviewed for eligibility. In a prior PART review, OMB noted concerns from outside groups that some specific HIV grantees did not use funds for their intended purpose. NCHHSTP has investigated those allegations and in a couple of cases, the HHS Inspector General (IG) launched independent investigations. CDC has worked to improve accountability of Federal managers for program performance through the DHHS' Senior Executive Service (SES) and Organizational Performance Management System and the Program Management Appraisal Program (PMAP). Together, these performance management systems connect expectations to mission and link performance ratings with measurable outcomes.

Are grants awarded based on a clear competitive process that includes a qualified assessment of merit?

Explanation: Funding Opportunity Announcements (FOA) are developed and reviewed prior to posting on Grants.gov in accordance with existing competitive policies and procedures. Funding announcements are published in the Federal Register, ensuring broad awareness of funding opportunities through the program. Program announcements are provided directly to program partners to alert them to new funding opportunities. The program adheres to the HHS Awarding Agency Grants Administration Manual (AAGAM) review procedures in the conduct of application evaluation and selection. Non-research and research applications are reviewed utilizing the objective and peer review processes respectively described in the AAGAM. The FOA review and approval process encompasses a review of the eligibility and competition aspects of the FOA. The application review and selection processes are designed to identify and fund the applications of greatest merit. The overwhelming majority (approximately 97 percent) of grants are awarded based on a competitive process with the exception of those grants for which only one agency or organization possesses the necessary expertise or a limited number of agencies are eligible to apply (limited or sole source agreements). All funding announcements include information on the eligibility criteria and the process for reviewing grant applications and clearly specify a budget period, typically 12 months, and the project period, typically two to five years, for the grant. Further, funding announcements include information on pre-decisional site visits which are the second step of the application review process. Pre-decisional site visits are conducted to ensure the applicant has accurately characterized its administrative and technical ability to perform the proposed activities. Grant awards are generally multi-year, and grantees are expected to submit information to the program for each budget year, and to re-compete for grants upon completion of their grant cycle.

Evidence: Evidence includes examples of funding opportunity announcements in the Federal Register that outline eligibility criteria, the application review process and assessment of merit, expectations of grantees, and other elements necessary for awarding funds through a competitive grant process. Evidence also includes technical review forms completed as part of the grant review process. Renewals for program grants are competitive. When CDC re-competed its funding program for its main HIV prevention program for community-based organizations, 572 organizations applied, while only 141 were funded. There was a turnover of about 2/3 in previously funded organizations.

Does the program have oversight practices that provide sufficient knowledge of grantee activities?

Explanation: The program conducts site visits to grantees on a regular basis to evaluate grantee performance and ensure that funding is being obligated for its designated purpose. The program also has reporting systems in place to document use of funds and grantee performance. NCHHSTP works closely with grantees to monitor performance and obligation of funding.

Evidence: Oversight of grantees is conducted through monitoring systems and collaborative working relationships. Accountability and oversight practices are outlined in all funding announcements for cooperative agreements and grants. NCHHSTP works with grantees from the point they submit applications for funding and throughout their activities to implement, monitor, and evaluate their prevention programs. NCHHSTP staff and grantees conduct conference calls on an on-going basis to discuss progress, barriers to achieving objectives, and strategies to overcome identified barriers. Program staff conducts site visits with grantees to observe and discuss ways of addressing problems and strategies for improving performance. Some programs have developed management information systems to assist the grantees in their on-going program evaluation and management efforts. These systems directly link the program objectives and data that are needed to assess whether the interventions are producing the desired results and whether changes are needed to achieve the program objectives. For those grantees that are having trouble achieving program results, NCHHSTP works with the grantee to determine steps that can be taken to improve performance. NCHHSTP actions include providing technical assistance, placing conditions on the use of funds, or with chronic failure to improve, restrictions on the award of funds.

Does the program collect grantee performance data on an annual basis and make it available to the public in a transparent and meaningful manner?

Explanation: The program collects grantee performance information on a timely basis, and works to make this information available to the public. Data is aggregated both program-wide, and at the State level. NCHHSTP manages several systems to collect timely and credible health outcome and other program performance data and presents this information to the public through a variety of forums.

Evidence: NCHHSTP provides funds to states and other grantees to collect surveillance data on HIV/AIDS, viral hepatitis, STDs, and TB. These data provide information regarding burden of disease, epidemic trends, and progress of prevention and control efforts. These data are compiled, validated, and reported annually in CDC's surveillance reports. Reports of surveillance data include not only national level data, from which national reports on performance measures are drawn, but state level data as well, often on these same measures. State, territorial, and national level data are stratified by key factors such as sex, age, and race/ethnicity. Every year CDC publishes several articles describing major findings, and issues press releases. The press releases include information are used by local news media to ensure communities have access to local information. In addition to surveillance data, all grantees are required to report other performance data in their interim and annual progress reports as outlined in each program announcement. While this information is not routinely made public on a grantee level, some aggregate level data are shared and relevant findings and information from these programs are shared and disseminated with the public in the form of recommendations, guidelines, articles, fact sheets, manuals, and presentations. In addition to prevention programs, grantees are funded to conduct research activities and are encouraged to publish their findings in peer-reviewed journals.

Has the program demonstrated adequate progress in achieving its long-term performance goals?

Explanation: The program has developed a group of ambitious performance goals and measures during the PART progress. The program has made measurable progress towards the achievement of five of six long-term outcome goals measuring accomplishments such as reductions in rates of TB in US-born individuals, and reductions in Hepatitis A rates. The program has created six new long-term measures related to HIV/AIDS in the United States. These measures are contingent upon the implementation of a robust new data collection system. Baselines and targets for these measures are under development.

Evidence: Evidence supporting Question 4.1 can be found in the measures tab accompanying this PART assessment. The program has long-term outcome goals in three of the four main program areas that have established baselines and targets. Long-term goals related to HIV/AIDS programs will have baselines and targets established in 2007, once the program's new data collection systems have been implemented.

Does the program (including program partners) achieve its annual performance goals?

Explanation: The program is generally doing a good job achieving annual performance measures related to the achievement of long-term performance measures. For annual measures related to prevention of STDs, hepatitis, and TB, the program is doing a good job making progress in achieving annual goals, and has shown improvements since the establishments of baselines. For ten of the twelve annual measures in these areas, the program has shown performance improvements since the establishment of baselines. In addition to these goals, the program has developed many new annual goals intended to support the achievement of NCHHSTP's HIV/AIDS-related long-term outcome goals. Baselines and targets for these goals will be available later this year, as the program is in the process of implementing a new data collection system that will reflect a significant improvement over existing data systems.

Evidence: Evidence supporting Question 4.2 can be found in the measures tab accompanying this PART assessment.

Does the program demonstrate improved efficiencies or cost effectiveness in achieving program goals each year?

Explanation: The program has two established efficiency measures. Prior to the establishment of these measures, the program did not have annual targets for performance. However, the program has been successful in achieving improvements over prior years. In addition to the efficiency measure, the program has undertaken many administrative initiatives that have improved efficiency and effectiveness.

Evidence: Evidence supporting Question 4.3 can be found in the measures tab accompanying this PART assessment. The program's efficiency measures improve the efficiency of HIV incidence reporting, and decrease processing time for a critical step related to effective obligation of program funds. Between 2002 and January of 2006, the program (and CDC) has more than doubled their supervisory ratio, from 1:5.5 to 1:12.6. The program has effectively used Voluntary Early Retirement Authority (VERA) to reduce administrative staff. In FY 2003, 73 staff retired early under VERA. In FY 2004, 39 staff retired early; and in FY 2005, 93 staff retired early. In FY 2006, 3 staff accepted VERA. CDC completed competitive sourcing studies from 2003 through 2005. CDC has consolidated 13 IT infrastructure functions, services, staff and fiscal resources into the new Information Technology Services Office, which reduced operating costs by 30% and staff by 29%. Several business services have been consolidated in recent years. In October 2004, the budget execution functions were consolidated, resulting in a 20% reduction in staff. In FY 2005, graphics services were consolidated, resulting in a 32% cost savings.

Does the performance of this program compare favorably to other programs, including government, private, etc., with similar purpose and goals?

Explanation: NCHHSTP is the only federal program whose mission is to prevent and control HIV/AIDS, viral hepatitis, STDs, and TB. NCHHSTP 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 U.S. NCHHSTP carries out this responsibility by providing national direction and coordinating the prevention efforts of public and private sector partners. There is no equivalent program at the national level.

Evidence: N/A

Do independent evaluations of sufficient scope and quality indicate that the program is effective and achieving results?

Explanation: The program is founded on strategies that have been rigorously tested and found to be effective. These evaluations meet the criteria of Question 2.6. Independent and external data have demonstrated the effectiveness of these efforts. Several peer reviewed articles in published journals have also indicated the effectiveness of NCHHSTP program strategies. In addition, NCHHSTP has conducted and commissioned evaluation activities to measure the effectiveness and relevance of its programs and the programs and strategies of its grantees. These evaluations have shown that NCHHSTP is achieving results. Further, external monitoring by several independent, federally chartered advisory committees have affirmed the effectiveness and appropriateness of NCHHSTP prevention strategies. Finally, research and major guidelines from the Center have been successfully peer reviewed. Findings are published in major peer reviewed journals.

Evidence: The program recommends annual Chlamydia screening for sexually-active women under age 26 and directly supports screening programs. A randomized control trial performed by independent investigators and published in the New England Journal of Medicine proved that Chlamydia screening lowered rates of pelvic inflammatory disease. A substantial body of published evidence exists regarding the effectiveness of various HIV prevention interventions administered by the program. For example, independently conducted meta-analyses of randomized control trials published in the Journal of Acquired Immune Deficiency Syndrome have shown that behavioral interventions reduce self-reported unprotected sex, and that behavioral interventions can reduce sexual risk, particularly when motivational and skill-based interventions are used in HIV-infected persons. In 2006, CDC's Director's Advisory Committee (DAC), a federally chartered independent advisory committee, undertook a review of CDC's HIV prevention activities. The DAC recommended a list number of priorities including: 1) routine diagnosis to facilitate care and interrupt transmission 2) removal of barriers for routine diagnosis; 3) support for testing in health care facilities where infected persons are likely to be seen; 4) an emphasis on partner notification; 5) support for name-based disease reporting; 6) prevention counseling that includes balanced messaging and an emphasis on the serious nature of HIV; 7) careful crafting of messages appropriate to the audience; 8) a greater emphasis on evaluation; 8) allocation of resources to strategies most effective in preventing new infections. These recommendations affirmed recent CDC actions including a 2003 initiative to increase diagnosis of HIV infection in the U.S.; demonstration projects begun in 2003 and subsequent recommendations for routine HIV testing in health care facilities; continued guidance to HIV prevention programs to use messages and programs tailored to the target audience; the development of a new Program Evaluation and Monitoring System PEMS - currently being piloted in states and community-based organizations; a 2005 recommendation to states to implement name-based reporting; and guidance to state health departments on partner counseling and referral programs and resource allocation. The effectiveness of strategies to control TB in the U.S. has been well-documented and are summarized in Controlling Tuberculosis in the United States: Recommendations from the American Thoracic Society, CDC and Infectious Disease Society of America. For example, evaluation of close contacts of TB patients has been shown to identify persons in the early stages of infection, when risk of disease is greatest.