The year 2008 will mark the 20th anniversary of the Centers for Disease Control and Prevention's (CDC's) formal HIV prevention capacity building efforts.1 The first two decades of HIV prevention capacity building in the United States have been marked by continuous maturation and adaptation to a constantly evolving epidemic.1 For example, CDC's capacity building efforts grew during the first years of the Congressional Black Caucus' Minority AIDS Initiative (in the late 1990s), and became even more intensively focused on the technical assistance needs of organizations serving communities of color with dramatically increasing rates of HIV infection. A substantial fraction of these organizations were receiving federal funding for the first time and had specific capability building needs.

Over the past two decades, CDC's capacity building activities have tended to focus on four major areas: (a) organizational development; (b) assistance with the delivery of evidence-based HIV prevention interventions; (c) community mobilization; and (d) post-1993, support of HIV prevention community planning groups. This special issue of the Journal of Public Health Management and Practice provides several articles focused on each of the first two of these four areas, and more concisely discusses community mobilization.

Nu'Man et al2 and Takahashi et al3 describe conceptual frameworks that can be used productively to guide efforts to develop the strength and resiliency of HIV prevention service provision organizations, with a special emphasis on organizations that serve racial/ethnic minority communities. Richter and colleagues4 present the empirical evaluation of a successful training program for leaders of community-based organizations. They found that their month-long training helped community-based organization leaders to have more managerial self-efficacy, to guide their organizations in the increased delivery of evidence-based HIV prevention interventions, and to react to changes in the epidemic by more systematically conducting organizational strategic planning. Another article in this special issue5 describes a comprehensive national capacity building system for organizations serving Asian and Pacific Islander communities. Qualitative data regarding that system indicate its success in growing professional networks of service providers, and preliminary quantitative data indicate its success in executive leadership development.5

Several articles in this special issue focus more exclusively on the delivery of science-based interventions. One article describes an agency capacity framework that can be used to guide technical assistance efforts to equip organizations with tools to deliver evidence-based HIV prevention interventions.6 This agency capacity framework posits that organizational environment, workforce development, and resources are input factors that can be catalyzed by organizational motivation and readiness. These factors, when mediated by experiential learning and external environmental control, determine the type and intensity of HIV prevention services provided.6 Consistent with this framework is the work of Ayala et al, who describe the experiences of organizations serving Latino communities; they note that many such organization wish to deliver even more evidence-based services but decry the paucity of culturally relevant intervention models in the scientific literature.7 Pierce and colleagues demonstrate how geospatial analytic techniques can be used to determine whether HIV prevention services for African American men who have sex with men are being delivered in the geographic areas with most acute need.8

The article in the special issue that most directly discusses community mobilization is that by Thurman et al.9 They describe a community readiness model with nine stages, ranging from no awareness of HIV/AIDS issues to preparation for action to intensive community ownership of the HIV-related needs and necessary responses.9 Capacity building efforts for communities can be most effectively and efficiently delivered when the community's stage of readiness is understood. The authors describe how they used this framework to address the HIV prevention needs of Native American communities.9

This special issue of the Journal of Public Health Management and Practice does not focus on the capacity building issues inherent in HIV prevention community planning. Nevertheless, the special issue provides a rich historical account of HIV prevention capacity building efforts sponsored by the CDC and its partners, describes successful models for building HIV prevention organizational capacity, and informs us about the barriers and facilitating factors for expanding the use of evidence-based HIV prevention interventions in community-based programs. Furthermore, a community readiness model is described that provide key insights for understanding whether and how communities have mobilized to address HIV/AIDS issues, and what types of capacity building activities might be most productive at various stages of community readiness.

Understanding the Return on Investment in Capacity Building Efforts

As the HIV epidemic unfolded in the United States, the national HIV prevention investment tended to flatten.10 Furthermore, HIV prevention efforts are held to high standards regarding their effectiveness and the return on public investment.11 Hence, being able to provide economic evaluation information about capacity building efforts may be important for their long-term sustainability.12

It is difficult to precisely say how many HIV infections have been averted by a particular capacity building program because the causal chain between funding the capacity building effort and changes in HIV incidence is rather long. A given capacity building effort might influence the leader of a community-based organization, who in turn starts a strategic planning process that leads to organizational acceptance and ultimate delivery of a culturally appropriate adaptation of an evidence-based intervention to reduce HIV-related risk behaviors. Successful changes in risk behaviors may then in turn lower HIV incidence in the community. This special issue contains examples of studies that assess the impact of capacity building efforts on the first several links in this chain; the literature contains other examples of studies (including randomized trials) that have found technical assistance efforts capable of modifying organizations' service delivery practices.

Any single study that would examine this entire causal chain would be extraordinarily expensive and complex (and perhaps logistically impossible). Hence, it is difficult to state precisely the cost-effectiveness of capacity building efforts. However, we can use economic evaluation threshold analysis to set performance standards for capacity building efforts, and then attempt to determine whether the capacity building effort's effectiveness is above or below that threshold.12,13 This is best explained by an example.

Suppose that CDC spends $1 million on a capacity building program. Every time an HIV infection is prevented, society saves between $200,655 and $303,100 in medical care costs averted (discounted at 3% into net present value). To be conservative, we take the lower end of that range. If we divide $1 million by $200,655, we can see that if the capacity building effort leads to the prevention of just 5 HIV infections, then the effort is actually cost-saving to society. We might not know exactly how many infections are averted by the capacity building effort itself, but we can attempt to determine whether the number is above or believe this rather readily achievable threshold.

Cost-saving is a high standard; most public health and medical interventions are held to a standard of cost-effectiveness.12 One typical standard is whether or not an intervention can save a quality-adjusted life year at a cost of roughly $50,000 or less.12 (In other words, a service might not be cost-saving, but could still be worth the investment in terms of quality-adjusted life years saved.) It has been estimated that every time an HIV infection is averted, between 9.34 and 11.23 quality adjusted life years are saved (discounted at 3% into net present value).14 Again, to be cautious, we take the lower end of that range. This would imply that society should be willing to pay $200,655 + (9.34 x $50,000) = $667,655 to prevent an HIV infection (and still consider the investment to be cost-effective). Hence, if a capacity building effort costs $1 million, and averts one and a half HIV infections, it should be considered a cost-effective investment of public resources. Again, we may not know exactly how many infections were averted by the $1 million capacity building program itself, but we can seek to determine whether the number is above or below the highly achievable threshold of 1.5 infections to be prevented.

We assert that the economic evaluation technique of threshold analysis can be very useful for conceptualizing the return on public investment in HIV prevention capacity building and other public health programs in which the causal chain between initial activity and final disease outcome is lengthy and complex.

Looking to the Future: Emerging Issues in HIV Prevention Capacity Building

One article in this special issue provides an intriguing listing of future issues in CDC-sponsored HIV prevention capacity building.1 These issues range from capacity building for health departments, to strategic planning within CDC's Capacity Building Branch for the further development of current capacity building activities, to expanding partnerships with other units within the CDC as well as the Office of Population Affairs in the Department of Health and Human Services.

We offer a complementary framework for considering the next generation of HIV prevention capacity building efforts sponsored by the CDC and its partners, and that is to link the maturation of capability building activities to the HIV prevention national plan. In January 2001, the CDC issued a national HIV prevention plan with an overarching goal of a 50 percent reduction in HIV incidence in the United States by 2005, and with a special emphasis on reducing HIV-related health disparities.15 The plan had four major subgoals focused on the following areas: (a) reduction of HIV-related risk behaviors; (b) increased awareness of HIV serostatus; (c) increased access to HIV care and treatment for persons living with HIV; and (d) intensified capacity building, surveillance, and evaluation activities. This plan did not meet its overarching goal, and is now expired.16 However, the CDC has held at least two external consultations to discuss the next national plan. While no new plan has been issued, the CDC has given some indication at its external consultations that in a new plan the subgoal on capacity building, surveillance, and evaluation may be rolled into other subgoals. Hence, once the overarching goal and subgoals of the new national plan are developed, a capacity building plan could be constructed for each.

Holtgrave et al have argued that the new national plan should aggressively attempt to lower HIV incidence in the United States, and directly confront health disparities.16 Furthermore, they argue that the subgoals of a new plan should consider at least the follow areas: (a) reduction of risk behaviors of at-risk HIV seronegative persons; (b) promotion of knowledge of serostatus via counseling and testing; (c) lowering of risk behaviors in the small minority of HIV seropositive persons who are aware of their serostatus yet continue to engage in behaviors that could transmit the virus to their partners; (d) increasing access to care and treatment; (e) promotion of basic HIV/AIDS knowledge in the general population; and (f) reduction of HIV-related stigma.16 One could conceive of a capacity building plan being developed for each of these subgoal areas (and then the six capacity building plans coordinated into one overall capacity building comprehensive plan and system). Furthermore, the capacity building plan in each of the six areas could productively include consideration of organizational development, evidence-based intervention delivery, community mobilization, and support of community planning deliberations in that specific topic area. Across all topic areas, the overarching goal of aggressively reducing new infections and reducing health disparities should be kept foremost in mind.

Whatever the final form of the next national HIV prevention plan, it is critical that capacity building efforts are clearly included. As can been seen in this special issue, HIV prevention capacity building activities have served to strengthen the national response to the epidemic by equipping organizations to deliver culturally appropriate services that are evidence-based. Only a handful of HIV infections need be prevented by these capacity building efforts in order for them to be considered cost-saving or cost-effective to society.

Furthermore, while much federal funding comes in disease-specific categories, one can imagine that resilient organizations who have received HIV/AIDS capacity building services are in a good position to address other public health challenges as well (including the challenges of emerging infectious diseases). Hence, these strengthened HIV prevention service delivery organizations are now a strategically important and perhaps underutilized part of the public health infrastructure of the United States.

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