As the HIV/AIDS epidemic enters its third decade in the United States, significant challenges remain. At the end of 2003, an estimated 1,039,000 to 1,185,000 persons in the United States were living with HIV/AIDS.1 There has been a disproportionate impact on racial and ethnic populations. In 2004, Hispanics accounted for 20 percent of new HIV/AIDS diagnoses while comprising 14 percent of the population in the United States.2 In 2004, African Americans accounted for half of the estimated number of HIV/AIDS cases diagnosed while representing 12 percent of the general population.1
In the United States, the Centers for Disease Control and Prevention (CDC) is the primary governmental agency responsible for the prevention of HIV infection on a national level. Since 1988, the Division of HIV/AIDS Prevention (DHAP) of the CDC has addressed the disproportionate impact of HIV infection in racial/ethnic minorities by developing and implementing a strategy for increasing HIV prevention capacity-building assistance (CBA) for CDC-funded programs to strengthen HIV prevention interventions for high-risk populations. In 2003, the CDC sharpened the focus for its capacity-building strategy through instituting the Advancing HIV Prevention (AHP): New Strategies for a Changing Epidemic initiative.3
Under the AHP initiative, HIV prevention capacity-building efforts are aimed at community-based organizations (CBOs) directly funded by the CDC that work with persons who are HIV-positive and their sex and needle-sharing partners, persons who are at high risk for HIV infection, and individuals unaware of their HIV serostatus. As part of this initiative, capacity-building assistance providers were funded to help build the capacity of community-based organizations to provide effective HIV prevention programs to persons living with HIV and those at high risk for infection.
Although there is no consensus on a definition, capacity for HIV prevention generally refers to the skills, infrastructure, and resources of organizations and communities that are necessary to effect and maintain behavior change, thus reducing the level of risk for HIV infection.4,5 As noted in the current literature, capacity building is a key strategy for the promotion and sustainability of HIV prevention programs.6-8 Studies show that capacity within an organization is associated with the ability to initiate behavior change among those served.9,10
Capacity building focuses on developing, maintaining, and increasing the organizational infrastructure and resources necessary to support interventions and the abilities of key personnel to plan and implement interventions and activities. The ability of organizations to plan, deliver, and sustain programs is an essential component in addressing HIV-related issues in each community.10-12 Partnerships are also key components of capacity building that require diverse collaboration at multiple levels.13 Collaboration among partner agencies and community stakeholders, and program supporters, promotes the effective implementation of community-based health-promotion activities.14,15 Emerging technologies in public health provide community-based organizations with opportunities to monitor and evaluate their programs, use data for program improvement, and disseminate information to their clients and stakeholders.16,17
The framework that the DHAP/Capacity Building Branch uses for operationalizing its capacity-building strategy integrates the major capacity-building concepts described in the literature above. This article (1) describes the evolution of the CDC strategy for building capacity for HIV prevention, (2) demonstrates how the lessons learned have been integrated into the strategy, (3) explains the current CBA framework and how it is being operationalized, and (4) identifies future directions in the strategy for building capacity for effective HIV prevention services.
Background
Since 1988, the CDC has provided competitive funding to nongovernmental national and regional minority organizations (NRMOs) to strengthen HIV prevention for racial and ethnic minority populations highly affected by the HIV/AIDS epidemic. In 1999, the DHAP designed a strategy and framework for providing HIV prevention capacity-building assistance to ensure the success of newly funded programs under the National Minority AIDS Initiative (NMAI).3 Although the CDC also funded other organizations to build capacity, such as Prevention Training Centers (PTCs) and the American Psychological Association's Behavioral and Social Science Volunteers Program (BSSV), this article will focus on the initial funding for NRMOs as the point of analysis.
Funding Cycles
During the first funding cycle (1988-1993) the goals of the HIV prevention CBA program were to increase core competencies of the staff of CBOs around issues related to fiscal, administrative, and program management; effective outreach practices; mobilizing communities; and identifying and developing leadership in HIV prevention at the grassroots level. The first of a series of CBA-funded programs supported NRMOs in providing comprehensive, regionally structured, and culturally appropriate CBA services. CBA providers were funded to work within their traditional networks and with affiliated agencies. Multiple strategies were used for CBA, including outreach and education, public information, training, technical assistance, resource development, and community intervention. No formal evaluation was conducted of the overall program, but a systematic assessment of lessons learned was completed.
During the second funding cycle (1993-1999), the CDC initiated a capacity-building program that was restructured on the basis of lessons learned from the first funding cycle. CBA providers were required to expand their work beyond their traditional networks and assist a broader range of organizations including health departments, CBOs, and nonminority organizations to work effectively with racial and ethnic minority populations.
This strategy focused on providing assistance related to programmatic and organizational development, including services integration. Evaluation findings and recommendations were used to structure consultations with representatives from the NRMOs, other nongovernmental organizations, local health departments, and other CBA providers. The evaluation findings identified capacity-building issues related to board development, human resource development, and program planning and management skills.
A recommendation to the CDC from the consultations addressed the need to have CBA providers use program management tools that focused on process objectives and deliverables, the need to provide guidance to CBA providers on evaluation and monitoring, and the need to develop a strategic plan for building organizational skills and facilitating networking and collaboration among grantees. These lessons learned during the second funding cycle were used to inform the planning process for the third funding cycle.
During the third funding cycle (1999-2003), an evaluation of this capacity-building initiative was conducted. The evaluation was designed to answer three major questions: (1) Was the new approach a successful design for the delivery of capacity-building services? (2) Was the CBA initiative providing CBOs and other constituents what they needed to develop effective and sustainable prevention practices? and (3) Was the system for managing CBA requests and referrals functioning effectively in getting CBA services in a timely manner to those who needed them?
Key findings from the third funding cycle indicated that there was no standardized and consistent use of process and outcome measures across the program; there was inadequate communication and collaboration between the CDC and the CBA providers funded to provide services; and there was inadequate communication among CBA providers related to service coordination. Staff turnover among CBA providers resulted in inconsistent access to expertise on a continuing and long-term basis. As a result, there was difficulty in monitoring individual CBA providers' performance and in evaluating the impact of the overall CBA program. Another significant change during the third funding cycle was the consolidation by DHAP of most CBA functions under one administrative unit, the Capacity Building Branch (CBB). The mission of the CBB was then expanded to include the diffusion of effective behavioral interventions (DEBI) to HIV prevention providers funded through the CDC.
Table 1 provides additional details about lessons learned and recommendations being incorporated into the current CBA Program, which is on its fourth funding cycle (2003-2009). These recommendations focused on comprehensive planning to improve the overall CBA program; addressing technical assistance and training needs of the CBA providers and other partners; and ongoing evaluation focusing on quality control and continuous improvement in service delivery for both the CBB and its partners.
A program model was also developed during this cycle to clarify the critical elements of the CBA program. This was in response to evaluation findings from the third funding cycle.
A comprehensive, long-term capacity-building strategy, guided by the program model, was developed. The intent of the strategy was to ensure a comprehensive and coordinated set of capacity-building services. Separate funding categories were established for each of four focus areas:
Focus Area 1: To improve the capacity of CBOs to develop and sustain organizational infrastructures that support the delivery of effective HIV prevention services and interventions.
Focus Area 2: To improve the capacity of CBOs and health departments to adapt, implement, and evaluate effective HIV prevention interventions.
Focus Area 3: To improve the capacity of racial and ethnic minority CBOs and communities to implement models that will increase the access to, and utilization of, HIV prevention and risk-reduction services.
Focus Area 4: To improve the capacity of Community Planning Groups (CPGs) and health departments to include HIV-infected and HIV-affected racial and ethnic minority participants in the community planning process, and to increase parity, inclusion, and representation on CPGs.18
Within each Focus Area, funds were allocated to target racial and ethnic minority populations and subpopulations in proportion to disease burden. Figure 1 demonstrates graphically the framework for the CBA model. In this model, CBA may be provided through multiple delivery mechanisms (defined in Fig 2) for each of the focus areas. It also ensures that specific standards are met in the design of core activities used in achieving the capacity-building goals for each Focus Area. Monitoring and evaluation are integral components in the model.
Implementing the Capacity-building Strategy
The capacity-building strategy is focused on improving the performance of the HIV prevention workforce by increasing the knowledge, skills, technology, and infrastructure to implement and sustain science-based, culturally appropriate interventions and HIV-prevention strategies. Capacity building is conducted through technical assistance, training, information dissemination, and technology transfer as defined in Figure 2. Capacity-building activities are accomplished through CBB's partnerships with national, regional, and nongovernmental organizations, contractors, and private sector agencies. The CBB also partners with federal agencies and offices such as the Health Resources and Services Administration (HRSA), Substance Abuse and Mental Health Services Administration (SAMHSA), National Institute of Mental Health (NIMH), and the Office of Minority Health (OMH).
Working with partners is a critical component in implementing the capacity-building strategy. Collaboration involves training for CBOs, HDs and their funded CBOs, and other stakeholders to address the HIV prevention service needs of high-risk populations and HIV-positive individuals and their partners. To maintain efficiency and effectiveness of the work, the CBB has taken steps toward enhancing the quality of the process for the diffusion of effective behavioral interventions and other prevention strategies.
Current Capacity-building Program Enhancements
Trainings for effective behavioral interventions were implemented throughout the nation. Some were accompanied by packaged interventions, and in some instances intervention materials were available electronically. Continuous Quality Improvement Teams (CQITs) for disseminating effective behavioral interventions and prevention strategies were established to improve and monitor implementation. A procedural guidance was developed and disseminated for planning, implementing, and ensuring the quality of 12 interventions, Counseling and Testing, and Comprehensive Risk Counseling and Services.19
Other areas for program improvements in response to partners' needs include a Spanish-language version of disseminated interventions for CBOs working with Latinos/Latinas and the establishment of national training partners for Training of Trainers (TOTs). Webcasts, monthly conference calls, and satellite broadcasts were established as consistent modes of communication to support effective implementation of the disseminated interventions. These also serve as feedback mechanisms to assist the CBB in timely responses to grantees' concerns and needs.
A Web-based systems approach was designed to promote accountability, improve resource utilization of the CBB and its partners, eliminate duplication of efforts, and, most important, to facilitate coordination and access to information and CBA services for grantees. The CBA portal houses the CBA Request Information System (CRIS), the Training Events Calendar (TEC), and links to CDC and other technical assistance providers became fully functional in 2005. An orientation was conducted via webcast to familiarize CBA providers and other partners with the special features of the system.
In the fall of 2005, CRIS was put into effect as the conduit for requesting and managing CBA requests. The CBB experienced immediate use with CDC project officers and grantees submitting CBA requests. The overwhelming number of requests during the first 2 months of operation point to a successful transition from a predominantly manual process to a fully automated, Web-based process for requesting CBA. Users (the CDC staff, grantees, and CBA providers) were provided a user ID and password that allows access to CRIS to request CBA at any time.
The TEC, which is an integral part of the CBA portal system, involves the automation of accepting and listing trainings, conducted by the CDC and by partner organizations. With the TEC application, all trainings are now accessible via the Internet, and registration for these events is electronic. The TEC allows users to register for CDC-supported training. A second feature provides CDC-funded CBA providers and health departments with a mechanism for posting and evaluating trainings.
In late 2005, a working group was established to develop an evaluation plan for the CBA Web portal. Subsystems were identified and preliminary goals and objectives were developed. Areas for evaluation within each of the subsystems were identified: the CBA portal itself, the CRIS and TEC, and overall user satisfaction and feedback.
Future Directions
As the HIV/AIDS epidemic changes, new issues evolve, requiring different emphases and alternate ways of working. New areas identified include the following:
* Capacity building for health departments: The CBB is working with the National Alliance of State and Territorial AIDS Directors (NASTAD) to conduct an assessment of capacity building needs of health departments and to develop a responsive plan for delivering capacity building assistance to implement effective behavioral interventions and other strategies.
* Strategic planning: The CBB is working toward a strategic plan to increase efficacy of HIV prevention practice and enhance dissemination of effective behavioral interventions for high-risk populations.
* Consultations: The CBB will hold consultations on strategies for more effective delivery of capacity-building services to health departments, especially on implementing and adapting effective behavioral interventions.
* Training: Additional trainings on effective interventions will be offered with a focus on Training of Trainers (TOTs) for health departments; new trainings will be added to include Fundamentals of Waived Rapid Testing (RT) and TOTs, Program Managers Course Series, RT in Emergency Rooms, and selected quality assurance products.
* Curricula: New curricula will be developed to include RT for Program Managers, revised fundamentals of HIV Preventions Counseling, RT in emergency rooms, and social networks.
* Translation/Interpretation: The CBB will be working with staff and consultants to translate additional curricula for training on effective behavioral interventions into Spanish.
* Collaborations: The CBB will continue its collaborations with the Epidemiology Branch, the Prevention Program Branch, the Prevention Research Branch, and the HIV Incidence and Case Surveillance Branch. It will forge new collaborations with the Office of Population Affairs in the Department of Health and Human Services, the Behavioral and Clinical Surveillance Branch of DHAP, and the four federal training centers.
Conclusion
Providing effective capacity-building services for HIV prevention on a national level is a complex business. The shifting HIV/AIDS epidemic, competing priorities, cultural competence, and diversity in prevention needs and local populations have all contributed to the challenge. In the 18 years that the CDC has supported capacity-building services for HIV prevention, resources have increased, technical expertise has become more readily available, planning has become more comprehensive, monitoring and evaluation of CBA has become essential, and there is a higher level of scrutiny of performance and impact.
The CBB has remained committed to ensuring that lessons learned from the experience of providing capacity-building services are used to enhance its capacity-building program. It continues to use evaluation data, data from quarterly reports, special-purpose evaluations, and other qualitative data gathered from meetings and conferences with its grantees for program improvement. The current framework has incorporated the myriad lessons learned from past evaluations. As a result, funding program announcements, orientation of grantees, documents to provide guidance, conference calls and meetings with partners, and training with both partners and prevention providers reinforce standards for program implementation. Examples of responses to grantees' request for interventions that work are the packaged interventions and accompanying technical assistance guidance documents. These materials and extensive trainings are supplied throughout the United States. CBA is delivered in collaboration with CBA providers, contractors, and other partners to provide technical assistance, training, and coaching to ensure that the diverse needs of all grantees are met to conduct effective and efficient culturally competent programs to reduce the spread of HIV/AIDS.
These new systems enable the CBB to offer a comprehensive multicomponent strategy to respond to grantees in a timely fashion. Through these systems, the CBB is better able to communicate and make resources readily available to enable partners to work effectively in their communities. Through careful planning, implementation, evaluation, monitoring, quality assurance, and overall coordination, the CBB has been able to expand its services and support to build the capacity of individuals, organizations, and communities to effectively address the HIV/AIDS epidemic.
REFERENCES