Managing System-Wide Change in HIV Prevention Programs: A CDC Perspective.

What are the variety and scope of administrative challenges faced by large bureaucratic structures when they implement system-wide change? Specifically, when decision making about priorities for human immunodeficiency virus (HIV) prevention programs was decentralized by the Centers for Disease Control and Prevention (CDC) and delegated to state and local departments of health, what were the implications for public health infrastructure, work force training, resource distribution, and policy development? Using a previously developed model of effective change management, Ronald O. Valdiserri describes, from a federal agency perspective, the variety of actions that were necessary to implement and sustain system-wide changes in the planning and priority setting of CDC's publicly funded HIV prevention programs. All citizens have a stake in improving HIV (human immunodeficiency virus) prevention efforts in terms of reducing the societal costs of this epidemic and mitigating its profound toll in human suffering. Administrators of publicly funded HIV prevention programs are especially interested in mounting and sustaining efforts that will have the greatest impact on preventing infection while making the best use of scarce public resources. It is not surprising, then, thee discussions of HIV prevention, whether in academic forums or practice settings, often center on the question of "What works?" In one of its last reports to the American public, the National Commission on AIDS (acquired immune deficiency syndrome) addressed the topic of behavioral and social sciences and the HIV epidemic. Although the commission affirmed that these disciplines "should be a major component of the U.S. effort to control the HIV/AIDS epidemic," their report concluded that "to a very disturbing extent, the potential contributions they could make have not been utilized in the fight against AIDS" (National Commission on AIDS, 1993; 1). Several important reasons were identified to explain this situation, including inadequate research, a tendency to favor "technologic fixes" over behavior-oriented primary prevention strategies, political interference, and improperly designed and poorly implemented HIV prevention programs. Published discussions of the behavioral and social science content of HIV/AIDS prevention programs often focus on important gaps in the research science base as major determinants of less than adequate program quality (Choi and Coates, 1994; Kelly et al., 1993) and consequentially imply that increased research will translate into better programs. However, the impact of scientific innovation on HIV prevention programs is neither guaranteed nor automatic. Administrators of publicly funded HIV prevention programs at all levels of government are challenged to develop processes and systems that will facilitate the incorporation of new scientific findings into ongoing HIV prevention programs. Organizational capacity to put into operation and to implement the scientific innovation, consumer and broader community attitudes about the innovation, and management's ability to identify new resources (or shift existing ones) to support implementation can all influence programmatic adoption of new scientific findings. Undoubtedly, sound science is essential to the development of effective HIV prevention strategies, whether biomedical or behavioral, but good science is not the only necessary ingredient for program success. Holtgrave and his colleagues, in summarizing the published literature on the subject, identified the following as general characteristics of successful HIV prevention programs: a basis in real, specific needs and community planning; cultural competency; clearly defined audiences, objectives, and interventions; a basis in behavioral and social science theory and research; quality monitoring and adherence to plans; use of evaluation findings and mid-course corrections; and sufficient resources (1995; 135-136). …