Abstract
Although modest declines in HIV transmission have been observed in recent years, HIV transmission has persisted in the United States during the past decade, with tens of thousands of new diagnoses reported annually.1,2 To accelerate progress and address the ongoing epidemic, the US Department of Health and Human Services launched the Ending the HIV Epidemic in the US (EHE) initiative in 2019, with a goal of reducing new HIV infections in the United States by 75% by 2025 (target: 9300 new infections per year) and 90% by 2030 (target: 3700 new infections per year). 3 National surveillance data indicate that progress toward these goals has been limited; in 2023, more than 39 000 people received new HIV diagnoses in the United States and 6 territories and freely associated states, and available estimates indicate that declines in new infections to date fall short of EHE benchmarks.1,2,4 This context underscores the importance of examining how EHE strategies have been implemented during the initiative’s first phase to identify what has worked, where gaps remain, and how lessons learned can inform efforts in the remaining years.
The EHE initiative is structured on 4 key pillars: diagnose, treat, prevent, and respond. 5 The prevent pillar aims to protect individuals likely to be exposed to HIV through evidence-based interventions, including HIV preexposure prophylaxis (PrEP), nonoccupational postexposure prophylaxis (nPEP), and syringe service programs (SSPs). 5 The Centers for Disease Control and Prevention’s (CDC’s) Division of HIV Prevention (DHP) has had a central role in the EHE initiative by supporting jurisdictions in developing and implementing community-specific prevention strategies that reduce HIV-related stigma and address local needs. 6 Through capacity development and enhanced flexibility in the use of funding, DHP empowered local leaders to design tailored prevention efforts that prioritize populations most affected by HIV. 6 To further support EHE’s goals, DHP established internal, pillar-specific workgroups in 2021; the Prevent Pillar Workgroup was initially led by Dawn K. Smith, MD, MS, MPH, a pioneering figure in biomedical prevention known as the “Mother of PrEP.” 7
This commentary highlights DHP’s most consequential contributions to the EHE prevent pillar, including the establishment and leadership of the Prevent Pillar Workgroup. Using illustrative (not exhaustive) examples, we summarize key accomplishments, distill lessons learned, and outline future directions to inform intra- and interagency efforts to accelerate progress toward EHE goals. This commentary focuses on organizational approaches, coordination mechanisms, and selected indicators of scale and scope based on publicly available information.
A Strategic Response: Purpose and Formation of the Prevent Pillar Workgroup
Through the Prevent Pillar Workgroup, DHP developed an internal coordination approach to support both intra-agency alignment and collaboration with external partners. Core elements of this approach included structured cross-division engagement, routine information sharing, use of shared epidemiologic and programmatic data to inform priorities, and iterative feedback loops with federal, state, and local partners to refine guidance and implementation strategies.
To operationalize this approach, the Prevent Pillar Workgroup functions as an ongoing coordination body, convening multidisciplinary experts from across the DHP and from various CDC divisions beyond its own, including the Division of STD Prevention and the Division of Viral Hepatitis. The workgroup reviewed emerging evidence, monitored implementation challenges, and informed guidance and technical assistance. Its objectives included providing technical guidance, translating research into practice, and fostering collaboration with other federal agencies, state and local health departments, community-based organizations, and clinical sites to advance the use of PrEP and SSPs in the United States.
Across these efforts, emphasis was placed on reducing differences in PrEP and SSP use among affected populations, enhancing cultural responsiveness, and strengthening community engagement. Through this coordinating role, DHP served as a catalyst for innovation, collaboration, and strategic communication, both within CDC and among partners supporting the prevent pillar across the country.
Programmatic Contributions: Advancing PrEP and SSP Implementation
DHP played a pivotal role and contributed to many efforts that expanded access to HIV prevention services in support of the EHE initiative (Table). Key areas in which DHP advanced HIV prevention include the following.
Examples of CDC Division of HIV Prevention projects supporting the Ending the HIV Epidemic prevent pillar, 2019-2025
Abbreviations: CDC, Centers for Disease Control and Prevention; EHE, Ending the HIV Epidemic in the United States; HCV, hepatitis C virus; MSM, men who have sex with men; nPEP, nonoccupational postexposure prophylaxis for HIV; NA, not applicable; PrEP, preexposure prophylaxis; PS, prevention and surveillance; RFA, request for application; SSP, syringe service program; STI, sexually transmitted infection; telePrEP, telemedicine for PrEP.
Technical Assistance and Capacity Building
DHP provided technical assistance to DHP-funded jurisdictions, especially those receiving funding from CDC through cooperative agreements. This technical assistance included supporting the development of evaluation tools, training materials, and consultation services tailored to local needs and informed by real-time programmatic challenges.
DHP also supported federal partners and jurisdictions to expand access to PrEP in nontraditional settings (eg, sexually transmitted infection [STI] clinics, primary care facilities, community health centers) and through emerging models, such as telePrEP and pharmacy-based PrEP delivery. For example, the workgroup reviewed and provided technical assistance on telePrEP-related educational materials developed by HealthHIV. 28 Engagement with the National Alliance of State and Territorial AIDS Directors and local health departments facilitated peer learning and dissemination of best practices, such as telePrEP implementation, across jurisdictions. 29 In addition, DHP assisted jurisdictions to improve access to services and support data collection. Efforts also focused on destigmatizing SSPs and integrating other services, such as HIV and hepatitis C testing and care, as well as doxycycline postexposure prophylaxis for STI prevention, to ensure people served remained informed about their STI status and engaged in care.
The workgroup enhanced CDC workforce capacity by regularly updating resources on the CDC intranet, including the latest science, guidance, and tools for PrEP and SSP implementation. DHP also collected and disseminated programmatic success stories and lessons learned from local leaders who were implementing EHE solutions. 30 These inspirational stories continue to serve as vital resources, illustrating how various jurisdictions use EHE funding to address the unique challenges in their communities.
Informing Funding Strategies to Integrate Prevention Activities
DHP pursued funding strategies during the EHE period to support the integration of prevention activities across multiple Notices of Funding Opportunities, including cooperative agreements supporting health departments and capacity-building assistance providers. These strategies promoted service integration (such as mpox vaccinations in PrEP clinics and SSPs 14 ), partnerships with community-based organizations13,15,26 (such as Alta Healthcare’s PrEP navigation services and technical guidance for implementation), and support for innovative delivery models (such as telePrEP 11 ) where prevention activities could be meaningfully incorporated.8,10,12,25,27
In addition, in 2024, DHP provided supplemental funding to increase PrEP and nPEP access and uptake among populations who are disproportionately affected by HIV and have low numbers of PrEP and nPEP prescriptions. 9 This supplemental funding represents a novel approach in that it allowed awardees to cover direct costs associated with PrEP and nPEP prescribing. 9
Development of Clinical Practice Guidelines and Other Clinician Resources
DHP developed and disseminated HIV prevention guidelines, notably the Clinical Practice Guidelines for PrEP 17 and Clinical Practice Guidelines for nPEP. 18 These guidelines, updated regularly, ensure the inclusion of new modalities, such as long-acting injectable cabotegravir and lenacapavir PrEP. 16 DHP scientists are active members in the US Department of Health and Human Services–led panel that develops and updates perinatal guidelines, 19 providing recommendations for the prevention of HIV transmission from mothers to infants in the United States. The work of this panel includes providing updated guidance on infant feeding for mothers with HIV and optimizing care of these mothers and their families.
In addition, DHP continued to update the Prevention Research Synthesis Compendium of Best Practices for HIV Prevention, which synthesizes evidence-based behavioral and structural interventions, including those focused on PrEP and SSPs. 23 Collaboratively, the workgroup reviewed and provided feedback on user-friendly resources (eg, web-based tools, clinical manuals, frequently asked questions, communication toolkits) developed by CDC-funded organizations or funded recipients. These materials were designed to be adaptable across diverse settings and populations. In addition, DHP contributed to funding and maintaining national PrEP and nPEP telephone warmlines, providing clinicians with needed direct consultation on individual cases. 24
DHP National Monitoring, Epidemiology, and Research
National PrEP use monitoring
DHP has been leading national and state-level monitoring of the uptake and expansion of PrEP in the United States with the development of a validated algorithm to identify PrEP prescriptions in pharmacy data prior to the start of the EHE initiative.20-22 The PrEP prescription data contribute to the calculation of the numerator for the EHE PrEP coverage indicator. In addition, DHP scientists developed advanced methods to estimate the need for PrEP in the US population,31,32 which has historically served as the denominator for the PrEP coverage indicator, one of the key indicators to monitor progress of EHE toward preventing new HIV infections. 4
Implementation science, research, and epidemiologic analyses
DHP has conducted multiple implementation research studies, including a pivotal ongoing study of real-life PrEP use and switch patterns in the United States (PrEP Choice Study 33 ), as well as demonstration projects to expand the use of PrEP in priority jurisdictions of EHE. An example is project THRIVE, 34 which demonstrated increases in PrEP uptake and larger declines in new HIV infections in funded jurisdictions compared with eligible but unfunded jurisdictions.
Through innovative analyses of large-scale health care data, including health insurance claims, pharmacy transactions, commercial laboratory results, and integrated electronic medical records, DHP has been able to conduct epidemiological research with real-world data that would otherwise not be possible. Studies have evaluated compliance with guidelines for PrEP care,35,36 PrEP prescription abandonment and persistence,37,38 and trends in PrEP uptake across demographic groups and health insurance categories.39,40 Such work helps document progress in PrEP implementation 41 and identify areas where additional prevention efforts are needed. 42
Cross-Agency Collaboration
To achieve prevent pillar goals, DHP collaborated with other federal partners. These partnerships supported harmonization of messaging, integration of services, and alignment of reporting metrics. For example, DHP facilitated 2 bidirectional meetings involving all US federal agencies engaged in domestic and global HIV prevention, care, treatment, and surveillance efforts. In addition, the workgroup’s collaboration with the Health Resources and Services Administration’s (HRSA’s) HIV/AIDS Bureau 43 supported efforts to incorporate PrEP awareness into Ryan White HIV/AIDS Program settings, expanding access to PrEP among serodiscordant couples. 44 In addition, DHP also offered technical support in algorithm design and external cross-check of electronic medical record–based monitoring of PrEP service use at HRSA-funded clinics.
Moreover, collaborative efforts among DHP, the Division of STD Prevention, and HRSA’s Bureau of Primary Health Care 45 included sharing educational resources that addressed gaps in training and technical assistance. Informational and educational needs that were addressed by one unit were shared with the others, resulting in the efficient use of capacity development funds and more widely distributing workforce development services and guidance across the US government to the respective unit’s state and local partners.
Responses to clusters and outbreaks of HIV frequently identify gaps in prevention services, where prevention resources are not effectively reaching populations experiencing rapid HIV transmission. 46 In these settings, collaborations among agencies are essential to address these gaps. For example, during an HIV outbreak among people who inject drugs in Cabell County, West Virginia, in 2019, response activities identified gaps in access to PrEP and SSP services. Following this outbreak, DHP collaborated with and provided technical assistance to the local health department, a federally qualified health center, and an academic medical system to integrate PrEP and SSP into primary health care settings. 47 By coordinating resources and expertise, DHP and its partners have been able to respond rapidly to emerging public health threats.
Lessons Learned and Future Directions
Since launching the EHE initiative, DHP has established a model for internal and external coordination in support of complex public health initiatives. Several key lessons have been learned.
Internal Coordination Drives External Impact
Effective collaboration across DHP allowed for timely responses to external needs, evidence-based messaging, and consistency in programmatic support. Structured coordination within the agency, including regular meetings of workgroups across divisions, shared priority setting informed by epidemiologic data, and coordinated review of guidance and technical assistance, created efficiencies and reduced duplicative efforts. While these practices built on preexisting collaborative approaches within DHP, they were formalized and expanded under the EHE initiative to support the scale and complexity of the national response.
Sustained Partnerships Are Essential
Engagement with federal and nonfederal partners enabled DHP to align national efforts and foster continuity across prevention programs. The Prevent Pillar Workgroup has effectively leveraged these broader relationships to strengthen its efforts.
Innovation Requires Flexibility and Expertise
The COVID-19 pandemic challenged many aspects of public health programming, including HIV prevention. DHP’s support for novel approaches—such as telehealth, mail-order PrEP, and at-home HIV testing—demonstrated the importance of flexible service delivery models that meet people where they are. DHP’s innovative use of multiple data sources allowed for timely, effective, and efficient monitoring of progress by establishing reliable epidemiologic indicators.
In addition, experiences during the first phase of EHE have highlighted persistent implementation challenges, including uneven access to prevention services across jurisdictions, workforce capacity constraints, structural barriers such as stigma and health insurance coverage limitations, and variability in local readiness to adopt and sustain evidence-based interventions. Explicitly identifying and addressing these gaps will be critical to inform strategic adjustments and accelerate progress toward EHE goals in the remaining years of the initiative.
Implications for Public Health Policy and Practice
DHP’s efforts offer important insights for public health systems implementing multisectoral initiatives.
Framework for Interagency Coordination
DHP activities offer a scalable structure for how public health agencies can coordinate to align with external public health goals. This model can inform responses to other national priorities, such as syndemics involving STIs, viral hepatitis, perinatal infections, and substance use, as well as whole-person/status-neutral approaches to prevention and care services.
Transparency in Federal Operations
Making visible the internal mechanisms that support national initiatives builds public trust, enhances accountability, and offers insight for state and local health departments seeking federal alignment.
Support for Emerging Policy Directions
As new policies emerge to support prevention (eg, Medicaid coverage of PrEP services, SSP expansion laws), DHP’s infrastructure ensures that implementation science informs policy adoption and execution.
Although developed in the context of a federal agency, the Prevent Pillar Workgroup coordination approach offers a transferable structure that may be adapted by state, local, and territorial health departments. Key features, including cross-program coordination, integration of data with implementation experience, and sustained engagement with external partners, are applicable across jurisdictions and may support alignment of prevention activities in complex, multipartner initiatives. In addition, other public health partners, including academic institutions, health care systems, and community-based organizations, may adapt elements of this approach to strengthen collaboration, implementation, and scale-up of evidence-based prevention strategies.
Conclusion
As the United States approaches the midpoint of the EHE timeline, DHP has played a central role in accelerating progress, particularly within the prevent pillar. One of DHP’s most consequential contributions is launching and overseeing the EHE Prevent Pillar Workgroup, a coordinating body that aligns national priorities, mobilizes cross-division expertise, and scales evidence-based biomedical and behavioral interventions. Through this leadership, DHP has translated science into practice and strengthened collaboration across agencies and communities.
Despite important progress in expanding access to prevention tools, national trends highlight the need for continued adaptation and acceleration of EHE strategies.2,4 CDC estimates indicate that approximately 2.2 million individuals in the United States could benefit from PrEP, but only about 500 000 received a prescription in 2023, representing just 22.4% of those in need.32,41 This substantial gap between PrEP and PrEP prescription underscores the continued urgency of closing the PrEP access gap and highlights the work that remains in the initiative’s final years. DHP remains at the forefront of national thought leadership, from the late Dr. Smith to today’s experts who are national thought leaders on HIV prevention, elevating visibility through presentations, publications, webinars, and community engagement, and effectively translating advances into impact.
The experiences described in this commentary demonstrate how organizational coordination, cross-sector collaboration, and implementation-focused approaches can support course correction and strengthen prevention efforts as EHE moves into its later phases. Moving forward, it is essential to expand equitable access to HIV prevention and care while sustaining innovation, rigorous monitoring of progress, and the flexibility to adjust strategies as gaps are identified. Ultimately, the success of the EHE initiative in achieving its goals hinges on sustaining guidance, adequate resourcing, and deep community partnerships to ensure timely access to effective prevention for all people at risk of HIV.
Footnotes
Acknowledgements
We remember the late Dawn K. Smith, MD, MS, MPH, with deep appreciation for her foundational leadership of the Ending the HIV Epidemic (EHE) Prevent Pillar Workgroup and her lasting contributions to biomedical HIV prevention. We also acknowledge the Prevent Pillar Workgroup members, past and present, and the Division of HIV Prevention leadership for their guidance and support. Finally, we thank colleagues across the EHE Pillars and our external partners, including federal agencies, health departments, community organizations, and clinical and research collaborators, for their essential contributions to advancing EHE prevention goals.
Funding
The authors received no financial support for the research, authorship, and/or publication of this article.
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Disclaimer
The findings and conclusions in this commentary are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.