HIV Prevention Community Planning Profiles: Assessing the Process and the Evolving Effects 

This issue of AIDS Information Exchange (AIX) is a summary of The U.S. Conference of Mayors (USCM) report, HIV Prevention Community Planning Profiles: Assessing the Process and the Evolving Effects, which was published in December 1998. The report is the third in a series of multiple-case studies of community planning conducted by USCM as part of a continuing effort by the Centers for Disease Control and Prevention (CDC) to evaluate the HIV prevention community planning initiative. The study focuses on ongoing and new issues related to the planning process, and on the evolving effects of the initiative. Particular emphasis is placed on issues that were prominent during the fourth year of planning (1996-1997). 

A multi-cultural team of researchers employed qualitative research methods to gather data on the experiences of five jurisdictions receiving HIV prevention funds from the CDC-Alabama, 
Arizona, California, Chicago, and Kansas. Importantly, all of these were previously profiled by USCM in earlier reports. This unique opportunity to gather longitudinal data in a number of health department jurisdictions allowed for the identification of evolving trends and issues both within and across sites. Data sources included documents, interviews with health department staff and community planning group (CPG) members, and focus group discussions with HIV prevention service providers. A technical advisory board of individuals with expertise in community planning, HIV prevention, and evaluation provided advice and feedback on site selection, research design, and a draft of the final report. 

Issues Related to the Planning Structure and to the Community Planning Groups (CPGs) 

Community Planning Structure. Although community planning has been under way for over four years, CPGs and health departments continue to make changes in their planning structure to find the right “fit” for their jurisdiction and streamline the planning process. The most significant structural changes occurred in California, where fifty-six local groups were added to the existing  single-group structure. In addition, during the fifth year of planning, California’s statewide CPG was merged with the state’s HIV/AIDS care planning group. Notably, most CPGs have restructured some or all of their committees to improve their efficiency. 

Member Retention. As the initial momentum of the planning process abates, CPGs are experiencing member “burnout” and a loss of membership. As a result, CPGs and health departments are adopting various strategies that promote the retention of members.

Achievement of Parity, Inclusion, and Representation (PIR). Issues related to PIR are a persistent challenge as CPGs are continuously reconstituted. A key challenge is achieving a membership that not only represents the epidemic but also possesses the skills to participate in a process that is becoming more sophisticated and demanding as it matures. While CPGs strive to fill specific demographic and risk-related gaps in membership, they are faced with the need to ensure that new members possess specific skills needed in the planning process, especially in epidemiology, evaluation, and behavioral science. Generally, they have attempted to fill gaps in expertise by hiring consultants and providing training to CPG members. However, gaps in representation and member skills remain and must be continuously addressed, said interviewees. 

Issues Related to Required Planning Activities 

Refining Epidemiologic Profiles. In recent planning years, CPGs have been focusing on updating and embellishing their epidemiologic profiles. These efforts have been hampered by persistent gaps in data, including data on HIV cases, populations thought to be undercounted, sub-groups within ethnic groups, and emerging trends. Another factor affecting the use of epidemiologic data is the fact that some CPG members lack the knowledge and skills needed to understand and apply epidemiologic information. As a result, many CPGs are doing more to provide members with basic epidemiologic training and are devising innovative ways to present epidemiologic information in an easy-to-understand manner. 

Needs Assessment Activities. Since the third year of community planning, needs assessment activities have focused on building upon the already extensive body of data gathered by each jurisdiction. The full report on which this AIX is based describes a number of ethnographic and epidemiologic studies that have been undertaken by several jurisdictions to fill gaps in data. 

The Priority-Setting Process. Priority setting is becoming more systematic in many jurisdictions even as it is frequently regarded as the most time-consuming, tedious, and “political” aspect of the planning process. As it did during the first years of the initiative, the process continues to create discord in some CPGs, particularly where it has caused shifts in funding. Given the limited resources available for HIV prevention and the many competing demands on those resources, some of the tensions the process engenders are unavoidable. However, the experiences of the profiled jurisdictions suggest that priority setting proceeds more smoothly when the CPG agrees upon a methodology in advance, when members feel ownership of the process, when they 
understand and feel comfortable with the methodology and data employed, when they are given sufficient time to work through difficult issues, and when consensus is established each time a vote is taken. 

Issues Related to the Impact of Community Planning
The key effects of community planning on health departments and HIV prevention service providers in the profiled jurisdictions follow. 

Health Department Staff Roles and Responsibilities. Community planning has generally increased the workload of HIV prevention staff in grantee health departments and has transformed the focus of some existing positions. While some departments have sufficient resources to meet the demands of implementing the initiative, others-particularly those in rural areas and lower HIV/AIDS prevalence states-do not. It is unrealistic, asserted some interviewees, to expect health departments to respond to increasing requirements from CDC and to growing expectations from CPGs in the absence of additional resources to support these efforts. Finally, community planning has highlighted the need for skills that many health department staff do not currently possess, particularly expertise in HIV prevention program design and evaluation. 

Health Department Funding Allocation. In order to implement CPG recommendations, health departments have made important modifications in how they allocate HIV prevention funds. Foremost of these is the targeting of resources based on documented need. Another is the adoption of formal methods to disseminate resources geographically. This has resulted in the wider distribution of HIV prevention monies across jurisdictions and first-time funding for many rural health departments. Further, there is increased tailoring of funding to specific at-risk populations within geographic areas of jurisdictions. Moreover, health departments have expanded efforts to ensure their request-for-proposal (RFP) processes support CPG recommendations by enhancing the style and content of RFPs, providing increased technical assistance to applicants, and inviting CPG members to serve on RFP panels. 

Efforts to Ensure the Efficacy of HIV Prevention Interventions. CPGs and health departments are increasingly supporting the development of effective, science-based interventions and calling for more accountability on the part of agencies receiving health department HIV prevention funds. Some health departments are requiring RFP applicants to pay closer attention to the design of interventions and are establishing more stringent contract monitoring procedures. Importantly, several health departments have taken crucial first steps to ensuring the effectiveness of funded interventions by creating science-based systems to evaluate their performance and hiring full-time program evaluation staff. AIDS service providers expressed mixed responses to the more stringent RFP and contract monitoring requirements adopted by health departments. Some applauded the increased emphasis on quality assurance. Others feared the new requirements might discourage smaller providers, who have limited staff and resources, from applying for health department funding. 

Capacity-Building Efforts. The community planning process has illuminated the need to build organizational capacity among HIV prevention service providers to ensure that CPG recommendations are fully realized. Participants in the process are finding that, beyond issuing RFPs based on CPG recommendations, health departments must address deficiencies in the organizational capacity of service providers. Various examples of such efforts are discussed in the full report. 

Information Sharing, Networking, and Collaboration. Community planning has offered service providers and others interested in HIV prevention significant, and frequently unprecedented, opportunities to network, share information, and collaborate. The benefits are particularly evident in rural and semi-rural areas, where there are few HIV prevention resources and where available HIV prevention funding is still relatively limited. 

Increased HIV Prevention Knowledge. Another important impact of community planning is the education it has afforded CPG members, especially in planning, epidemiology, and behavioral science. Members have used their new knowledge to design or enhance HIV prevention programs and to keep current on the field of HIV prevention. They also report sharing their knowledge with colleagues outside the CPG, thereby broadening its reach and impact. 

Relations Between Participants in the Process. Following are some of the changes that have resulted in relations between participants in the community planning process:  

  •  Relations between state and local health departments. In jurisdictions with multiple planning groups, the requirements of administering the community planning process have frequently increased contact and collaboration between state and local health department staff and have generally improved their working relations.

  • Relations between health department staff and service providers. Interviewees across jurisdictions reported that, generally speaking, the experience of working together in the community planning process has improved relations between health department staff and service providers. Trust is a key factor in improving relations and is closely linked to the willingness of health departments to be open with community members about their activities and decision-making processes. In several jurisdictions, CPG members reported increased tensions with health department staff due to incidents in which staff did not share valuable information or appeared to be covertly manipulating the CPG agenda. CPG members stressed the need to work continuously to preserve the trust and open communication that has developed. 
  • Relations among service providers. Service providers across jurisdictions reported that, in many instances, existing ties with other providers were strengthened and new ties forged, eading to increased formal and informal collaborative ventures. However, in some cases enhanced relations have been threatened by the priority-setting process, which has exacerbated pre-existing tensions among providers. 

Perceptions about the Value of Community Planning. A majority of interviewees, including long- term “veterans” of the process, expressed their support for community planning and its potential for effecting changes in HIV prevention. Those who voiced concerns said the process is labor- and resource-intensive. Others were not pleased with funding shifts that had occurred as a result of the process. Nevertheless, even those critical of the initiative acknowledged it has become an important force in shaping the local and national dialogue concerning HIV prevention and has transformed approaches to HIV prevention and relations between participants in the process. 

Emerging Issues of Note

Political Context of Community Planning. The external political context in which community planning takes place is increasingly affecting implementation of CPG recommendations. In some of the profiled jurisdictions, local and state government scrutiny has resulted in delays in, or withdrawal of, funding for HIV prevention interventions selected through health department RFP processes. In other cases, funded programs have been modified due to their potentially controversial content. This illustrates the fine line that health departments and CPGs must walk when recommending and supporting HIV prevention measures that are potentially unacceptable to the general public, even when the measures are based on scientific evidence. 

Evolving Roles of CPG Members. The roles of CPG members have expanded to include involvement in activities beyond those outlined in the CDC community planning guidance. These include providing input on the content, language, and style of health department RFPs; serving on health department proposal review panels; assisting the health department in making funding allocation decisions; devising guidelines for HIV prevention interventions funded by the health department; and designing and implementing HIV prevention interventions based on CPG recommendations. Of these, participation in decisions regarding allocation of HIV prevention funds and service on health department proposal review panels are the most controversial roles because they are perceived as constituting a conflict of interest. The tension that many CPG members feel between “planning” and “doing” is likely to continue and will require CPGs and health departments to address the issue continuously. 

Combining Prevention and Care Planning. Efforts to coordinate planning for HIV prevention and Title I/II Ryan White CARE services have increased steadily since USCM began profiling the jurisdictions. In three jurisdictions a number of local CPGs and Title II consortia meet jointly or have combined. In addition, local care and prevention groups in several jurisdictions have shared planning resources and statewide care and prevention groups have conducted joint strategic planning or are considering doing so. Paralleling coordination at the local level have been recent steps toward joint planning at the jurisdiction level. In California, the statewide CPG and HIV Comprehensive Care Working Group recently voted to merge. In Chicago, a new HIV/AIDS strategic plan calls for the merger of the city’s CPG and HIV/AIDS Services Planning Council and for joint monitoring of HIV/AIDS care and prevention contracts. 

The Future Direction of Community Planning. As CPGs enter their fifth year of planning, members and health departments are increasingly asking: “We’ve planned. Now what?” There is a growing perception in many jurisdictions that something more than planning and making recommendations is needed to effect a long-term impact on the epidemic. Interviewees expressed a general desire to know whether community planning was “making a difference” in stemming HIV infections in their communities. CDC’s forthcoming guidance on evaluating the community planning process and HIV prevention programs addresses this issue.  

HIV Prevention Community Planning Profiles: Assessing the Process and the Evolving Effects
Aids Information Exchange Recommendations
Overview of USCM Research Sites
Member Retention Strategies
Management Team

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The United States Conference of Mayors

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