chapter outlines who and what issues are prioritized
for funding, whereas the Community Assessment chapter discusses the priorities for how to conduct
HIV prevention with different populations.
The ultimate priority of HIV prevention is to eliminate new HIV infections. In order to accomplish this,
HIV prevention must address the complex needs of people and communities. HIV prevention is
challenging because it is no longer just about education for example, handing out condoms and bleach
kits and showing people how to use them. It is about dealing with a much broader set of issues in order
to promote health and wellness among individuals and communities.
This chapter is the foundation for this expanded approach to HIV prevention. It identifies the highest
priority populations and the highest priority issues that must be addressed in order to do effective
prevention, and it directs the funding accordingly, from a planning perspective. It is supplemented by the
Community Assessment chapter, which describes the broader HIV prevention needs and issues of people
at risk for HIV. Together, these two chapters represent San Franciscos approach to HIV prevention.
How to Read This Chapter
Readers who are familiar with the history and structure of San Franciscos priority-setting model may
choose to focus on Section II, which outlines the priorities for 2004 and beyond. Readers needing more
context for the model are invited to read the whole chapter.
Cofactor
A condition that can increase risk for HIV, increase susceptibility to infection, or
decrease ability to receive and act upon HIV prevention messages.
Priority-setting
The process that community planning groups, such as the HPPC, use to deter-
mine recommendations for the distribution of available HIV prevention funds.
Subpopulation
A demographic group defined by race/ethnicity, age, gender, or other factor.
137
Introduction
Terms and Definitions San Franciscos first priority-setting model was developed in 1995. Although it has gone through several
iterations since then, the underlying philosophy has remained the same:The priorities for San Francisco
are designed to reflect the local epidemic and are based on local epidemiologic evidence, research, and
practice. Exhibit 1 presents the evolution of the model, along with a summary of its strengths and
weaknesses over time.
The priority-setting model for 2004 through 2008 attempts to build on the strengths of the 2001 model,
while simultaneously addressing its limitations.The new model is presented in Section III (pp. 146-152).
Introduction
Chapter 4: Priority-Setting
Section I: History of the Model
Reviews the evolution of the priority-setting model since its inception in 1995.
Section II: Priorities for 2004 Through 2008
Summarizes the priorities for 2004 through 2008 that result from the application of the priority-
setting model.
Section III: Background and Rationale
Outlines each step in the model, how and why it was developed, and how it was applied to establish the
final priorities for 2004 through 2008.
Appendix 1: 2001 and 2004 Behavioral Risk Populations
Appendix 2: Process for Determining Priority Subpopulations and Cofactors
138
Chapter Outline
SECTION I
History of The Model Introduction
Chapter 4: Priority-Setting
139
EXHIBIT 1
History of the HPPCs Priority-Setting Model
A populations level of risk
was determined based on:
(1) the odds of being exposed,
(2) physiological cofactors, and
(3) behavioral cofactors
Twelve behavioral risk popula-
tions (BRPs) were created and
then ranked by anticipated
number of new HIV infections
per year
The twelve BRPs from the 1997
model were collapsed into eight
BRPs, which were then ranked
by anticipated number of new
HIV infections per year
Subpopulations within each
BRP that had 8% or higher
seroprevalence were identified
and ensured funding
BRPs were grouped into three
tiers, and recommendations
regarding the percentage of
funding to be allocated to each
tier were made
The eight BRPs are ranked by
anticipated number of new
infections per year
Both subpopulations and
cofactors are identified and
prioritized for funding, based
on prevalence, incidence, and
behavioral data
BRPs are grouped into four
tiers, and recommendations
regarding the percentage of
funding to be allocated to each
tier are made
Accounted for both biological
and social influences on risk
Focused on behavior through
identification of populations
at risk
Established specific epidemio-
logic criteria for setting priorities
Provided an effective tool for
planning
Focused on behavior through
identification of populations
at risk
Included specific epidemiologic
criteria for setting priorities
Provided an effective tool for
planning
Identified high-risk subpopula-
tions to be ensured funding
Guided resource allocation in line
with current epidemiology
Used data and estimates that
were reported in BRP format*
Focuses on behavior through
identification of populations
at risk
Includes specific epidemiologic
criteria for setting priorities
Provides an effective tool
for planning
Identifies high-risk
subpopulations and cofactors
to be prioritized for funding
Guides resource allocation in
line with epidemiology
Uses data and estimates that
are reported in BRP format
Is accompanied by a commu-
nity assessment that talks
about the broader needs of
individuals and communities,
not limited to behavioral risk
No specific criteria for setting
funding priorities, so funding
prioritization was subjective
It was difficult to implement
priorities effectively because
existing data did not conform
to the BRP categories
Did not address important
high-risk subpopulations within
each BRP
The model could tend to put too
much emphasis on looking at
the world in terms of BRPs,
instead of promoting a holistic
approach to HIV prevention that
addresses what happens in the
real world
Is based on consensus estimates
developed three years ago,
although epidemiologists
believe that there has not been
a substantial change in new
infection rates since then
1995
1997
2001
2004
YEAR
COMPONENTS OF MODEL
LIMITATIONS
STRENGTHS
*At a 2001 convening of HIV researchers called the Consensus Meeting, communication and collaboration between the HPPC and researchers resulted in the generation of information
that could be directly incorporated into the planning process. Introduction
Chapter 4: Priority-Setting
Overview of Priorities
Exhibits 2 and 3 present the priorities for 2004 through 2008, based on the new priority-setting model
approved by the HPPC in 2003. (The model is explained in greater detail in Section IV.)
The priorities in Exhibits 2 and 3 are organized in the following manner:
Behavioral Risk Populations (BRPs).
BRPs are categories that define people by their risk
behavior, not their demographics.The highest risk BRPs are the highest priorities. BRPs are listed from
highest to lowest priority (Exhibit 2).
Subpopulations and Cofactors.
Within each BRP, the highest risk groups and issues are
prioritized. Unlike BRPs, these groups are defined by demographics (subpopulations) or factors that
increase risk for HIV (cofactors) (Exhibit 2).
Resource Allocation Tiers and Guidelines.
The BRPs are grouped into tiers, and a
recommended proportion of funds is given for each tier (Exhibit 2).The higher the level of risk in the
tier, the higher the recommended level of funding.
Other Considerations.
Additional considerations to guide the selection of proposals and allocation
of resources are offered (Exhibit 3).When the HIV Prevention Section issues a request for proposals
(RFP) for HIV prevention programs, these considerations should be taken into account when deciding
which programs to fund.
Interpretation of Priorities
Several points are important to remember when interpreting Exhibits 2 and 3:

The HPPC reviewed a wealth of data to prioritize subpopulations and cofactors, looking at both
unpublished and published studies, needs assessments, anonymous and confidential counseling and
testing data, and many other data sources.The subpopulations and cofactors listed represent an objective
review of as much data as was available.

As the epidemic evolves over 2004 to 2008, the HPPC will adjust the priorities accordingly and issue
updates to the community.

The demographic subpopulations and cofactors listed in Exhibit 2 are the highest priorities for
receiving funding.These are not the only priorities for HIV prevention in San Francisco. Proposals that
address subpopulations or cofactors not on this list will still be considered for funding. (See Chapter 3:
Community Assessment, pp. 45-136, for a full description of San Franciscos high-risk populations,
the important cofactors, and the HPPCs priorities for how HIV prevention should be implemented
with these populations.) For example, sex work is not a prioritized cofactor under BRP 2 due to lack
of data to conclusively demonstrate that MTF transgendered sex workers are at higher risk than non-
sex workers. However, the Community Assessment chapter recommends that risks related to sex work
get addressed in prevention programs for MTF persons.
140
SECTION II
Priorities for 2004 Through 2008 Introduction
Chapter 4: Priority-Setting

Although the HPPC reviewed numerous sources of data, it is impossible to get access to all available
data.Therefore, providers are invited to make a case in their applications for subpopulations or cofactors
that meet the criteria outlined in Step 2 of the model (see pp. 148-149) but are not listed here. In
addition, the HPPC will review new data and studies annually and/or priori