Almost 640,000 Americans have died after being diagnosed with AIDS. Remarkable treatment advances have reduced the death toll. Yet 20,000 Americans living with HIV still die every year, an annual toll that exceeds the rate of U.S. combat deaths in Vietnam. Many of these deaths could be prevented or delayed if people living with HIV were identified and treated earlier, and had more treatment and care.
But the HIV prevention effort has yet to match the scale of this problem. The annual number of new HIV infections has remained basically unchanged since the early 1990s, with roughly 50,000 Americans newly infected every year.
These stable numbers are more troubling than they first appear. Men who have sex with men (MSM) have accounted for a rising proportion of new infections over the past two decades, and now account for almost two-thirds of new infections. You might presume that this trend reflects successful prevention among injection drug users and other populations at risk. I fear the truth is simpler: HIV has burned through these populations. MSM is the only high-risk group that demographically replenishes itself, with large numbers of individuals at risk for infection every year.
How can we put these numbers in perspective? In 2010, an estimated 29,800 MSM were newly infected with HIV. No one knows the precise number of American men who have sex with other men. An estimated 6.9 percent of American men indicate that they have ever had sexual contacts with other men. Given 2 million male births annually, back-of-the-envelope calculations indicate that roughly 138,000 male infants are born every year who will have some sort of same-sex experience in their adult lives. On our present course, more than 20 percent of these men will be infected with HIV. An estimated 2.9 percent of men indicate some same-sex contact within the past year. Lifetime prevalence in this group would obviously be higher.
Leaving aside the moral, ideological, and budgetary obstacles that beset public health policy, HIV prevention would still be a difficult challenge. The virus is commonly spread through intimate and stigmatized behaviors among young adults who are not particularly in sync with information on how to reduce their risk for infection. Fear is also a powerful motivator. Legions of gay men born before 1970 watched scores of friends die horribly from AIDS. Those born after 1980 had a different experience.
Injection drug users welcome clean, sharp syringes, but many people are notably less enthusiastic regarding condom use. Fully 54 percent of MSM surveyed by the National HIV Behavioral Surveillance System reported that they had had unprotected anal intercourse with a male partner in the past year. One might assume that risk-taking is confined to the young. That’s not entirely so. Jacobs and colleagues examined sexual behaviors in a group of HIV-negative MSM over the age of 40. Twenty-two percent reported that they had put themselves at risk for HIV infection within the previous six months.
An estimated 208,000 Americans carry the HIV virus but don’t know it. These men and women form an epicenter of all new HIV infections. The majority of infected young gay men don’t know their status. Rates of undetected infection are especially high among African American and Latino gay and bisexual youth.
President Obama’s 2010 National HIV/AIDS strategy seeks to address these challenges. The plan includes ambitious goals, most notably a 25 percent reduction in the number of new HIV infections by 2015. The strategy emphasizes prevention services for those already infected. Under the “seek, test, and treat” approach, medical and public health authorities are doing much more ambitious population screening: finding infected people and helping them get and keep getting proper care. This approach builds on 2006 CDC guidelines, which encourage broad screening within routine medical care, even for people with no apparent HIV risks.
This is a promising approach. Early detection and treatment promotes improved health and quality of life. Individuals who discover that they are HIV+ cut their rates of unprotected sex by more than half. People in treatment reduce their viral load, which further lowers HIV transmission risks. Having a concentrated population of identified HIV+ people already under medical treatment offers many possibilities for cost-effective preventive care.
This approach brings challenges, too. New groups of providers such as dentists and emergency room staff must be enlisted to identify infected patients who may have no obvious risk factors or who do not otherwise access the health care system. Successful screening in new settings requires a real cultural shift among patients and providers.
Effective prevention costs money. David Holtgrave, a professor of health policy at Johns Hopkins who researches AIDS prevention, estimated that the national HIV/AIDS strategy required about $15 billion between 2010 and 2015 in dedicated expenditures. Certainly nothing close to that was made available by the federal government. Meanwhile, state and local public health agencies have lost tens of thousands of positions since 2008. There are fewer boots on the ground to perform HIV testing, to trace sex partners of infected people, to provide counseling on how to avoid risks.
It’s hard to directly assess the epidemiological impact of such budget cuts. One useful, necessarily speculative study appeared this year. Feng Lin and colleagues at the Centers for Disease Control and Prevention explored the consequences of the 70 percent, $16 million decline in funding forn HIV prevention over much of California. The authors estimated that funding cuts prevented public health authorities from identifying 348 HIV-infected people and that 8,000 fewer clients were provided prevention services. An estimated 55 people contracted HIV who would otherwise have remained uninfected. Yes, the lifetime treatment for those who could have avoided infection might well exceed the original $16 million in funding. That’s hardly the most foolish aspect of such policies.
HIV is by no means the most neglected public health concern. It’s just one area in which the human consequences of under-funding and neglecting policy are obvious and acute. Our medical economy expends $2.8 trillion on so many activities of dubious utility or cost-effectiveness. Yet it’s inordinately difficult to find 0.1 percent of this amount to support basic public health work.
Harold Pollack is Helen Ross professor at the School of Social Service Administration. He is also co-director of the University of Chicago Crime Lab and an executive committee member of the Center for Health Administration Studies (CHAS) at the University of Chicago. He has published widely on the connections between poverty policy and public health.