Why the U.S. Has Not Stemmed HIV

An international AIDS conference in Toronto this week will focus on global progress against HIV and, perhaps, the lack of progress in the United States.
An international AIDS conference in Toronto this week will focus on global progress against HIV and, perhaps, the lack of progress in the United States. (By Nathan Denette -- Associated Press)
By David Brown
Washington Post Staff Writer
Sunday, August 13, 2006

The number of people in poor countries taking AIDS drugs -- about 1.4 million -- rises by tens of thousands every week. The spread of AIDS in Africa seems to have peaked. Three countries there -- Uganda, Kenya and Zimbabwe -- report declining HIV prevalence, largely thanks to changes in people's behavior. Even in India, considered AIDS's ticking time bomb, efforts to defuse the epidemic are paying off in some places.

Amid these optimistic trends from around the world, however, is another statistic that is stuck in time, right here at home.

The number of new HIV infections in the United States has been about 40,000 a year for the past decade and a half. It has not budged -- not with new drugs, new prevention strategies or new administrations. Five years ago, the Centers for Disease Control and Prevention launched an effort to cut it in half. It did not move.

The intransigence of the AIDS epidemic in the place where it emerged -- and where many of the strategies against it have been developed -- will be on the minds of many this week as 20,000 people gather in Toronto for the 16th International AIDS Conference.

There is little question that, for public health experts and AIDS activists, the fact that the HIV infection rate has not changed since 1990 is an embarrassment. At the same time, it is a testament to a victory -- albeit one that happened long ago.

AIDS was first recognized in June 1981. Incidence of the disease -- the number of new cases in a period, generally a year -- peaked at 160,000 in the mid-1980s. With intensive effort to reduce risky behavior in gay men and, to a lesser extent in injecting drug users, it fell to 40,000 by 1990. It has remained there since.

"It's very much a glass-half-empty-glass-half-full situation," said David R. Holtgrave, a professor at the Bloomberg School of Public Health at Johns Hopkins University. "Prevention seems to work. But it seems like we have a lot of work left to do."

In the eyes of Chris Collins, who wrote a new report on U.S. AIDS policy for the Open Society Institute, "America is in many ways failing its own citizens in its domestic response to the epidemic." Government inaction has produced "needless mortality," he wrote.

But Grant Colfax, a physician at the San Francisco Department of Public Health, said last week that "as someone who tries to figure out new ways to reduce the number of infections, I don't sit here and blame the CDC for this rate remaining at an unacceptable level for 15 years."

What does bother him, though, is the lack of money for prevention. "As a society, there is just not enough commitment to addressing this," he said.

The number of new HIV cases each year has not changed despite a dramatic increase in HIV prevalence, the number of Americans infected at a given time. That number stands at 1.1 million and is growing as people on combination antiretroviral therapy live far longer than AIDS patients used to. Deaths from AIDS in the United States dropped from 52,000 in 1995 to 15,800 in 2004.

Normally, a rising number of infected people would lead to a rising number of new infections each year, as more people are able to transmit the virus. But that is not happening. One of the main reasons is that HIV-positive people today are more likely to know they are infected -- and to know to take precautions -- than was the case in the past.

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