Why the U.S. Has Not Stemmed HIV
Activists Blame Infection Rate, Unchanged Since 1990, on Policies and Funding

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.

Consequently, a stable rate of 40,000 new cases a year is a "very, very significant finding," Ronald O. Valdiserri, deputy director of the CDC's HIV and AIDS activities, said last week. "We think it represents some level of success in HIV prevention. We will not deny that we have a ways to go."

What would it take to lower the infection rate?

Holtgrave, who worked at the CDC and at Emory University before moving to Johns Hopkins, tried to answer that in 2002 and recently updated his calculations.

He estimates that the number of new infections could be cut in half if the 5 million Americans at highest risk of HIV -- 4 million because of sexual activity and 1 million because of drug use -- received the full battery of proven interventions. Those include HIV counseling and testing, free condoms, one-on-one or small-group counseling sessions, and needle exchange.

The CDC now spends $720 million a year on HIV prevention. It would need to spend $415 million more to reduce new cases by 50 percent, according to Holtgrave's calculations.

He and his collaborators further estimated that the country would need to prevent 12,000 infections each year to save money in the long run. HIV infection is expensive to treat, and newly infected people will need to be treated for decades -- a huge cost to the health-care system.

There is a lot of evidence that there is much more prevention to be done.

The CDC last month published a survey of 10,000 men who have sex with men -- the term preferred by epidemiologists, as some such men do not consider themselves gay or bisexual. They were questioned at bars, dance clubs, gyms, raves, beaches and on the street in 17 cities between 2003 and 2005.

The survey found that 77 percent had been tested for HIV in the previous year. Testing is a crucial prevention tool. Studies have shown that each year, 11 percent of people who do not know they are infected transmit the virus to someone else, compared with 2 percent of those who do know. Overall, it is estimated, about one-quarter of infected Americans do not know their status.

Forty-seven percent of those interviewed said that in the past year they had engaged in unprotected anal sex -- the riskiest activity. Ninety-eight percent had gotten free condoms. But only 15 percent had had one-on-one risk counseling, and only 8 percent had had peer-group sessions -- two interventions found to change behavior.

The population most vulnerable is young black men who have sex with men. In a study of five cities -- Baltimore, Los Angeles, Miami, New York and San Francisco -- published last year, CDC researchers found that 46 percent of people in that category were infected. Two-thirds of them did not know it.

Many of those men are difficult to reach for testing and risk counseling, and some organizations that work with that population have found it increasingly difficult to get government money for their efforts.

"I think it's fair and certainly honest to say that over the past several years we've gotten more stringent with our funding," Valdiserri, of the CDC, said last week.

Men of Color Motivational Group was a 14-year-old organization of gay black men in Detroit with two missions: outreach to teenagers and outreach to adults. It had a $1.2 million budget, with $650,000 provided by the CDC.

Last year, it lost that funding and closed.

"Over the years, there were ups and downs," said Mark J. McLaurin, a New York AIDS activist who sat on the group's board. "But I don't think there was any question that dealt the deathblow."

The strategy for reducing new infections many experts consider most overlooked is needle exchange for drug addicts.

The CDC estimates that 17 percent of new infections each year come from contaminated needles. Evidence suggests that 65 percent of those could be prevented if every addict had access to a clean needle. However, federal law prohibits using federal money for that purpose.

Nevertheless, there are 150 needle-exchange programs around the country, including one in the District, supported by local budgets and contributions. They have had dramatic effects.

In Baltimore, 60 percent of new infections came from drug use in 1994, the year before the city offered needle exchange. In 2003, 41 percent of new infections came from needle use -- and over that period the total number of new infections, from all causes, declined.

Exchanging 2.2 million needles a year, Seattle is not just protecting addicts. Most heterosexual transmission occurs between male drug users and their female partners. In Seattle, very few women are becoming infected that way, which in turn means that few pregnant women are HIV-positive. That is part of the reason the city hasn't had a baby born with the virus since 1997, said Robert W. Wood, the physician who heads HIV-control efforts in the Seattle health department.

"Is prevention effective? We've spent a lot of money and a lot of effort toward IV drug users, and I hope that's not for naught," he said.

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