By Jose Antonio Vargas and Darryl Fears
Washington Post Staff Writers
Sunday, March 15, 2009; A01
At least 3 percent of District residents have HIV or AIDS, a total that far surpasses the 1 percent threshold that constitutes a "generalized and severe" epidemic, according to a report scheduled to be released by health officials tomorrow.
That translates into 2,984 residents per every 100,000 over the age of 12 -- or 15,120 -- according to the 2008 epidemiology report by the District's HIV/AIDS office.
"Our rates are higher than West Africa," said Shannon L. Hader, director of the District's HIV/AIDS Administration, who once led the Federal Centers for Disease Control and Prevention's work in Zimbabwe. "They're on par with Uganda and some parts of Kenya."
"We have every mode of transmission" -- men having sex with men, heterosexual and injected drug use -- "going up, all on the rise, and we have to deal with them," Hader said.
In addition to the epidemiology report, the city is also releasing a study on heterosexual behavior tomorrow. That report, funded by the CDC, was conducted by the George Washington University School of Health and Health Services.
Among its findings: Almost half of those who had connections to the parts of the city with the highest AIDS prevalence and poverty rates said they had overlapping sexual partners within the past 12 months, three in five said they were aware of their own HIV status, and three in 10 said they had used a condom the last time they had sex.
Together, the reports offer a sobering assessment in a city that for years has stumbled in combating HIV and AIDS and is just beginning to regain its footing. A more accurate accounting of the crisis offers a chance to contain what is largely a preventable disease.
So urgent is the concern that the HIV/AIDS Administration took the relatively rare step of couching the city's infections in a percentage, harkening to 1992, when San Francisco, around the height of its epidemic, announced that 4 percent of its population was HIV positive. But the report also cautions that "we know that the true number of residents currently infected and living with HIV is certainly higher."
The District's report found a 22 percent increase in HIV and AIDS cases from the 12,428 reported at the end of 2006, touching every race and sex across population and neighborhoods, with an epidemic level in all but one of the eight wards. Black men, with an infection rate of nearly 7 percent, carry the weight of the disease, according to the report, which also underscores that the District's HIV and AIDS population is aging. Almost 1 in 10 residents between the ages of 40 and 49 has the virus.
The report notes that "this growing population will have significant implications on the District's health care system" as residents face chronic medical problems associated with aging and fighting a disease that compromises the immune system.
Men having sex with men has remained the disease's leading mode of transmission. Heterosexual transmission and injection drug use closely follow, the report says. Three percent of black women carry the virus, partly a result of the increase in heterosexual transmissions.
"This is very, very depressing news, especially considering HIV's profound impact on minority communities," said Anthony Fauci, director of the National Institutes of Health's program on infectious diseases. "And remember: The city's numbers are just based on people who've gotten tested."
Ron Simmons, who is black, gay and HIV positive, said he's not shocked by the study's findings. "You have a high incidence of HIV among African Americans, and a lot of African Americans live in the city," said Simmons, who is a member of a black gay support group. "D.C. also has a high number of gay men, and HIV is high among gay black men."
Charlene Cotton, a D.C. resident who got an HIV positive diagnosis five years ago, said breaking the taboo on discussing HIV is the key to moving forward. "You need to start at home and talk about it," Cotton said. "It's so hush-hush."
Mayor Adrian M. Fenty (D) said he is aware that some advocates have called on elected officials and others to more aggressively and publicly address the crisis. He praised the city's recent efforts, however, and expressed his frustration about the struggle ahead.
"In order to solve an issue as complex as HIV and AIDS, you have to step up," he said. "It's the mayor and certainly other elected officials. But it's also the community. You have this problem affecting us, and you tell people how serious it is and it literally goes in one ear and out the other."
David Catania (I-At Large), chairman of the D.C. Council's health committee, said that although the District's testing and monitoring have improved in the past two years, the AIDS office is still playing catch-up. The city was in the forefront of the crisis when it created the office in 1986, but it fell far behind. Hader took control in 2007. She is its 12th director and the third in five years.
"Frankly, there can be no excuse for the state of the HIV/AIDS Administration that I found in 2005," Catania said. "I cannot speak to why it was not a priority previously. For years prior to 2005, mayors and previous individuals allowed things to exist in an unacceptable way. And I do blame this government for part of the epidemic we're confronting."
Until recently, the District's AIDS office lacked a fully staffed surveillance unit to collect, analyze and distribute data. Inevitably, the office lost credibility, and although it has received millions in federal and local funds -- $95 million this year -- some care providers questioned whether resources were being properly allocated.
Critics also say congressional control over the District had restricted the AIDS office's ability to combat the virus among drug injection users by banning the use of local tax dollars for a needle exchange program. After almost a decade, the ban was lifted last year.
The study is the most precise count to date, according to the authors. The document is an update of a breakthrough 2007 report, which brought into clearer focus a picture of a city in the grip of a complex and "modern epidemic" that had traveled from a mostly gay population to the general one and disproportionately hit blacks.
For years, District HIV/AIDS workers depended on estimates that put the rate at 1 of 20 living with HIV and 1 of 50 living with AIDS.
The current study notes that its tracking occurred as the city made a switch from a code-based counting system to a name-based one. The surveillance unit interviewed medical providers to find unreported cases, pressed providers who did not consistently report to the administration and searched databases for unreported cases.
More than 4 percent of blacks in the city are known to have HIV, along with almost 2 percent of Latinos and 1.4 percent of whites. More than three-quarters -- 76 percent -- of the HIV infected are black, 70 percent are men and 70 percent are age 40 and older.
Heterosexual sex was the principal mode of transmission for blacks with the disease, 33 percent. Men having sex with men was the chief mode of transmission for white residents, 78 percent; and Latinos, 49 percent. Black women represent more than a quarter of HIV cases in the District, and most, about 58 percent, were infected through heterosexual sex. About a quarter of black women were infected through drug use.
The companion study, "Heterosexual Relationships and HIV in Washington, D.C.," is a detailed look at those whose social networks include individuals at high risk of infection and aims to analyze people's choices and actions before they set foot in a clinic or get HIV.
The 750-participant study targeted four areas in wards 1, 2, 5, 6, 7 and 8 with both high rates of AIDS and poverty. Salaries of a majority of participants -- 60 percent -- were under $10,000 yearly; a similar percentage had never been married; and 43 percent were unemployed.
The survey's methodology -- interviewing those with connections to high-risk networks rather than those who exhibit high-risk behavior themselves -- highlights a shift in the direction by the CDC, which developed the survey protocol.
There is good news in the AIDS office's report: More people are getting HIV diagnoses early, while they are still healthy, as a result of a policy of routine testing implemented by the city in mid-2006. Publicly supported HIV testing expanded by 70 percent.
Walter Smith, executive director of the DC Appleseed Center for Law and Justice, praised the study but also lamented that it did not offer more current data on new infections. The report said that detailed information on new HIV cases is not included because the transition from the code-based tracking system to a name-based one takes five years to be mature, according to the CDC.
"I'm not criticizing them for that," he said. "But we've had more testing, more needle exchange programs. We don't have, at this moment, any understanding about what impact the new programs have had."
Staff writers Jon Cohen and Jennifer Agiesta contributed to this report.