AIDS in the District Is Serious, But Not Critical

By Craig Timberg
Sunday, March 22, 2009

District health officials brought new attention to AIDS in our city last week. But many key trends shown in the report got lost amid the alarm. Although the epidemic is serious -- and more extensive than most suspected -- the report also suggests that the situation is in some ways improving, and has been for years.

New cases of full-blown AIDS are down. AIDS deaths are down. The headline-grabbing fact that the District's HIV rate rose to 3 percent, though troubling, is largely a product of antiretroviral drugs that allow patients to live longer and better lives. Little in the data suggests, as many commentators have last week, that we are experiencing a burgeoning, African-style epidemic.

I spent the last seven years reporting in Washington and Africa for The Post. In many places I visited in Africa, morgues overflowed with shrunken bodies. People flipping through old snapshots came across face after face of dead friends. One Kenyan man I interviewed had lost almost his entire extended family to AIDS. In Washington, there has been nothing like that scale of devastation since antiretroviral drugs arrived.

"If they're talking about an epidemic that's out of control, or that things are getting worse, that's just not in the data," said epidemiologist Rand L. Stoneburner, a former New York City health official who has worked extensively in Africa for the World Health Organization and the Global Fund to Fight AIDS, Tuberculosis and Malaria. "You go into Nairobi, and you get a much higher prevalence."

That's not to minimize what is happening in Washington. The city has concentrations of high-risk groups: men who have sex with men, injecting drug users and people who have spent time in prison, where anal sex and drugs are major transmitters of HIV. The report also suggests some heterosexual transmission, mainly among African Americans and Latinos.

The D.C. Health Department's top AIDS official, Shannon L. Hader, deserves praise for the groundbreaking research. But Hader's comments that AIDS here is "on par with Uganda and some parts of Kenya" muddied the picture.

"I wouldn't carry the comparison to developing countries too far," said Jim Curran, dean of Emory University's Rollins School of Public Health and a former top AIDS official at the Centers for Disease Control and Prevention.

Some African nations do have HIV rates of 3 percent, but the variation on the continent ranges from 26 percent in Swaziland to nearly zero in North Africa. In Uganda, which Hader compared with the District, it's 6 percent, according to a study in the Journal of the American Medical Association last year. In Uganda's urban areas -- a far better comparison with Washington -- it's 10 percent.

There are even bigger differences in the pace of new infections. If Washingtonians were getting HIV as quickly as urban Ugandans, the capital would have more than 10,000 new infections a year. The D.C. report doesn't give a comparable calculation, but such a rate seems unlikely. The federal Centers for Disease Control and Prevention estimate that there were 56,300 infections last year in the entire nation. The number of new cases of full-blown AIDS in Washington, meanwhile, has been falling since 1993 (aside from a statistical blip in 2002 caused by a tracking system change). It reached 648 last year. AIDS deaths are down since 1994.

What's clearly rising here is the number of people surviving with AIDS because of medicine not easily available in most African countries. Another striking difference between the situation here and the one in Africa is that more than three-quarters of Washingtonians with AIDS are in their 40s or older, making clear that more and more people here are living with the disease rather than dying from it.

When I asked Hader whether she had any evidence of a rising infection rate in Washington, she agreed that there was none but left open the possibility that improved HIV surveillance may yet turn up some. "We know there's a lot of ongoing transmission that's preventable," Hader said. That's true. All HIV transmission is preventable. But successful programs are built on careful science and precise portrayals of what's happening.

I worry about the hyperbole surrounding Washington's AIDS problem, because the response in Africa was long hindered by inaccurate data flowing out of the United Nations along with unreliable characterizations of the epidemic's path.

The result was poor decisions. President Bush's big anti-AIDS program, for example, poured much of its resources into some relatively modest epidemics, such as Rwanda's, while Swaziland, with an infection rate that's eight times worse, got much less.

So what's happening in Washington? And what should we do?

The city has a severe, mature AIDS epidemic that is causing much less death and sickness than during its peak 15 years ago. Antiretroviral treatment is now widely available. Improving medical services will continue to better the lives of people with the disease. Expanded HIV testing efforts will help get people into treatment earlier.

To take another step toward eliminating new HIV infections, a main target must be drug users, who make up about one in four new cases in Washington. Routine availability of clean needles would help, and should be possible now that the federal ban on needles programs here has been lifted.

To slow sexual transmission, which accounts for at least 60 percent of the spread in the city, one comparison with Africa might prove useful. Research shows that HIV moves quickly in some regions of the continent because of the widespread sexual networks created when people have intercourse with more than one partner in the same month or year. The same is true for sexual transmission anywhere, whether it's men with men or men with women.

Hader's proposed solutions, mainly condom promotion and HIV testing, are not enough. The African countries that have seen steep drops in new cases of HIV, such as Uganda and Zimbabwe, first had large drops in casual sex and long-term, concurrent sexual relationships with multiple people.

Any effort to finish off a declining epidemic would make sexual behavior priority No. 1. School sex-education programs in the United States have traditionally emphasized either condoms or abstinence to prevent HIV, but they have shied away from discussing the risks of several concurrent sexual relationships.

Programs focusing on those issues are "as important [as], and possibly more important" than condom promotion, said Doug Kirby, a researcher who has studied the relationship between AIDS and sexual behavior in the United States and in Uganda.

Several African countries are making that shift, with ads that directly target sexual behavior. The subject is even more sensitive there -- polygamy is an ongoing practice in some places -- than it is here. Most countries in the AIDS epicenter of southern Africa have begun or are planning campaigns on the issue.

We'll know that a similar seriousness has arrived in Washington when the rhetoric cools and the billboards that I've seen in Botswana and Swaziland start appearing here, too.

Craig Timberg covered D.C. politics and Africa for the Post. He is writing a book, "Dr. Livingstone's Children: Why We Are Losing the War on AIDS, and How to Win." He'll be online Monday at 11 a.m. to take reader questions. Submit your questions before and during the discussion here.

© 2009 The Washington Post Company