HIV/AIDS in Washington, D.C.

The District's rate of HIV/AIDS is probably the worst of any major U.S. city, yet the city's response to the epidemic remains badly understaffed, poorly coordinated and especially lacking for youths and other at-risk groups, a report set for release today concludes, Washington Post staff writer Susan Levine reports in Wednesday's Washington Post.

Read the full story: D.C. Criticized for Not Treating AIDS as a Citywide Health Crisis (Post, August 10)

Dr. Philippe Chiliade, medical director for Whitman-Walker Clinic, was online Wednesday, Aug. 10, at 1 p.m. ET to discuss HIV/AIDS in Washington, D.C.

Chiliade, a native of Belgium, was the Attending Physician at University Health System in San Antonio, Texas. He was also the Director of the HIV Program and Attending Physician for the South Texas Veterans Health Care System. Chiliade is board certified in both infectious diseases and internal medicine.

Prior to his work in San Antonio, Chiliade completed a Fellowship in Infectious Diseases and Immunology at the New York University Medical Center. While he served as the Attending Physician at St. Claire's Hospital and Health Center at the Spellman Center for HIV-Related Diseases (1990-1994), he was also the Director of AIDS Clinical Research at the AIDS Clinical Trials Unit of Memorial Sloan Kettering Cancer Center.

The transcript follows.

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Dr. Philippe Chiliade: Good afternoon ,

A lot of great question and many concerns that I share.

I will do my best to answer them in some logical order.

Philippe

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Washington, D.C.: Do you have any good statistics on what the estimated HIV/AIDS infection rate in the D.C. area is and what percent of people are aware of their status?

Dr. Philippe Chiliade: As you probably read in the DC Appleseed report we are lacking reliable data mostly on number of people with HIV infections. We have good data on AIDS cases.

The rate of AIDS case in the District is around 10 time the US rate. Rate per 100,000 citizens US 15 and DC 170.

More male with AIDS than female: male US 36 DC 300 female US 12 and DC 109

The problem is that it take on average 10 years (if not receiving treatment) to develop AIDS. We need to know who are the populations that now are infected and who are most at risk for acquiring HIV.

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Washington, D.C.: Dr. Chiliade,

At this time African Americans are being disproportionately affected by this devastating disease.

What methodologies would you put in place to promote prevention, testing, and treatment in the African American community of D.C.?

Dr. Philippe Chiliade: Clearly African Americans are disproportionately infected. The reason is probably multifactorial. Economic issues, poverty, education, rate of drug use, rate of incarceration, too often strong negative vue (social and religious) toward gay AA community members that leads to isolation, but it could also be possible that to the same level of risk taking / exposure to HIV that AA could be more easily infected than white (I know that this is very controversial at this point).

For States where we have reliable data on HIV infection the CDC has estimate that 47% of people now living with HIV in the US are AA, 34% white, and 17% Hispanic.

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Washington, D.C.: Three questions:

1. Is the rate of new infections for gay men increasing, decreasing, or staying the same? Does the answer change by age range?

2. How bad do you think the problem of young gay men not being diligent about protecting themselves (and not thinking of HIV as a big deal) really is?

3. Roughly what percentage of newly infected gay men were using crystal meth at the time they were infected?

Thanks!

Dr. Philippe Chiliade: Based on recently published data from the CDC, 63% of new HIV infections in 2003 were in the gay/bisexual men community. The number of women (mostly AA women) infected heterosexually increase rapidly but is in not in the proportion seen in gay men.

In gay men one of the group at the highest risk is AA youngs.

Why still so many infections in gay men? This is difficult to answer. In my mind a lot of gay men are aware that unprotected anal sex is very risk. However, clearly they more and more frequently take risk. Is it safe sex fatigue, the tendency to behave as the rest of your community and follow the group in the path of taking more risk, club drug use + alcohol + Viagra or the like, new young population of gay men who did not leave through the devastation of the early 1980s, the knowledge that we have medications that have transformed HIV in a less lethal chronic disease? It is probably for each of these gay men a combination of some of these reasons.

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Washington, D.C.: Hello! Could you please comment on the gender dimensions of HIV/AIDS in the District. My understanding is that young heterosexual minority women are particularly vulnerable. Why do they have greater vulnerability than their male counterparts? Thank you!

Dr. Philippe Chiliade: We know that world-wide there are nearly as many men as women infected by HIV (even a little more women). This is probably because in the developing world the disease is mostly transmitted heterosexually. In the US (and Europe, Australia, Canada) only a quarter of people infected are women and again the majority of these women are infected through heterosexual contact. Probably that a good number of these women have only one or few sexual partners and they do not see themselves at risk. Nobody knows for sure what her/his sexual partner is doing outside. If that partner has a lot of unprotected sex with various people including other men than there is good risk of bringing that infection back to the regular partner. It is unclear at this point how much the "downlow" problem (men in heterosexual relationship who have secret unprotected anal sex with other men) is fueling the epidemy in women. The "downlow" issue has been widely publicized in AA but clearly this affect also other racial / ethnic groups.

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Washington, D.C.: When will people wake up and start taking responsibility for their own health? Isn't it common sense to use protection nowadays? My parents were not fans of birth control, but sheesh, I sure had enough common sense to use protection AND birth control when I had sex. Please don't misunderstand me to be saying the people with AIDS deserve it, etc., and I certainly hope we find a cure, but I'm tired of people passing the buck here. Same with smoking and cancer.

Dr. Philippe Chiliade: I am a gay men but clearly I understand your frustration. It seems to be a simple equation but trust me knowing what is risky and behaving according to this knowledge are two different things. Behavior modification is very difficult to accomplish and people need coaching as well as support from their own community as well from the whole community.

One of the reasons why I see that we are going to have difficulty to prevent new infections is that close to 50% of these new infections are transmitted by people who themselves just became infected and of course are not aware that they are infected. The worst is that during that period of recent infection (most people are the most infectious to others) the regular HIV test is often negative. It takes a few weeks to a few months after infection for the HIV test to turn positive.

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Takoma Park, Md.: Dr Chiliade,

Thanks for taking questions. Talk about the "battle fatigue" with the gay community fighting this battle for over 20 years - is the HIV infection rate climbing within the gay populace?

Dr. Philippe Chiliade: Again, from recent data published by the CDC I think that the rate and the number of new HIV infections in gay men is increasing. There are terrible report (also from the CDC) that in some large cities like Baltimore now 40% of men who have sex with men are HIV positive and that the majority of them were not aware of their infection. Again in Baltimore gay men affected were disproportionately young and African American.

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Leesburg, Va.: Does the lack of access to health care due to decline of public health infrastructure, such as the closing of D.C. General and the underfunding of community health clinics, contribute to the non-treatment of the HIV/AIDS epidemic in D.C.?

Dr. Philippe Chiliade: Yes we need more funding if we want to adequately respond to the HIV epidemy both at home and abroad. Society has to decide how much of its resource it is will to put into health care (my feeling it should be a lot more) but we need to keep in mind that this could be at the detriment of other important programs such as education. Clearly there are things where we should not spent so much of our limited resources....

As for DC General closure, I agree that this had a negative effect initially. Some people drop out of care and are still not receiving care. If the District could fix the DC Alliance vitual insurance system that will be already a big help. The biggest problems are: 1) to test people who are HIV infected but are not aware of it and 2) to find a way to bring people who know they are HIV + into care. This influx of "new patients" into care will require more resources.

At the same time health care providers, like Whitman-Walker Clinic, have to become more and more efficient with the dollars that we receive and find new way of providing services. I think we could provide more efficient care (cheaper care) without automatically decreasing the quality of our care.

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Washington, D.C.: Do you think that the administration at HAA is up to the task required to address the problem of rising HIV infection in the District given the public statements that MS. Watts has said about her lack of belief in needle exchange programs as HIV interventions, and her leanings toward Faith based initiatives?

Dr. Philippe Chiliade: I never discuss with Mrs Watts about her view on these issues. But it is clear that needle exchange save life and is cost-efficient. I doubt that HAA or the DC DOH would not support needle exchange if Congress would allow it. As for faith-based organizations and churches in particular, they first need to be more willing to accept people the way they are (or were made). I think they could become one of the best partner in recommending people to be tested and if diagnosed positive to enter into care. I do not think that negative assertions about sex in general and about gay sex in particular is in anyway helpfull.

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Washington, D.C.: Could you name three concrete steps that you think should be taken within the D.C. Dept of Health's HIV/AIDS office to improve the many and varied challenges to prevent, detect, and treat HIV/AIDS in the District?

Dr. Philippe Chiliade: I am running out of time. But I think we need to know who is getting infected. There are proven epidemiologic techniques that can get us there without forced HIV testing and by keeping that information anonymous. HAA should provide leadership in forcing more collaboration between providers but a big part of the collaboration problem is that funding is often competitive. HAA is in the process of starting monitoring quality of care including efficiency of care, that is necessary because we need to ensure that providers provide the best outcome with what will always be limited resources. Funding cycles should be every 2 years in place of annually and HAA should try to keep the administrative burden as low as possible

Thanks for everyone for your questions. Sorry, I know I did not answer them all.

Philippe Chiliade

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