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Outlook: AIDS in the District Is Serious, But Not Critical

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Craig Timberg
Former Washington Post Johannesburg Bureau Chief
Monday, March 23, 2009; 11:00 AM

"D.C. 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. Though the epidemic is serious - and more extensive than most suspected -- the report also suggests that the situation in some ways is improving, and has been for years... 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 both Washington and Africa, first as The Post's D.C. politics reporter, then as its Johannesburg bureau chief. 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."

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Craig Timberg, former Johannesburg bureau chief for the Washington Post, was online Monday, March 23 to discuss his Outlook article disputing recent accounts that suggest the rate of HIV/AIDS infections in Washington, D.C. is as bad as that in parts of Africa. 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."

A transcript follows.

Archive: Transcripts of discussions with Outlook article authors


Craig Timberg: This is Craig Timberg, on line to talk about AIDS in Washington,D.C. I used to cover politics in the city, and then spent four years covering AIDS in Africa as part of my job as the Post's Johannesburg Bureau Chief. I'm now on leave, writing a book about the epidemic and why it's going so badly in some parts of Africa. I also blog on the subject, and other things African, at http://craigtimberg.com. I'm thrilled to talk about any and all of these subjects, so fire away!


Oxon Hill, Md.: When I read the article about the increase of AIDS in the Washington, DC area, I knew that something was wrong with the data and/or the reporting, especially the statement that a high percentage of persons with AIDS in the area did not know they had it. I know we extrapolate projections based on known data, but sometimes the data can be skewed and the results do not come about.

Craig Timberg: Hi Oxon Hill. Thanks for your question. I don't think the problem was with the data but the portrayal of the data. The upshot is: We have a real AIDS problem in our city. But there's no evidence that it's getting worse, or much that it resembles the hard-hit parts of Africa. And thank goodness! I think we should all take a deep breath, focus on the problem and figure out smart ways to tackle NEW infections now. That's about all we can control.


D.C.: I would like to ask this question from a scientific and epidemiological standpoint. Am I wrong to conclude that antiretroviral treatment of HIV/AIDS in Africa and elsewhere encourages the spread of HIV/AIDS and the persistence of a high HIV infection rate because people are living longer with the virus and can spread it? I read somewhere, that HIV infections may not go down because of the success of antiretroviral drugs. I'm not trying to sound callous or anything, however, is not it true when more people are living with the HIV virus because of the success of antiretroviral drugs, that this makes it harder to reduce or even end the HIV/AIDS epidemic - is not maintaining a viral load or epidemic in this way somehow not what happens in the natural world and animal kingdom with viruses and epidemics? In the non-human animal kingdom, aren't viruses and epidemics successfully cleared and eradicated, because those who are infected - who can't be cured of the infection - are left to fall out of the ecosystem by succumbing to the disease, thereby curtailing the spread of the epidemic/disease?

It seems to me that the better use of money and aid would be to stress prevention as much or even more so than antiretroviral treatment.

Craig Timberg: Great question but a tricky one. Good antiretroviral treatment, rigorously adhered to over a lifetime, ought to cut transmission because well-suppressed HIV is very, very difficult to spread. Plus, I believe there is a moral imperative to treat diseases that are treatable. Period.

However, treatment in settings where you reach only a part of the infected population, as is the case in much of Africa, has a problem called "dis-inhibition," meaning that people stop fearing the disease, and maybe fail to protect themselves adequately. I COMPLETELY agree that prevention should be job #1 in Africa, and that is has been neglected. The trick is: How do we save sick people now, while trying to turn back the epidemic as a whole. That's much of what my book is wrestling with. For more on the treatment dilemma, please see my piece from a couple years ago: http://www.washingtonpost.com/wp-dyn/content/article/2007/06/19/AR2007061901971.html


Greenbelt, Md.: Public health leaders have tried to de-stigmatize one of the main routes of transmission (unprotected anal intercourse) by using terms like Men-Having-Sex-With-Men and then compressing it into MSM, which can sound innocuous and/or cryptic. I understand they are trying to avoid causing queasiness in some quarters, and to avoid vilifying gay and bi-sexual men.

But by using this medical euphemism, haven't they had the effect of undercutting a central message of prevention: anal sex is dangerous! And aren't they also diluting or obscuring the warning for heterosexuals, leaving too many with the mistaken idea that anal sex is not risky unless your male partner is an IV drug user or bi-sexual?

In this way, hasn't the acronym "MSM" become counter-productive?

Craig Timberg: I too struggle with the Men-having-sex-with-men construction because it is so inelegant. The problem, however, is that lots of men who don't consider themselves gay also have sex with men, because they are bisexual, or in all-male prisons, or, in some parts of the world, because they are sex workers. So the language here is fraught.

It certainly is true as well that they key fact here is that anal sex is much more dangerous than vaginal sex for physiological reasons. Condoms cut that risk, but not entirely. Mutual monogamy cuts that risk even more, if the partners are not infected. I think AIDS prevention messages almost everywhere could be clearer and sharper, and perhaps even scarier.


Greenbelt, Md.: The Post's Jose Antonio Vargas reported in 2006 that between '98 and '06 the city distributed nearly $500 million in federal and local funds to dozens of community groups charged with prevention, housing and health care.

And yet here we are today with the highest known infection rate of cities in the US.

Aside from the shocking failure to contain HIV in DC, do you have any thoughts about where or how half a billion dollars could have been better spent to save lives and fight new infections?

Do you have an opinion about how much money is enough, in DC, to defeat the epidemic? Do dollars go further in Africa? Save more lives or better preserve quality of life?

Craig Timberg: I hate to say this, because it always makes people angry, but I don't think there's such a linear relationship between money and good prevention programs. I also don't think there's any evidence that AIDS prevention in D.C. is a shocking failure. I have seen NO data showing an increase in new infections here. Maybe it's happening, but there's no data to support the claim.

In any case, you could spend $1 billion and not stop AIDS transmission anywhere if you don't rigorously and carefully target the things that really spread HIV.


New York, N.Y.: In some cases, people with AIDS have claimed to have been cured. Yet these seem to have been cases where the people could afford expensive medication. If this a disease that can be defeated, but only if you can afford it?

Craig Timberg: There is no cure for AIDS. There may never be. The only way to defeat the epidemic is to head off new infections. Along the way, of course, we must extend whatever care and treatment available to those already infected.


Alexandria, Va.: The 'new' HIV/AIDS epidemic is primarily ravishing black American women who tend to contract the disease through heterosexual encounters.

It is widely known that many black American women regardless of socioeconomic status tend to mostly date black men. In urban areas, we know that a substantial number of black men have spent time in prison. This is relevant because prison populations tend to have very high rates of HIV/AIDs.

You wrote, "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." Please note however, that for certain groups such as black American women in the district, this is a crisis and an epidemic! Black women in the district account for the majority of newly infected persons.

Since we know that the primary route of HIV infection amongst blacks tends to be heterosexual, and we know that by and large much of the HIV/AIDS infections stem from the close sexual networks of black women dating men from the community that spend time in and out of prison, why is there relatively little discussion about educating the prison population with regards to safe sex and IV drug use practices?

Also, do you believe that states should implement mandatory HIV/AIDS testing for men incarcerated for 6 months or more?

-- A concerned black woman

Craig Timberg: I guess that's "new" in the sense that it's getting more attention than before, and that's certainly welcome. But the DC AIDS/HIV report shows that 70 percent of new AIDS cases over the last five years were among men. Among women, heterosexual encounters are indeed a majority of new cases, but that's still only 17 percent of new infections. So, yes a new problem, but AIDS in D.C. remains a disease with many more male victims than female.

That said, I think African American women need to be very vigilant about this. I'm going to take a pass on whether men in prison need mandatory HIV testing mainly because it's a tricky issue I haven't thought much about. But more HIV testing, in general, is good.


Gaithersburg, Md.: Craig:

I am not sure about the point you are trying to make. Yes, some commentators have compared D.C. to some parts of Africa. But such a comparison has never been the focus of their point. I mainly saw it as a way to draw more attention to the seriousness of the AIDS epidemic in D.C. Why would you make the D.C./Africa comparison the focus of your article? Is this going to help the fight against AIDS in D.C. or Africa?

After all if one can trust AIDS statistics in D.C., I wouldn't trust African AIDS statistics that much. I am survey statistician born and raised in Africa, trained in the US, and know how daunting a task collecting health data can be in most African countries. The WHO itself relies upon local statistical bureaus to do most of the fieldwork (because only them know the field), which is often very poorly done.


Craig Timberg: Thanks for your question. You may be right that D.C. officials weren't trying to make the D.C.-Africa comparison, but I can tell you that this is what was heard around the world. So my sense is it needed to be tackled directly.

As for AIDS surveillance, there is indeed a history of very bad data, from health ministries, the U.N., pretty much everybody. But this has improved remarkably, in part because of a group in Calverton, MD called ORC Macro that does very good studies of HIV rates, with U.S. govt dollars. Other research has gotten better too. Overall, I think it's much easier to tell what's happening with the epidemic in, say Uganda, then in Washington, D.C. (just blogged on that exact point). That, to me, is an incredible shame.


Freising, Germany: What is the current situation regarding the availability of cheap antiretroviral drugs in various African nations? I recall, many years ago, that Mbeki made sounds of encouraging the import of cheap antiretroviral drugs from India or Brazil, but then he backtracked significantly, questioning if the antiretrovirals were a help or a poison.

Craig Timberg: There are a lot of cheap antiretroviral drugs in Africa. The price is not the main barrier any more. The main barriers are the underlying weaknesses of the public health systems in most African countries and also the reluctance of many people to admit they have AIDS and seek treatment. On the treatment front, both those issues need much more attention.


Craig Timberg, I think you are OFF: Craig Timberg, I think you are OFF. The report doesn't compare DC to Africa. It compares HIV/Aids in DC to that in West Africa.

Craig Timberg: Hi. The report doesn't actually do that either. The report itself, in fact, is pretty darned good, much better than anything that's come before in D.C. But the city's top AIDS official, Dr. Shannon Haider, made exactly that comparison in the Post:



Philadelphia, Pa.: The title of your book ends with a positive note about the war on HIV/AIDS when it states "how to win" the war. How do we win the war against HIV/AIDS?

Craig Timberg: Well, given that the book is not yet out, I'll give a preview. The first and biggest flaw in the world's response to AIDS in Africa is that it has been driven by Westerners who don't understand the cultures there, especially the subtleties of sexual cultures. In terms of what works, there are a few things that have gone well, and plenty that haven't. My first two choices for success stories are places that decreased the rates of casual sex and ongoing, multiples sexual relations. In Uganda from about 1986 to 1994, changes in sexual behavior saved more than 1 million lives. In Zimbabwe between about 1998 and 2003, they saved 600,000 lives without any real resources and a collapsing economy: http://www.washingtonpost.com/wp-dyn/content/article/2007/07/12/AR2007071202369_pf.html

In addition, it's clear that circumcising men dramatically slows the pace of HIV transmission. Programs making that procedure more widely available are finally coming online after more than two decades of data pointing in that direction:


I also blog on this stuff if you can't wait for the book!


Pensacola, Fla.: To say that AIDS in the district is serious, but not critical, relays the message that HIV/AIDS is simply a manageable disease that one should not be afraid of. I work in a charter school in D.C. and that message frankly terrifies me. The children and teens of D.C. are already engaging in risky behavior. The STD rates for teen girls in D.C. is so above the national average that it makes you want to cry. We know that exposure to other STDs ups the chances of contracting HIV. To add a "hey, it's not that bad" message on top of that is reckless and negligent. Even if you feel the concern is alarmist, maybe it is what is needed to get the message out and protect the youth of D.C.

Craig Timberg: Hi. You raise an excellent point, and I wasn't crazy about the "not critical" part of that headline.

BUT, I can tell you that my experience in Africa suggests that continually ringing alarm bells, especially in the absence of good messaging, doesn't help. My point is: Let's be clear about what the problem is. Let's attack it carefully. That allows for sustained good programming. As I said in the piece, we have to talk about sexual behavior much more explicitly.


Washington, D.C.: Wow - so you guys have done an article contradicting a prior article on the same topic, or to clarify it. And now you're doing a chat. Thank you!

Some commentators on the City Paper's site noted that the rate HAD been 5% and now it's 3%, which indicates a fall-off.

Also, some other people pointed out that people are living with AIDS longer.

Craig Timberg: Hi there. I am not contradicting the previous article. Jose and Darryl are terrific reporters whose work was first rate. All I'm attempting to bring to the conversation is a bit more context because I have had the benefit of experience in a different place, courtesy of course, of the Post's Foreign Service.


Washington D.C.: I am somewhat dismayed that we do not have statistics on the incidence of HIV infection in D.C. While great improvements in surveillance and reporting of HIV in the District have come about in recent years, thanks to prodding from the D.C. Appleseed Reports, the arrival of Dr. Shannon Hader and collaboration with the GWU School of Public Health, it is still amazing that our data is so patchy. I think Craig Timberg's article was 'spot on' in putting the situation in D.C. into perspective, especially in light of AIDS in Africa. Without accurate data we cannot begin to attack the problem in the District adequately. I am very keen to see the HIV/AIDS administration of the DOH adopt new epidemiological approaches that could obtain a better measure of our situation. I would like them to fine tune the incidence data and to adopt what I have termed "Community Viral Load" indices. This is the only way we will be able to identify core aggregates and target interventions to reduce transmission in our neighborhoods. We must own this epidemic, starting at the community level. Thank you very much for this discussion.

Mary Dooley, MPH, RN Assistant Clinical Professor, Community Health CUA School of Nursing

Craig Timberg: Wow! I couldn't agree more.


Chicago, Ill.: The Vatican blames condoms. The Pope was rightly condemned in the Western world for saying that safe sex exacerbates the disease, but what has the reaction been in Africa? It seems there is much stronger resistance there to preventive measures.

Craig Timberg: I'm not in Africa right now so I don't know. I will briefly share my thoughts on this, though. While the Pope surely was wrong in some ways, the reaction seems outsized and too much resembling a sledge-hammer. Condoms clearly have helped in some places, in Thailand for example, and also in the American and European gay community. And for the many couples in which one person is infected and the other is not, what else is the Pope suggesting?

At the same time, their record in Africa is more mixed. If huge emphasis on condoms was going to fix the epidemic, it would have happened by now. That's was the heart of the global response in Africa from the early 1990s onward. So condoms are good, but we need to stop imagining that they are the panacea. They are useful, but not enough.


Greenbelt, Md.: D.C. officials have acknowledged, when asked, that some of the very high HIV rate can be attributed to earlier and more pervasive testing, and to decreased mortality from medical treatment.

I understand from others that D.C. (and California) are very unusual (by US standards) in offering free medical care to those with HIV/AIDS. What portion of D.C.'s extraordinarily high HIV+ rate might be attributable to HIV+ people moving to D.C. from out of state to avail themselves of these costly (to the government) benefits? Has that been studied by anyone?

Craig Timberg: I don't actually know the answer to that one. I don't cover D.C. at the moment, so I don't have regular contact with that kind of information. Anyone out there in the blogosphere know the answer?


Greenbelt, Md.: Jail/prison is reportedly where many men become infected with HIV. I understand that at the D.C. Jail, HIV tests are mandatory for all inmates, and I've heard Council member Catania claim the infection rate in that facility is -lower- than in D.C.'s unincarcerated population.

Those facilities that do test, I'm told, often do so only before releasing inmates. A test upon entry with a second test before release could demonstrate an inmate was infected in the jail and open the jurisdiction up to lawsuits. Does the D.C. jail test inmates only once? If so, is it upon entry or exit?

If only upon exit, how can they know whom to provide with appropriate medical services and, perhaps, whom to segregate or quarantine while in custody?

Craig Timberg: I'm sorry to say I don't know the answer to those questions either? Any help out there?

By the way, I am under the impression that a fair number of people who live in Washington, D.C. have spent time in the prisons of other jurisdictions, and also federal prisons too. So I think these issues, as always with D.C. things, must be thought about more broadly.


Greenbelt, Md.: Can you (or anyone else) please answer two apparently taboo questions on the D.C. epidemic:

1) What is the rate of infection/number of infections for white heterosexuals in D.C.? Not suggesting any demographic can afford to be careless with this disease, but that particular demographic is a very large one in D.C., and this figure seems so far unreported.

2) How many of the cases ascribed to heterosexual transmission can be traced to unprotected anal intercourse, male to female? Is vaginal intercourse -really- the leading route of infection among heterosexuals (non-MSMs)? Please don't skip this question on the basis of squeamishness. "Decorum" has done enough damage in fighting this epidemic.

Craig Timberg: Good questions. I'll do my best to answer them:

1. The report says that of the 3,622 new AIDS cases reported in the last five years, 311 (8.6 percent) were among white people. Of other ethnic groups, 85 percent were African American, and 5.4 percent were Latino. Among white people, 226 of those infections were men-with-men sex, and 14 from injecting drug use. Of the remaining, 29 were from heterosexual sex, but the city's tracking system is passive. In places that investigate such things, they often find other risk behaviors such as drug use and/or sex between men.

2. Regarding transmission by unprotected male-to-female intercourse, the study doesn't offer any data. Sorry. On the second question, the report suggests that heterosexual sex in general accounts for 31.5 percent of transmission BUT as I said above, that number ought to be taken with a grain of salt in the absence of routine investigation. Also, because there are so many more heterosexual acts of intercourse in any given year, the rate per act surely is lower than it seems from that data.

Am I making sense?

On your point about decorum, I totally agree.


Alexandria, Va.: All racial groups have their share of promiscuity and drug use.

It seems as if increased condom usage and widespread 'harm reduction' tactics could substantically reduce the number of infections within the black D.C. population.

Why do you think tactics which focus on increasing condom usuage is not enough? I'm confused.

If everyone practiced 'safe sex' there wouldn't be an epidemic. But I guess you don't see 3% of the DC population being infected as a true epidemic.

Please however realize that we shouldn't feel comfortable comparing ourselves to African countries that do not have access to the same levels of resources and education.

Therefore yes, 3% of a given American population with this preventable disease is an outrage, and rightly justified as an epidemic.

Craig Timberg: Hi Alexandria. Sexual behavior and drug use actually does vary widely across countries, and within countries. We shouldn't assume that everybody is the same. In fact the cause of many missteps in Africa has been the West's failure to grasp how different cultures function.

Regarding condom use and risk reduction, I don't think the clean-needle route has been tried enough in D.C. to know if it's working, though on the surface it makes sense. Regarding condoms, the push on that front has been coming for decades now. I covered the installation of condom machines in dorms at my alma mater, Connecticut College, in 1989 I think. EVERYBODY knows that condoms help, and they are widely available, so the question becomes, how do reach the rest of the people who aren't using them? I don't know but lots of people have tried and failed.

Regarding the term "epidemic," I think that we can lose clarity when we fall into easy language. My point is: We have a very bad problem, with too many sick people, but it's not obviously getting worse, and it's not like in hard-hit parts of Africa. As I said in my piece, I am not seeking to minimize a serious problem, just put it into context.

I agree, as you said, that it's an "outrage."


"Safe Sex" oxymoron: Part of the problem, I believe, is the idea that there is such a thing as safe sex. There is no safe sex - just safer sex. You can use a condom and still get AIDS.

The thing is, the Pope is right. If a clean person only has sex with their committed partner, and both are uninfected, and neither do IV drugs, then they're safe, failing blood to blood contact from an accident. Condoms aren't a cure-all.

Craig Timberg: Yeah, to a point I agree. I actually wrote earlier in this chat about my thoughts on the Pope.

I'll briefly recap here: The Pope's denunciation of condoms, to my ear, was much too sweeping. But so was the condemnation of his comments. We need to understand what condoms have done well, and not done well. They've helped a lot in Thailand and among gay men in the U.S., Europe and elsewhere. In Africa they have been more of a mixed bag, and I think we should all be honest about that.

People tend to use them with sex workers, and in casual hookups, but not with long-term partners. Sadly a huge amount of HIV is transmitted among long-term partners, especially when men and women have more than one long-term partner. Here's a story I did attempting to tackle this:


So, condoms are useful but they don't solve the problem. To get farther in combating new infections, we need to be explicit about the underlying sexual behavior itself.


Craig Timberg: Thanks to everybody who sent in questions. If you haven't had enough, you can read more of my thoughts on AIDS, Africa and related subjects on my regular blog at http://craigtimberg.com. My book should be out this time next year.


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