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.

An estimated one in 20 city residents is infected with the virus. In light of that, the 170-page study by the D.C. Appleseed Center for Law and Justice identifies HIV/AIDS as "one of the most severe health problems facing the District, both in terms of disability and lost lives."

It urges top city officials "to speak frequently, strongly and clearly" about the disease and to take "committed and strategic steps" to improve management of surveillance, prevention, funding and treatment.

Among several dozen recommendations, it calls for immediate creation of an executive-level commission to lead the turnaround.

"This challenge is of life-and-death importance," the report says. "Simply put, business cannot go on 'as usual.' The District's efforts to address HIV/AIDS have fallen far short and addressing the epidemic must move front and center as a priority of District government."

The study began in early 2004 at the request of the Washington AIDS Partnership and with the support of Mayor Anthony A. Williams (D). The mayor has questioned why tens of millions of dollars in annual programs was not having more impact. D.C. Appleseed, a public interest organization, worked with the law firm of Hogan & Hartson, which donated more than 4,000 hours of research and writing to produce the report.

Some findings echo recent criticism of the city's HIV/AIDS Administration. During hearings before the D.C. Council's health committee and in an audit released by the D.C. inspector general in late June, the agency was faulted for significant dysfunction in how it funded, monitored and reimbursed organizations that deliver services to residents with the virus.

Such problems were underscored late last month when an official with the federal Centers for Disease Control and Prevention flew from Atlanta when a key HIV prevention planning group sought "immediate assistance" because the health agency had failed repeatedly to provide data needed for the group to do its job.

Today's report, "HIV/AIDS in the Nation's Capital," shows more fully the breadth and depth of the situation. The Williams administration is not contesting its conclusions or recommendations, said Gina Lagomarsino, a senior adviser to City Administrator Robert C. Bobb.

"Certain of the findings we're beginning to work on," she said. "We think they are generally fair."

As of 2003, the District's AIDS rate was 170.6 per 100,000 residents -- up sharply from 119 in 2001. African Americans have represented an increasing percentage of new AIDS cases.

The incidence of District residents with HIV remains a rough estimate because of one crucial shortcoming: the city's dearth of epidemiological information.

Without accurate, complete statistics that such epidemiological studies would provide, prevention efforts and the allocation of resources for treatment and care are severely hampered, the report contends.

The city agency, it notes, did not begin collecting HIV case reports until December 2001 and has yet to release data from those, although other major cities do quarterly postings and make numbers available for independent analysis. The District's surveillance program suffers from long-standing employee vacancies of more than 50 percent and continuing interim leadership.

"We have no way to track our progress . . . no way to judge what we're doing," said Nicole Lurie, a primary care physician who works on health policy for the RAND Corp. "It's just a disgrace."

Among the report's other major findings:

* The District's coordination and supervision of government agencies and private service providers is insufficient on several fronts, including enrollment of individuals who need medical assistance, payment and management of grants and monitoring of programs' effectiveness. (A letter from Deputy Mayor Neil O. Albert, included as an appendix to the report, says officials are moving to consolidate eligibility and enrollment procedures to help those with HIV or AIDS get medical benefits.)

* The District's prevention efforts include no strategy for routinely offering HIV testing and counseling in such settings as its tuberculosis and sexually transmitted disease clinics, substance abuse centers and hospital emergency rooms. The city's initiative to purchase and distribute condoms, which distributed just half of its goal last year, requires "expansion and improvement."

* For certain at-risk groups, services need to be strengthened considerably. The public schools pay little attention to HIV education for teenagers, with a lack of "clear, consistently applied standards" for current programs. And while there are more than 10,000 intravenous drug users in the District, the city has no comprehensive HIV prevention strategy for this population, and budget shortages have limited major improvements in substance abuse programs. Finally, D.C.'s detention facilities, where the "vast majority" of inmates have a history of substance abuse, can offer treatment to less than 2 percent of them.

"The District is in some respects 10 to 15 years behind where it should be in mounting a concerted, effective response," the report says, citing a high-ranking city official whom it does not name.

Its lengthy recommendations include quickly filling those surveillance positions, combining HIV and AIDS databases, providing case managers with more specialized training and increasing interagency collaboration. Lagomarsino said the suggested task force, which would be charged with ensuring that reforms are implemented, makes sense. She said D.C. Appleseed's call for a fall public meeting to discuss how the government will move forward seems "very reasonable."

The public interest center has notified officials that it will follow up in six months. "We think the resources are there to get the job done," said D.C. Appleseed's executive director, Walter Smith. "What's been missing is commitment from the top to make sure we allocate the resources to address the epidemic and to do so expeditiously. People are dying."

Paola Barahona, executive director of Prevention Works, which runs the city's sole needle exchange program, said she hopes the report will help build a much stronger partnership between the D.C. Health Department, the HIV/AIDS Administration and community organizations.

City officials must focus on the District's tragically high infection rates, Barahona said. "They've got a lot to do. They've got a lot of issues. They need to be reminded," she said. "This report will remind people."

The full D.C. Appleseed report can be found at www.dcappleseed.org. Philippe Chiliade, medical director for the Whitman-Walker Clinic, will answer questions online today at 1 p.m.; visit www.washingtonpost.com/liveonline to participate.

A mobile HIV testing lab visited Northeast Washington in June. One in 20 D.C. residents is estimated to be infected.