Deadly inattention to HIV

A new infection every 10 minutes in the U.S. is not acceptable

it's time to renew the AIDS fight

August 31, 2008|By David R. Holtgrave and Julie M. Scofield

Every 9 1/2 minutes, someone in the United States is infected with HIV. That's about 150 every day - more than 1,000 a week. This is part of the news from the Centers for Disease Control and Prevention's recently unveiled HIV incidence statistics, and it has critical implications for the nation.

Previously, it was thought that there was an infection every 13 minutes. But the CDC's new tool for estimating HIV reveals that there are more than 15,000 more HIV infections annually than had been previously estimated. Roughly 200 of those 15,000 people will die each year because of HIV disease. The number of new infections among gay and bisexual men of all races is on the rise, and the disproportionate impact in racial and ethnic minority communities is staggering.

Do the new statistics mean that HIV prevention services are failing? To the contrary, incidence - the number of people newly infected in a given year - has been stable for several years, while prevalence - the total number of people with HIV - has grown. This means that the HIV transmission rate from people living with HIV to HIV-negative partners is decreasing. Further, the transmission rate is declining even while the CDC's HIV prevention budget has shrunk by 19.3 percent (adjusted for inflation) since fiscal year 2002. Carefully conducted scientific studies have demonstrated that HIV prevention services (such as counseling by influential peers) can alter HIV-related risk behaviors and help stem the spread of the disease.

The new HIV incidence statistics do, however, indicate that the U.S. has much work to do. The fact is, we have the tools to drastically reduce the number of new HIV cases, but as a nation we have chosen not to do so. We believe that there are seven things the U.S. can do now to get smarter and better at fighting the epidemic:

First, we must reject the CDC's anemic plan to reduce new infections by 10 percent by 2010 and replace it with aggressive, measurable goals to reduce new infections by 50 percent in five years.

Second, to achieve such bold goals, we must scale up HIV prevention services in the U.S. to an annual investment of $1.3 billion - a funding level that would address the erosion of HIV prevention and core surveillance funding since 2002, and would expand the reach of prevention services across the nation.

Third, as part of this investment, the CDC should fund additional states - not just the 22 states whose data were used in the new incidence study - to utilize the new testing technology that enables better HIV incidence estimates and allows the creation of a locally useful dashboard by which to manage the local epidemic. Sadly, Maryland is one of nine jurisdictions that the CDC has stopped funding for incidence surveillance, and the state has suffered a 40 percent loss in overall federal dollars to monitor the epidemic. Ultimately, this loss could result in a decrease in federal funds for HIV treatment, since the allocation of these resources is based on reported cases of HIV and AIDS.

Fourth, even though gay and bisexual men of all races account for more than 50 percent of new HIV infections in the U.S., the CDC allocates a substantially smaller percentage of its budget to programs serving this community. This must be immediately remedied.

Fifth, as the CDC's HIV prevention budget has shrunk, so too has funding for a special, cross-agency federal program to address HIV/AIDS in minority communities (the Minority AIDS Initiative). This funding trend must be reversed. Further, governmental and nongovernmental organizations must address the root causes of HIV/AIDS disparities, including racism, sexism, homophobia and income inequality.

Sixth, we must see information, discussions and stories about HIV return in great numbers to the news pages, television shows, kitchen tables and classrooms of the U.S. Our national foundation of basic facts about HIV is crumbling, according to national surveys.

Seventh, while HIV testing is critical, we must not mistake the CDC's heavy emphasis on "opt-out" HIV testing in health care settings for a truly comprehensive national HIV prevention program, including needle exchange services, behavioral interventions, adequate HIV housing, comprehensive sexuality education and other evidence-based services.

We are pleased that Congress will hold a hearing in September on the implications of the new HIV statistics, but the next president must go further and once again make HIV in the U.S. a priority. Perhaps the U.S. is waiting for a cure, or a perfect vaccine. But the cost of waiting is a new HIV infection every 9.5 minutes.

This national path of apathy is not only ill-advised and expensive but also unethical and a public health error of the greatest magnitude.

David R. Holtgrave is chairman of the Department of Health, Behavior and Society at the Johns Hopkins Bloomberg School of Public Health. Julie M. Scofield is executive director of the National Alliance of State and Territorial AIDS Directors, Washington.

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