Increasing HIV rate result of several factors
Goal is to cut infections in half by 2005
[AIDS Alert asked Ronald O. Valdiserri, MD, deputy director of the National Center for HIV, STD, and TB Prevention at the Centers for Disease Control and Prevention (CDC) in Atlanta, to discuss the significance of some of the CDC’s HIV research presented at the XIII International AIDS Conference, held in July in Durban, South Africa. Here are his answers:]
AIDS Alert: CDC research now demonstrates how well HIV prevention efforts work among the highest-risk populations in the United States. So why are we beginning to see a resurgence of HIV risk behavior among gay men, and what can be done about this problem?
Valdiserri: There most likely is no single factor contributing to the increases in risk behavior we are seeing among gay men, but rather a complex combination of factors, including fatigue with safer sex messages and the misperception that HIV is no longer a serious disease with the availability of more effective treatments. Private funding for HIV prevention programs has been drastically cut as donations to AIDS-related community-based organizations have dropped off.
In addition, throughout the last decade, the need for HIV prevention has expanded to multiple populations, yet public funding for prevention has remained fairly flat compared to increases for treatment and research. Therefore, many HIV prevention programs have not been sustained in recent years. HIV prevention aimed at gay men must be comprehensive and sustained for each new generation.
AIDS Alert: In the past couple of years, the CDC and Clinton administration have focused more effort and funds on targeting prevention programs for African-Americans, Latinos, and women. Do you believe these efforts will be enough to stop the high incidence of HIV among these groups, and, if so, when do you think we’ll begin to see a drop in their HIV infection rates?
Valdiserri: HIV prevention needs are greater today than ever before in terms of the expanding diversity of people affected and the increasing number of people living with HIV. With resources for prevention being stretched further and further, it is difficult to predict when we may see declines in HIV infections in any group at risk. CDC has long recognized the disproportionate impact of the epidemic on communities of color and has been working with community-based organizations since the 1980s to provide HIV prevention services in African-American and Latino communities.
Recent supplemental and emergency funds from Congress have enabled us to take an important step in building capacity in communities of color to address gaps in HIV prevention infrastructure and other critical needs in these communities. However, we still have a long way to go if we are going to achieve our goal of reducing the number of annual HIV infections by half by 2005. Reaching this goal will require an increased commitment from both the public and private sectors.
AIDS Alert: Do you believe it is possible that we’ll ever see the HIV rates of infection among women and minorities fall to pre-1990 levels, despite the problem of injection drug use and the fact that the current Congress is solidly against any needle exchange programs? If so, why, and if not, what’s the best we can hope for?
Valdiserri: I do think it is possible to make tremendous strides in reducing the number of new infections in all groups at risk for HIV infection, given adequate will and resources to do so, continued collaboration with the communities affected, and the ability to implement effective strategies. Some of our greatest prevention successes have been among injection drug users where programs have been applied that include access to sterile injection equipment, substance abuse treatment, prevention case management, and other basic prevention strategies.
Needle exchange programs have proven an effective aspect of these efforts but are clearly not the only intervention needed. Substance abuse treatment programs are crucial — not only for injection drug users, but for all HIV-infected individuals who have a substance abuse problem.
AIDS Alert: Does the CDC have any plans to target prevention efforts to the bisexual male population, which your research shows to be an important "bridge" for HIV transmission to women? How would a prevention program aimed at this population work?
Valdiserri: We are currently providing prevention outreach to bisexual men through a number of initiatives. Most recently, we funded several organizations serving gay and bisexual men of color, a population where a significant percentage of men who have sex with men actually identify themselves as heterosexual. A key factor to reaching these individuals is to provide information in a way that does not require a man to self-identify as "gay" or "bisexual" in order to obtain HIV prevention services.
For example, we fund a program in St. Louis that organizes an annual blues festival that provides HIV prevention information to African-American men who have sex with men but may not self-identify as "gay" or "bisexual." The festival does not advertise or identify as an HIV/ AIDS event but provides HIV workshops, makes HIV counseling and testing available, and distributes condoms and HIV prevention literature alongside the entertainment events and cultural programs. Additionally, at a community level, we continue to work to address the stigma that prevents these men from accessing the services they need.
AIDS Alert: How can health officials and the CDC solve the problem of young gay men and other at-risk people not being tested for HIV? Do you think the rapid HIV test, introduced at the recent international AIDS conference, will help improve the testing rate of at-risk groups?
Valdiserri: Certainly, advances in technology that make HIV testing more accessible and acceptable are critical for HIV prevention. Approval of new rapid tests in the U.S. could be one of the most important HIV prevention milestones in this decade. Of the estimated 800,000 to 900,000 people currently living with HIV infection in the United States, one-third do not know they are infected. Studies have shown that, in addition to receiving the benefits of early HIV treatment, infected individuals who learn their HIV serostatus adopt safer sex behaviors, which can help prevent the further spread of the epidemic.
CDC is moving forward with a major initiative to increase the number of HIV-infected individuals who know their HIV serostatus. Additionally, we are funding several communities to evaluate innovative approaches to testing. However, it is important to remember that HIV testing is only one element of a comprehensive approach to HIV prevention, which should also include components such as outreach, peer education, and comprehensive school health education.
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