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The Clock is Ticking: AIDS in America

David Holtgrave

On the occasion of World AIDS Day, David Holtgrave, an expert on U.S. HIV prevention programs, addresses the state of AIDS in America. Twenty-five years into the epidemic, there are an estimated 40,000 new cases each year in the U.S. Holtgrave, chair of the Bloomberg School’s Department of Health, Behavior and Society, looks ahead to a time when there are no new HIV infections in the U.S. “Getting to that state is much more a matter of national will than national skill,” says Holtgrave, PhD, former director of the CDC’s Division of HIV/AIDS Prevention, Intervention Research and Support. “The question is, ‘Are we going to commit ourselves as a nation?’ The clock is ticking.”

Jackie Powder, a writer with the Office of Communications and Public Affairs, recently spoke with Holtgrave about the AIDS epidemic.

JP: From a big-picture perspective, how would you assess the AIDS epidemic today?

DH: Clearly, we have much work to do all over the world in terms of making treatment available as well as in prevention. Even in the U.S. there are still many treatment and prevention challenges. For instance, the number of people who aren’t aware that they’re HIV positive is about one-fourth of the people living with HIV. That means roughly 250,000 persons. If you don’t know you’re infected, you can’t access lifesaving care that may be available.

JP: Who is being hardest hit by the AIDS epidemic now?

DH: In terms of new infections, you still see many racial and ethnic health disparities. The African-American community is still very heavily impacted by HIV infection and the Latino community is disproportionately impacted as well. Heterosexual transmission, and same-sex transmission, may be on the increase. With regard to injection drug use, HIV infection is probably on a little bit of a decrease.

JP: With new HIV infections holding steady at 40,000 for the last several years, the CDC fell far short of meeting its five-year-plan goal of halving HIV incidence by 2005. Why?

DH: I don’t think we’ve invested as much in the way of resources as we need to. We’re probably roughly $340 million a year short from what would be necessary in the U.S. to provide prevention services to everyone who needs them. I also think there’s some under-utilization of the evidence-based programs we’ve found to be very effective. They’re not being used at the rate they need to be.

I think another issue is that not enough attention has been paid to HIV prevention in the U.S. for a while. I think that there’s a broad sense that maybe there’s a cure for AIDS in the U.S. And I believe that knowledge about HIV is crumbling. According to a Kaiser Family Foundation poll, about 43 percent of those who participated got at least one basic question wrong on a straightforward quiz about HIV facts (regarding how HIV is transmitted, how people can protect themselves from infection, and so on). I simply think there’s a general sense of malaise about HIV prevention.

JP: What are your thoughts on the CDC calling for routine “opt-out” testing in all health care facilities?

DH: I am working on an analysis right now that looks at the impact and cost of doing routine HIV testing versus doing something a bit more targeted. It seems to indicate that there may be important public health benefits of including counseling with testing (opt-out testing, in contrast, would discard risk assessment and most counseling). Also, the analysis indicates that we need to consider some targeting to get the most public health impact. I think targeting can be done in a non-stigmatizing way. For instance, you can identify geographical areas with high HIV prevalence, or identify venues like STD clinics or drug treatment centers, which by their nature deal with HIV-related risk, and intensify counseling and testing efforts there as a first, urgent priority.

JP: Can you talk about housing as an AIDS prevention tool?

DH: I think housing is really an important issue when talking about both prevention and treatment. For instance, Amy Knowlton, who’s on the faculty here, authored a paper that found that persons who are homeless are much more likely to have high levels of viral load. Even though it’s not necessarily surprising, I think it is important because it shows that there really is a biological consequence of homelessness. One of the things we’ve been working on with CDC and HUD is a prospective study to determine if, as people get into stable housing, you can actually see changes in risk behavior levels and if you can see improvements in terms of being able to access treatment services. So there are important treatment issues related to homelessness, but also important prevention issues as well.

JP: Even though much remains to be done in stemming the AIDS epidemic, have there been signs of encouragement in the past several years?

DH: I think it’s always important to keep in mind that we went from 160,000 new HIV infections a year in the mid-1980s down to 40,000, which is a testament to the success of prevention programs. We’ve gone from an AIDS-related funeral in the U.S. every 15 minutes in the 1990s to one roughly every half hour now. That is better, but we have much more work to do. We can’t rest on past prevention and treatment successes; we must urgently press on.

JP: What role does social capital play in the fight against AIDS?

DH: Social capital refers to the cohesion in a society. For instance, in a state, do people vote, do people say they trust other people, do they have friends, do they belong to PTAs? We found that a method of measuring social capital developed by Robert Putnam at Harvard is very predictive of AIDS case rates in a state, as well as teen pregnancy, STDs, adolescent risk behaviors related to HIV, even TB and chronic disease rates as well.

If a community is able to build stronger social organizations, there may be a change in the HIV epidemic in that area. I think that would be a very interesting thing to try with further research. And because social capital is related to a number of disease areas, you might get a payoff across the board with regard to public health, not just with regard to HIV.

JP: Where do things stand in terms of an AIDS vaccine?

DH: Although there are many AIDS vaccine trials right now, we are still several years away from having a vaccine. And it’s always important to keep in mind that when a vaccine finally becomes available it seems very unlikely that it would be 100 percent effective—at least right away. It will be important to bundle any kind of vaccine rollout with prevention measures that are social and behavioral as well, so that you don’t inadvertently have a vaccine that’s, say, 30 percent effective and people think “Now I can take the vaccine and I’m protected so I don’t have to be as ‘safe’ as I have been.”

JP: Why are only half of the people who need HAART (highly active antiretroviral therapy) receiving it? Recently, three people died while on a waiting list for the treatment.

DH: Number one, it’s a resource issue. Right now, Congress is debating whether to pass a new reauthorization of the Ryan White Care Act, so it’s literally a matter of national policy whether to make these resources available and at what level. Also, even if they can afford care, some people don’t feel comfortable going to what might be called or known to be an AIDS clinic; they’re afraid that others will find out they’re living with HIV. There are still troubling issues with stigma and HIV in the U.S.

JP: Twenty years from now, where will we be with the AIDS epidemic?

DH: I hope in the next few years that we would have a program in place in the U.S. that enables the last 25 percent of people living with HIV who don’t know they’re infected to become aware of it so they can access lifesaving care and treatment. And, I hope everyone in need of care and treatment receives it. Also, I hope we can develop a comprehensive national HIV prevention plan that will at least reduce new infections by half within 3 to 4 years, and then get us all the way down to no new infections per year thereafter. It will be a complex matter of addressing structural issues, providing housing, boosting social capital, ramping up efforts to do behavioral interventions and combating stigma. I think a program like that is something we could envision and something that could be doable in 20 years—and hopefully much, much faster.