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HIV/AIDS: Wake Up, America

David Holtgrave

The good news, says David Holtgrave, chair of the Department of Health, Behavior and Society, is that HIV transmission rates are down in the U.S. However, there is a new HIV infection roughly  every 9.5 minutes, and an AIDS-related death approximately every 33 minutes; furthermore, the “HIV/AIDS knowledge base is crumbling” among the general public, and that fact, paired with an erosion in funding in recent years, leaves us on shaky ground. Today there are about 1.1 million Americans living with HIV/AIDS; and about 21 percent of these 1.1 million are unaware that they are living with the virus. Taken together, these facts create a picture of a complex epidemic in which some progress is being made, but there is still urgent work ahead of us.  In a recent interview, Holtgrave, PhD, former director of the CDC’s Division of HIV/AIDS Prevention, Intervention Research and Support, offered some advice to President-elect Barack Obama. “We need immediate movement on a national AIDS strategy, within the first 100 days if possible.”

Christine Grillo, a writer with the Office of Communications and Public Affairs (OCPA), spoke with Holtgrave about pressing HIV/AIDS issues.

OCPA: In September you testified before U.S. Representative Henry Waxman’s Committee on Oversight and Government Reform regarding HIV/AIDS incidence and prevention, and you drew attention to transmission rates in the U.S. Why is it important to look at transmission rates?

DH: To get a sense of the speed of the spread of the epidemic, you can’t look at incidence alone (the number of new HIV infections per year); there’s no context when you look only at incidence. If you divide incidence by prevalence (the number of people living with HIV), you get an idea of the proportion of people living with HIV who are transmitting the virus.

OCPA: And there’s good news about transmission rates?

DH: Definitely. The transmission rate is just under 5, and that means that at least 95 percent of people infected with HIV in the U.S. are not transmitting the disease in a given year. We examined the U.S. transmission rate trends in detail in a new paper in Journal of Acquired Immune Deficiency Syndromes (JAIDS). 

OCPA: How low could the transmission rate go?

DH: A transmission rate of 5 is already fairly low. This transmission rate is the lowest it’s ever been in the U.S. down 88 percent in 1984, and 33 percent in 1997. But what kind of effort do we need to get that figure down to 4, 3…even 0? The closer we get to 0 percent, the more difficult it becomes. But I think we could reduce the transmission by half in a few years with the right investment.  And the investment level is key; if we don’t scale up evidence-based prevention services, we will never get the transmission rate substantially lower.

OCPA: What’s the global picture?

DH: In 2007 there were about 33 million people living with HIV in the world, and about 2.7 million new infections. This implies a transmission rate of 8.2, which is substantially higher than the US transmission rate. So, although there has been much global progress in confronting HIV across the planet, there is much work left to be done.

OCPA: There was discouraging news earlier this year, about the incidence of HIV infection in the U.S.

DH: Yes. CDC’s previous estimate for new infections has been about 40,000 per year since 1990. That’s an old, “informal” estimate; it was calculated from the best available numbers and with methodologies that needed to be improved. Now we’re better at measuring incidence, and the number turns out to be closer to 56,000 per year. So there hasn’t necessarily been a jump in incidence, but there are more infections that we had previously thought.

OCPA: How should we evaluate our progress regarding the HIV/AIDS epidemic?

DH: Just like we need a dashboard to drive our car, we need a national HIV dashboard, something that will guide us in how to manage the epidemic. And we need to look at all the pieces of the dashboard: incidence, prevalence, deaths, transmission rates, late diagnoses in the course of illness, and behavioral surveillance…. We need all of these dashboard “instruments” to know where we are going in managing the epidemic.

OCPA: We don’t have a national AIDS plan, do we?

DH: The United Nations has recommended that every country have a national AIDS plan, and every country that receives PEPFAR (President’s Emergency Plan for AIDS Relief) aid has one. The U.S. doesn’t have a plan, really. We have some older, piecemeal strategies, but nothing that fully weaves together a true strategy and the resources for HIV prevention, care, treatment and housing in the US. We do need a plan, one that’s comprehensive and coordinated, and one that lets us annually assess our investments in HIV/AIDS services, and the impact those services are making. We must be able to track our investments, programs and success level annually so we can make mid-course corrections to constantly improve our programs.

OCPA: What’s your message to President-elect Obama?

DH: First, we need immediate movement on a national AIDS strategy, within the first 100 days if possible. Second, he needs to work very hard to raise resources devoted to HIV/AIDS prevention,  treatment, care and housing. And third, even if new resources are not immediately available, he should look at policies that can be attended to right away. For example, he should look at the ban on federal funding for needle exchange. He can quickly undo that restrictive policy. The same goes for a reexamination of abstinence-only programs. We need resources, but we also need policies that allow the programs with the best evidence base to be implemented.

OCPA: Should Obama appoint an AIDS czar?

DH: Whether or not the person is called the “AIDS Czar,” someone needs to be appointed by The President-elect to coordinate all the HIV/AIDS services [prevention, treatment, housing, programs serving veterans, testing] currently managed out of different offices (such as the CDC, HRSA, HUD, and the Veterans Administration). This type of high-level coordination is sorely needed. This person also needs to spearhead the development of the National AIDS Strategy. If the President-elect’s administration doesn’t come up with a national AIDS policy early in 2009, I believe that the AIDS community will write their own national plan.

OCPA: The CDC’s HIV prevention budget has dropped dramatically over the years. What kind of funding do we need?

DH: Adjusting for inflation, there’s been a decrease of over 19 percent in funding to the CDC for HIV prevention since fiscal year 2002. That means essentially that 1 in 5 prevention dollars is gone since 2002 (adjusted for inflation). You’d have to add $171 million per year to CDC’s HIV prevention budget just to get back to the 2002 level. And to appropriately address unmet need, you’d have to increase CDC’s HIV prevention budget to about $1.3 billion per year.

OCPA: If you were AIDS czar…

DH: I think it is critical to address unmet HIV prevention needs in the U.S. As I testified recently before Congress, my wish for a five-year plan would be for $1.3 billion in prevention funding per year. I might front-load that a bit, so maybe it’s $1.6 billion in the first year, and so on. Over that five-year period, I estimate that as a nation we could reduce transmission by half—but we’d need that substantial investment. And if we really saw a drop in new infections, that higher level of funding might sunset in several years, so we wouldn’t necessarily have to continue to fund it at $1.3 billion per year.

OCPA: …and what about funding in terms of treatment versus prevention?

DH: I like to say “prevention-treatment-housing” all in the same breath. We need additional resources on all those fronts. Of all the AIDS money in the U.S., about 4 percent of it is allocated for prevention—that’s a very small slice of the AIDS portfolio. I think we need to invest more in prevention in the front end. But treatment and housing also need immediate attention. Everyone in the U.S. should have access to good quality medical care, and everyone should have a place they can call home; this is also true for people living with HIV. We should not rest until this is a reality.

OCPA: Why is housing such an important part of an HIV/AIDS plan?

DH: There is an increasing body of scientific studies showing that one’s housing status is related to HIV-related risk behaviors and even viral load. There are biological, as well as social and behavioral consequences of living with HIV and being homeless or unstably housed.

OCPA: With successes in antiretroviral therapy, are people still practicing safe sex?

DH: Sadly, people are paying less attention to HIV. According to national polls conducted to determine how much people know about HIV, we are seeing an erosion  in very basic knowledge about HIV. Many people think there’s a cure, but there’s not a cure yet. This is still a disease to be avoided; sadly, there is still an AIDS-related death about every half hour in the U.S. That is unacceptable.

OCPA: Twenty-five years into the epidemic, why are there still so many new cases every year in the U.S.?

DH: Keep in mind, incidence is higher than we previously thought in the U.S. Our (inflation adjusted)  prevention funding dropped over 19 percent in the last several years—and funding and incidence are very related. For too long, there’s been a sense of complacency in terms of interest, investment and media attention. There aren’t a lot of domestic HIV stories in the media. It’s only recently that the media is interested again since the unveiling of CDC’s recent incidence estimates. We must take that recent expression of national interest, and put it into a real energetic movement that includes completing a high-quality, actionable and impactful national AIDS strategy before Memorial Day, 2009. As a nation, we can do this. If we can bailout Wall Street for $700 billion, we can find a way to do what needs to be done for HIV/AIDS in the U.S.

—Christine Grillo