Special Report: HIV Prevention at 25 Years

Open Society Institute criticizes US progress

U.S. didn't come close to its own goals

A new report about the state of HIV/AIDS in America finds fault with how 25 years of presidents and Congresses have handled the AIDS epidemic domestically, which the report says has exploited longstanding inequities in American society.1

"The country has failed to come to grips with an interwoven set of social factors—including economic inequality, racial and gender disparities, racial discrimination, and homophobia—that create vulnerabilities to HIV infection and lead to poorer outcomes from health care services,"1 states the Public Health Watch/Open Society International report. The report, titled "HIV/AIDS Policy in the United States," was issued May 23, 2006.

The biggest problems with the United States' response to the AIDS epidemic has been the reliance on a multi-tiered health system in which the best medical care and outcomes go to the people who have access to private health insurance coverage and the growing disconnect between prevention programs with scientific validity and what is funded by federal dollars, the report says.1

"U.S.-funded AIDS research has led to lifesaving scientific breakthroughs. Hundreds of thousands of infections have been prevented, and many lives have been saved through publicly funded treatment and care programs," says Chris Collins, author of the report and a Public Health Watch consultant. Collins spoke at a teleconference about the report. "But it is also true that needless mortality, inadequate access to care, persistent levels of new infection, and sharp inequalities define AIDS in America today," Collins adds.

About half of the people in the U.S. who have HIV receive regular HIV-related medical care, and only about half of the people who meet government criteria for antiretroviral drugs receive antiretroviral treatment, Collins says.

The other problem is that HIV prevention funding is limited, it has not been allocated in the most cost-effective manner, and it's often at odds with evidence-based prevention knowledge, Collins says.

Evidence-based strategies ignored

The Open Society report illustrates the disconnect between public health consensus on effectiveness of evidence-based HIV prevention and current U.S. policies that undermine it, says Judy Auerbach, PhD, vice president for public policy with the American Foundation for AIDS Research (amfAR) of New York, NY.

Funding for abstinence-only until marriage education has grown from $80 million in 2001 to $178 million in 2006, Auerbach says.

"At the same time, the U.S. currently denigrates condom effectiveness in its public health material," Auerbach says. "Then it prohibits programs that receive this abstinence-only funding from even mentioning that condoms are proven to be 80% to 95% effective in preventing HIV transmission, when used correctly and consistently."

HIV prevention research, itself, has been under attack, and this contributes to the problem, Auerbach says.

The Open Society report points out the glaring racial disparities in the HIV epidemic with African Americans accounting for 40% of AIDS diagnoses through 2004, despite their 13% share of the U.S. population.1 Likewise, Latinos represented 20% of new AIDS diagnoses in 2004, although they represent 14% of the U.S. population.1 "Survival after AIDS diagnosis was lower for African Americans and Latinos than for whites and Asians," the report says.

"The U.S. is failing in efforts to reduce the racial and economic disparities that are the hallmark of HIV/AIDS epidemic in America," says Phill Wilson, executive director of the Black AIDS Institute of Los Angeles.

"Twenty-five years into this epidemic, its burden falls more heavily than ever on people of color, especially African Americans, men who have sex with men [MSM], women, the young, and the poor," Wilson says. "In 2006, AIDS in America has become virtually a black disease."

CDC data show that half of the black MSM in some cities are HIV positive, and two-thirds of these men don't know that they're infected, Wilson says.

"Reducing the HIV burden in poor and disenfranchised communities in the U.S. will require a real effort on the part of our government to reach out into black and other communities of color with programs that are developed for and targeted to, rather than just simply adapted for those communities," Wilson adds.

AIDS is the number one cause of death among African American women, ages 24 to 34, says Pernessa Seele, founder and chief executive officer of The Balm in Gilead of New York, NY.

"AIDS diagnosis among women rose from 8% of total diagnoses in 1985 to 27% in 2004," Seele says. "Among women diagnosed with AIDS in 2004, 64% were African American, and 18% were Latino."

One of the problems is that non-governmental organizations (NGOs), such as The Balm in Gilead, have not been invited to participate in the process of evaluating the U.S. government's response to the epidemic to make certain it's efficient and effective, Seele says.

"In recent years, there has been growing concern about perceived federal harassment of NGOs providing AIDS services that may not reflect the ideology or power positions of the government," Seele says. "For example, in October, 2003, Representative Henry Waxman noted that HHS may be inappropriately using its authority to penalize groups that promote comprehensive sex education."

The report provides suggestions for improving the state of HIV/AIDS in the U.S., and these include accountability, addressing racial disparities, and focusing on effective interventions.

"First, America should hold itself accountable for steadily improved results on HIV prevention and care," Collins says. "We should use concrete targets as part of an ongoing effort to systematically assess programming and policy."

Secondly, racial disparities need to be addressed in a much more intensive way, Collins says.

"The government should launch a vigorous, federally managed effort to test, refine, and deliver innovative programming that improves outcomes for communities of color," Collins says. "We have to better understand how to deliver services to those who are often not reached in the current healthcare system."

And, third, the U.S. should dedicate more resources to proven effective interventions, Collins says.

"On HIV prevention, the CDC and other agencies should tie programming much more closely to evidence of what works," he says. "This includes needle exchange, condom availability and abstinence-plus education."

In the CDC's recent report about HIV prevention after 25 years, there's a table listing some of the CDC's prevention interventions from the CDC Diffusion of Effective Behavioral Interventions (DEBI) project.2 The DEBI list represents scientifically-proven intervention methods, and states and community-based organizations are encouraged to use and adapt one of these methods for their own prevention work.

Critics say the DEBI list, which so far has less than 20 interventions included, is too limited and does not address all of the populations at high risk for HIV infection.

Part of the problem is that most of the CDC's approved evidence-based interventions were not designed by or for African Americans, Wilson says.

"They're not programs that have credibility in black America," Wilson says. "So, as a result, while these programs may have evidence that they work in some communities, there is not evidence that they are culturally appropriate in black America."

While there are some interventions on the DEBI list that were designed for African American women, there are none that were specifically designed, tested, and found to be effective for African American men who have sex with men, says Richard Wolitski, PhD, chief of the prevention research branch at the CDC.

"So one of the challenges now is how to take these effective interventions and culturally tailor and adapt them so they can be effective for African American MSM, while at the same time developing new interventions for this population," Wolitski says.

At present, the CDC is working with the North Carolina Department of Public Health to implement and test an adaptation of the popular opinion leader intervention on the DEBI list to be used for African American MSM, Wolitski says.

The intervention initially was designed and tested on a primarily white, at-risk MSM population.

The adapted model has been implemented at three sites in North Carolina, and the preliminary evaluation data from the project are very promising, Wolitski says. "And we'll present results of that evaluation as part of an oral presentation at the International AIDS Conference this summer."

"There has been a significant reduction in risky sexual practices among MSM who were sampled in community venues over a one-year period of time," Wolitski says.

Once an adaptation is proven effective then the CDC will provide training and technical assistance to organizations that wish to use it, Wolitski adds.

"This project suggests at least in one case taking an effective intervention and adapting it for another population has promise," Wolitski says.


  1. HIV/AIDS policy in the United States. Monitoring the UNGASS Declaration of Commitment on HIV/AIDS. Public Health Watch/Open Society Institute. May, 2006:1-76.
  2. Evolution of HIV/AIDS prevention programs—United States, 1981-2006. MMWR Morb Mortal Wkly Rep. 2006;55(21): 597-603.