25 Years of HIV/AIDS

CDC to remove pre-test counseling requirements

Latest stats: Nearly half of infected are black

After two and a half decades of fighting one of the most insidious and stigmatized public health epidemics in recent history, U.S. public health officials say they are ready to simplify HIV testing guidelines, including eliminating requirements for HIV pre-test counseling.

This move is expected to make HIV testing more routine and easier for clinicians to use as a screening tool for all patients, rather than as a recommended part of care only for high-risk patients.

"We're proposing to simplify and remove pre-test counseling in clinical settings, says Kevin Fenton, MD, PhD, director of the CDC's National Center for HIV, STD, and TB Prevention. Fenton recently spoke at a national teleconference that highlighted the progress made and challenges remaining as the epidemic reaches the 25-year mile post.

"What we're essentially trying to do is address the barriers for HIV testing, and we know that one significant barrier is the amount of time it takes for pre-test counseling," Fenton says.

"One of our current strategies is to increase the number of people who know their HIV infection status," says Timothy Mastro, MD, acting director of the CDC's division of HIV/AIDS prevention.

"These guidelines address clinical settings, and they recommend routinizing the nature of HIV testing so it's not based on an assessment of the risk of an individual or the prevalence of the community in which the person resides so that there would be a routine screening for HIV of all persons between the ages of 13 and 64," Mastro says.

People with ongoing risk behaviors should be tested more frequently, but everyone else in the 13 to 64 age group should be tested at least once, Mastro adds.

Infectious disease and other clinicians have been reluctant to push for routine HIV testing among patients because of the amount of time it takes to meet counseling guidelines, health care officials have said.

The new guidelines about pre-test counseling, which are expected to be released this summer, will remove that concern, Fenton says.

A recent study, presented at the 2006 National STD Prevention Conference, held May 8-11, 2006, in Jacksonville, FL, demonstrated success with a policy switch from a selective HIV testing system to an opt-out system, in which HIV testing became routine.

The most recent update on the state of the HIV/AIDS epidemic in the United States confirms the major accomplishments in reducing AIDS deaths, but also confirms one of the epidemic's most disturbing trends: African Americans are disproportionately impacted by the epidemic, representing nearly half of all AIDS cases.

In the early years of the epidemic, about 60% of the people with AIDS were white, and blacks accounted for about 25% of AIDS cases. Now, blacks account for 49% of AIDS cases, while white AIDS cases have remained under 30% for five years. (See chart on proportion of AIDS cases among adults and adolescents.)

AIDS cases among Hispanics has risen from 15% of the total AIDS cases in 1985 to 20% in 2004.

The CDC estimates that 47% of people living with HIV infection are black, while 34% are white, and 17% are Hispanic.

"African Americans are the hardest hit by AIDS, accounting for more than one-third of deaths to date," Fenton says. "African American men who are men who have sex with men (MSM) are especially hard hit." One study found that half of black MSM in one area were infected with HIV, he says.

AIDS cases by gender also have changed considerably since the 1980s, the CDC reports. While female AIDS cases were one-tenth the number of male AIDS cases in 1985, by 2004, women had one-third as many AIDS cases as men. (See estimated AIDS cases by sex and year of diagnosis.)

The city of Baltimore, which has a high prevalence of HIV/AIDS cases, has seen a similar trend to the national statistics, says Kima Joy Taylor, MD, MPH, an assistant commissioner of health promotion and disease prevention at the Baltimore City Health Department.

"Our actual numbers [of HIV cases] seem to be leveling off, but the numbers of African Americans and women are increasing," Taylor says. "So even though the overall prevalence seems to be flattening out, we still have to address these groups."

Much of the credit for the U.S. epidemic's decline in transmission belongs to the gay community, which has been a strong force in promoting HIV prevention and funding for the past 25 years, says James W. Curran, MD, MPH, dean of Emory University's Rollins School of Public Health in Atlanta, GA. Curran was among the first health care authorities to discover links between the first men presenting with AIDS symptoms.

"We in public health played a role, but much of it was due to the overwhelming presence of the epidemic and the willingness [of the gay community] to discuss HIV and get tested and know about it," Curran says. "AIDS was palpable in the gay community; everyone knew people who were sick or infected, and they knew people who had died, and that presence led to a constant discussion which impacted young people."

Now, attention to the epidemic has subsided, and the pressure is off politicians, making it more difficult to sustain attention and focus on prevention, Curran notes.

"New things are news, and old stories are not news," Curran says. "And it's been more difficult in the highly active antiretroviral therapy era to find newsworthy items that relate to the domestic situation."

The continuing spread of the epidemic among young gay men is not as compelling a story as it would be if it was more broadly spread among middle class people, and the continued invisibility and stigmatization of homosexuality is probably a factor, Curran adds.

The AIDS epidemic began as an insidious infection that first came to public health authorities' attention in June, 1981, with the unusual cluster of Pneumocystis carinii pneumonia infections among five young men, who all were gay, Curran says.

"Shortly thereafter, in the next few months, cases were reported in the injecting drug users [community]," Curran says.

"Even in the early 1980s, we were always greatly concerned that we would underestimate the burden and impact of AIDS around the world," Curran says. "Perhaps silence still does equal death in the worldwide scene."

The past 25 years have gone by in a heartbeat, and the scientific progress has been amazing, Curran says.

"But I'm more amazed at the progress of the virus around the world," Curran adds.

Although AIDS cases peaked in the United States in 1992, and there is some evidence that they may be reaching a peak worldwide now, this trend is no reason to become complacent in HIV prevention efforts, Mastro says.

"We're in this for the long haul, and we're 25 years into it," he says. "Despite our efforts on HIV prevention to date, while we may create success in some areas, the epidemic continues to change, and there are, we think, an ongoing 40,000 infections in the United States."

The CDC would like to bring down the number of new HIV diagnoses considerably, Mastro says.

An increase in HIV testing is one of the key initiatives promoted by the CDC and the U.S. government, Fenton says.

Also, more attention must be paid to HIV prevention, particularly among the populations most impacted by the epidemic, Fenton says.

"In the face of 40,000 new infections each year, clearly the work is cut out for us, and not only with MSM, but with other populations that are marginalized in our society," Fenton says. "The nature of the evolution of the epidemic means we need to look at the driving factors in a whole new way."

Drug use and sexually transmitted diseases place African Americans at increased risk for HIV, and there is no simple solution for reducing HIV transmission, Fenton says.

"One element of a comprehensive approach is to involve communities at risk with implementation and evaluation and development of interventions," Fenton says. "We also need to ensure we work more closely with community leaders to make sure interventions are appropriate."