HIV prevention efforts reach a crossroad as signs point to rising infections

Meanwhile, politics is deciding prevention strategy

Nearly halfway through the five-year HIV prevention plan unveiled by the Bush administration in early 2001, all signs point to discouraging news about HIV infection rates and funding and prevention policies, AIDS activists and other critics say.

In the spring of 2001, officials with the Centers for Disease Control and Prevention (CDC) announced that by 2002, the nation’s incidence of new HIV infections would be reduced by 6% and by 2005, the incidence would be reduced by 50% to 20,000 new infections per year.

More than two years later, there is no evidence that new HIV infections are declining, and most signs suggest that incidence rates are on the rise. While the CDC still doesn’t have data from all 50 states about new infection rates, the information that is available does not look promising. Twenty-five states, representing about one-quarter of U.S. AIDS cases, have been reporting new HIV diagnoses for several years. They show an 8% increase in these diagnoses between 1999 and 2001, says Ronald O. Valdiserri, MD, MPH, deputy director of the National Center for HIV, STD, and TB Prevention at the CDC.

Broken down, the data show that new diagnoses among injection drug users have decreased, while new diagnoses among men who have sex with men (MSM) have increased by 14% during that period. Among heterosexuals exposed to HIV through sex, the increase between 1999 and 2001 was 10%. Further evidence that HIV rates could be increasing is the data showing how primary and secondary syphilis rates have increased recently among MSM.

Also, pessimistic news comes from Linda Valleroy, PhD, CDC researcher, and her colleagues who performed de-tuned HIV assays on sera from representative samples of MSM recruited from six U.S. cities between 1998 and 2000, Valdiserri told HIV clinicians at the 10th Conference on Retroviruses and Opportunistic Infections, held Feb. 10-14, 2003, in Boston.

Valleroy’s research found that overall HIV prevalence and incidence were high, but among African-American MSM, these were extraordinarily high, Valdiserri said. "Nearly one in every three young African-American MSM in their sample was infected with HIV, and these researchers found an annual incidence rate of nearly 15%."

In light of the data suggesting that HIV incidence has not declined and possibly is rising, the CDC is asking clinicians to renew their efforts at HIV prevention and educate both HIV-infected individuals and at-risk people through proven HIV risk reduction interventions that target MSM and other at-risk groups. Valdiserri told HIV clinicians that, according to research, the most effective interventions promote interpersonal prevention skills and seek to change sexual and drug-use at-risk behavior, including increasing condom use. None of the studies reviewed or cited by Valdiserri involved abstinence-only interventions.

Yet abstinence-only programs targeting both youth and adults are precisely the approach that the Bush administration is advocating, and the administration’s agenda is philosophically on the same page as social conservatives who want sex education and prevention programs to discourage condom use, say AIDS and public health advocates.

"Social conservatives wanted to insert language into a House bill that would make abstinence a priority in HIV/AIDS prevention," says Heather Boonstra, MA, senior public policy associate for the Alan Guttmacher Institute (AGI) of Washing-ton, DC. AGI is a pro-choice organization that promotes sexual and reproductive health and rights. House Democrats were able to defeat that amendment, Boonstra says.

"We’re going from prevention funding based on behavioral and science research to funding based on values," says Ana Oliveira, executive director of the Gay Men’s Health Crisis (GMHC) in New York City. "Behavioral and science research say that one size doesn’t fit all. Abstinence may be a viable option for many people in different times in their lives, but to promote abstinence as a desirable behavior and the only one to behave for many people is not appealing, and it’s not a choice for some people."

Catch 22

Also, abstinence-only prevention programs aimed at adults send the message that everyone should be married before having sex, and this completely ignores the lives of gay and bisexual individuals, she adds.

Just the suggestion that the current administration favors abstinence-only HIV education above all other forms already has had a chilling effect on HIV prevention programs, Oliveira notes. "We work with colleagues in the field, and now people have an enormous fear about producing educational materials that speak about sex. Here’s an area where it’s having a ripple effect that’s very bad."

Meanwhile, funding for HIV prevention remains flat in the president’s budget proposal at the same time that the administration proposes adding millions of dollars to the budgets for abstinence-only education programs.

"We’re concerned that domestic programs are being cut for HIV prevention, especially in a time when we have seen rising infections, rising sexually transmitted disease (STD) rates," says Scott Brawley, director of public policy at AIDS Action in Washington, DC.

While the proposed Bush budget shows a net decrease of more than $850,000 for domestic HIV programs, the administration has proposed increased funding for abstinence-only programs for both youth and adults.

Last year, the government provided more than $100 million for abstinence-until-marriage programs, and another $50 million of CDC funding for HIV/STD prevention that also could be used for abstinence programs. Some of the abstinence funding is a matching fund program in which states can receive $4 of the federal funding grants for every $3 of state funds. Other abstinence-only funds are not matching grants and are distributed directly to individual organizations and programs.

Bush proposes to increase this funding by 30% despite the fact that there is no evidence the programs work, critics charge.

"To date there has been no federal evaluation of these programs," says Cynthia Dailard, JD, an AGI senior public policy associate.

Abstinence-only program funding still is a relatively small part of the federal budget, but the actual amount is deceptive because studies have shown that this type of funding results in a "crowding out" of other sex education and prevention programs, says Rebecca Schleifer, JD, MPH, a researcher with Human Rights Watch of New York City. Schleifer authored a 2002 report, called Ignorance Only: HIV/AIDS, Human Rights and Federally Funded Abstinence-Only Programs in the United States; Texas: A Case Study, about the impact of abstinence-only funding in Texas.

States that opt to receive the matching funds for abstinence-only programs have essentially agreed to earmark scarce state funds to educational programs that are not permitted to say anything positive about condoms or safe sex. The rationalization is that studies have shown that condoms are not 100% effective for 100% of sexually transmitted diseases (STDs).

This means that there will be less state money available for comprehensive sex education and HIV prevention programs that talk about abstinence and condoms, Schleifer and other critics say.

"In states that have heavily pushed abstinence-only programs, it has greatly influenced what they do with CDC funds," Schleifer says.

When a state, such as Texas, which has one of the highest rates of teenage pregnancy nationally, fully embraces federally subsidized abstinence-only education, there is a crowding effect in which other types of HIV, STD, and pregnancy-prevention information is lost, she adds. "One HIV educator told me she was going to use the CDC grant for HIV prevention to teach refusal skills. She doesn’t teach about condoms as part of HIV prevention because she has been told by school nurses that school administrators in her area won’t allow her to do so and because of community concerns that people should remain abstinent until marriage to prevent pregnancy and disease."

While abstinence-only programs, even when there are no studies showing that they succeed at their goals, may be seen by many as a benign way to educate youth, there is evidence that the Bush administration wants to change HIV prevention policy for adults to include abstinence-only education, Schleifer says.

"Bush stressed that abstinence-only is an integral part of HIV prevention policy, and he appointed [obstetrician and former congressman] Tom Coburn, a staunch advocate of abstinence-only programs, to the HIV board," she says.

Coburn is the co-chair of the Presidential Advisory Council on HIV/AIDS (PACHA), which is directed by Patricia Funderburk-Ware, a former actress who has lobbied against HIV prevention and education efforts that include information about safer sex.

"There is a wealth of evidence that giving kids more complete education about preventing HIV through condoms and comprehensive programs can be effective in reducing HIV risk behavior, and there are no reliable data that abstinence-only programs prevent HIV," Schleifer says.

Teaching both

Research clearly demonstrates that young people will change their behavior and have less unprotected sex if they are educated about both abstinence and condoms, says Douglas Kirby, PhD, senior research scientist for ETR of Scotts Valley, CA. "Some education programs emphasize abstinence and also talk about condoms, and these actually delay the onset and frequency of sex," he says. "So it’s clear that it works."

Alternatively, the impact of abstinence-only education easily can be seen in the field, Schleifer says. "I asked kids in Texas who have been in abstinence-only prevention programs how they could prevent HIV infection, and they said that other than abstinence they didn’t know how," she adds.

Another very real harm of the abstinence-only education is when states use the money for media campaigns that provide distorted information about condoms, Schleifer notes.

It would be impossible given existing data to determine the public health impact of abstinence-only programs. But in Texas, where new HIV case information has been collected since 1999, there has been a recent increase in reported HIV cases.

"In 2002, there were 4,731 reported cases of HIV, an increase over 2001 where we had 3,940 cases, and that’s a statewide total of HIV cases that have not progressed to AIDS," says Sharon Melville, MD, HIV/STD epidemiology division director at the Texas Department of Health in the Bureau of HIV and STD Prevention in Austin.

The state’s 20% increase in reported HIV cases between 2001 and 2002 could be due to an actual increase in HIV cases or a statistical increase due to changes in reporting criteria, she says. "As we get further away from the year 2000, we’ll be able to interpret trends better."