New data from the CDC confirm HIV is on the rise
Latest statistics offer sobering look at epidemic
A new report on HIV diagnoses among 29 states for 1999 to 2002 is as strong a statement as national public health officials have ever given to confirming anecdotal reports that HIV infection rates are on the rise.
The report published by the Centers for Disease Control and Prevention (CDC) in the Dec. 1, 2003, Morbidity and Mortality Weekly Report still refers to new HIV diagnoses, instead of using the term "cases." But it also states that the increase in HIV diagnoses more likely reflects an increase in new cases rather than more intensive testing efforts.
"We’re trying to keep saying here, You put all the pieces together, and it’s not headed in the right direction,’" says Ronald O. Valdiserri, MD, MPH, deputy director of the National Center for HIV, STD, and TB Prevention at the CDC in Atlanta.
The four states, including Florida, which have been added to the report, include states with high Hispanic populations, he says.
"We would like to get to the point in time when we can talk about trends in all the states, but this is the largest sample we have," Valdiserri adds.
However, because the states vary in the way they collect HIV data, a clear-cut HIV trend still may be years away. For instance, Florida, which now is among the 29 HIV reporting states, saw a significant increase in its new HIV diagnoses in 2002 because of its testing push, which resulted in a 9% increase in HIV testing, says Lorene Maddox, MPH, data analyst manager in the Division of HIV in Tallahassee.
In 2003, the new HIV diagnoses in Florida have leveled off to the 5,000 to 6,000 a year that the state had experienced prior to 2002, she says.
One problem with Florida’s HIV data is that the state does not permit a viral load test to be used as confirmation that someone is HIV-positive for purposes of surveillance. In other words, people who were diagnosed as positive prior to 1997 and who have not since then developed AIDS but have periodic viral load tests as part of their treatment need to be retested before they can be counted as an HIV diagnosis for purposes of Florida’s data collection, Maddox explains.
Overall, the 29 states saw a 5% increase in HIV diagnoses from 1999 to 2002. Among Hispanics, that increase was 26%, and among men who have sex with men (MSM) of all ethnic backgrounds, there was a 17% increase from 1999 to 2002. Heterosexual women had no increase in new diagnoses.1
"The rates of diagnoses among injection drug users (IDUs) and heterosexuals are relatively stable, and the only significant increase in diagnoses was among MSM," Valdiserri says.
Also, there were no significant changes in new HIV diagnoses among African-Americans and Asians/Pacific Islanders.1
HIV clinicians were not surprised by the CDC’s report because they’ve seen firsthand a recent trend of increased HIV cases, says R. Scott Hitt, MD, chief executive officer of the American Academy of HIV Medicine (AAHIVM) in Los Angeles.
"When I talk to providers, I hear that they see a disturbing increase in infections," he says.
Howard Grossman, MD, has seen an increase in HIV cases in recent years in his general internal medicine practice, the Polari Medical Group in New York City. He sees about 950 HIV-infected patients.
"I think it’s incredibly alarming," Grossman says. "It’s a scary time with HIV right now, and a lot of us don’t know what’s going to happen next."
With so many people becoming infected, there’s a real possibility of another huge explosion in new HIV infections, he adds.
Another clue that new HIV infections were on the rise was the increase in syphilis infections in the last few years, notes Rowena Johnston, PhD, associate director of basic research at the American Foundation for AIDS Research, also in New York City.
"You’ll get syphilis if you have unprotected sex, and if you see an increase in any other sexually transmitted disease (STD), you will see an increase in HIV," she says.
Reasons for this increase include the complacency that has surrounded HIV infection among some high-risk groups, as well as the attitude among heterosexuals, particularly people in some ethnic groups, that they are not at risk of infection, Johnston explains.
"Non-Caucasians have felt they were not at risk because all previous prevention messages targeted one group, and they didn’t grow up or have themselves surrounded by people who died of AIDS," she says.
Needed: More money and more patience
Effective HIV prevention requires more resources and patience, Johnston points out.
"We’re talking about sex, one of the most complicated issues there is; and certainly, there will not be one program applicable to every member," she adds.
AAHIVM recently called for the federal government to turn around the trend by increasing funding for HIV prevention programs.
"The sad part of all of this is the government didn’t say, What we’re doing is working, and we will add new money into this,’" Hitt says. "Instead, they said, We’d like you to do better, but we won’t give you the resources to do it,’ and that puts the CDC in a tough place."
Instead of increasing HIV prevention funding, the Bush administration and Congress have earmarked some of the existing spending for certain types of programs, and that leaves less in the pie for proven prevention strategies, he says.
Examples include abstinence-only education programs and the prevention for positives program, Hitt says.
"Congress didn’t include funding for the new programs, and second of all, I think these programs for HIV-positive people have a very real possibility of increasing the stigma of HIV," he adds. "Some people see that [positives prevention program] shifting all responsibility for new infections on the people living with HIV."
Whenever there’s a culture in which one group is targeted as causing the damage, then there’s a real chance of stigma, Hitt explains.
Valdiserri says the CDC is sensitive to the issue of stigma and has taken steps to make sure it doesn’t happen.
"We’ve had a series of national meetings with various groups, including one on the issue of stigma, and we’re very sensitive to that issue," he says. "I think that, in short, what it means is we have to work very closely with these communities so that the prevention message gets out in ways that are beneficial to communities and society."
The CDC also is investing in its early testing initiative with the objective of getting more people tested for HIV and into treatment, Valdiserri explains.
Money for drugs and treatment needed, too
Hitt and other critics have said that while the early testing program is a laudable goal, it also should be accompanied by increased funding, especially for HIV treatment, since states and AIDS Drug Assistance Programs already are struggling to serve the people who need help with their HIV medication.
So far, no additional funding for treatment has been proposed. That means if early testing programs are a success, it creates a large population of people who know they are HIV-positive but who are not able to receive antiretroviral treatment, Hitt says.
"One branch of government says we need to test all these people and get them into care, and the other branch has no contingency for treating all these people," he continues.
The CDC and the Health Resources and Services Administration in Rockville, MD, are working closely throughout the implementation of the early testing initiative and are developing estimates of how many people might be reached during the first years of this initiative, Valdiserri says.
"We are not naïve, and we do understand concerns about resources," he points out. "We’re talking about people who already are infected with HIV and who are unaware and may be transmitting this virus to others, so there’s an ethical imperative to try to provide people with that information."
Also, not all of the people diagnosed with HIV will be ready for antiretroviral therapy, and it’s still better from the medical and public health standpoint to diagnose people early in the disease, Valdiserri says.
Critics say the federal government’s prevention initiatives are underfunded, and the CDC is hamstrung by the Bush administration’s political agenda to come up with an effective plan to stem the rising epidemic.
Referring to the political side of the issue, says Grossman: "Everything is so fear-based and faith-based that they’re never going to come up with effective messages. There are people at the CDC who care, but I don’t think there’s anybody in the [Bush] administration who cares."
The nation’s local and state health departments too often are hobbled by inadequate resources and an ideology that is too anti-science to do their job, says Paul Feldman, public affairs director of the National Association of People With AIDS in Washington, DC.
In the meantime, it appears the CDC will not succeed with its five-year plan to cut new HIV infections in half by the year 2005.
"Obviously, the CDC has had its knuckles rapped over that [plan]. Unfortunately, we’re living in a time when there’s been an emphasis on abstinence-only sex education, and anyone who looks at scientific evidence out there knows this is not the way to decrease the incidence of HIV," Johnston says.
The federal government and the CDC need to change the way they look at HIV prevention and education, using a corporate marketing and advertising model as their guide, suggests Cornelius Baker, executive director of the Whitman Walker Clinic in Washington, DC.
"We need to think of prevention in HIV and STDs as a lot more like selling Coca-Cola," he says. "The reality is that there is not a market Coca-Cola would ever leave off the table."
The goal should be to sell HIV prevention to as many people as possible with a generalized message for that population, Baker adds.
"But distribution messages are different, so while you have one overall universal message, you also have to layer it and cut it and reach deeper into some communities that you know are more likely to be interested," he explains.
With HIV prevention there also needs to be a general message for the American public, because even people in monogamous relationships could hear the message and help influence the behavior of people who are at greater risk, Baker says.
Likewise, there should be a full, scientifically based comprehensive sexual health education program in every school in the country, Baker says.
"Things only become barriers if there is not the political will," he says. "The real challenge for our nation’s leaders is: Do they have the political will, or are they prepared to be judged harshly by history?"
1. Increases in HIV Diagnoses — 29 States, 1999-2002. MMWR 2003; 52(47):1,145-1,148.