Special Report on Prevention Initiatives

Epidemic continues to stabilize except for black females, MSMs

New testing, prevention efforts being tried

The latest surveillance data from the Centers for Disease Control and Prevention (CDC) continue to show a stabilization of the HIV epidemic in the United States. However, data also show there are increases among men who have sex with men (MSM) — and black women are being disproportionately affected.

HIV diagnoses among MSM rose 10.8% between 2000 and 2003, while the overall HIV diagnosis increase among men was 4.9%.1

"We saw the biggest increase [in 2003] in Latino MSM," says Robert Janssen, MD, director of the CDC’s divisions of HIV/AIDS prevention — surveillance and epidemiology support.

The report also notes African American women are 19 times more likely to be HIV-positive than white women, a trend that has continued since the epidemic’s beginnings, he says.

"When you look at the HIV rates, the rates were higher among minorities since the beginning, but the numbers [of women becoming infected] didn’t catch up until the mid-1990s, and since then, it’s predominantly been a racial minority epidemic," Janssen adds.

"Looking at women and African American women historically, most cases were among women and injection drug users, and now the majority are the result of heterosexual sex," he points out.

African American men and women accounted for 25% of all AIDS cases in 2003, an increase from the 20% in 2001.

More than half of new HIV diagnoses are among African Americans, although they represent 12% of the United States population. African American women represent 72% of the new HIV diagnoses among U.S. women.2

Socioeconomic factors play a part

The racial disparity of HIV infection among women pertains particularly to low-income women of color who often are coping with various other issues, including socioeconomic factors and lack of access to health care and preventive services, says Allan Rosenfield, MD, dean of the Mailman School of Public Health at Columbia University in New York City.

Prevention programs developed for African American women should include easier access to the health care system, needle exchange programs, and better educational efforts, he explains.

Domestic and world health officials also point to the need for effective microbicides that women could use without their partners’ knowledge and the need for prevention programs that address the socioeconomic problems, including domestic violence, sexual abuse, lack of adequate housing, and lack of financial resources.

Although some trends can be seen in the most recent data, there are several limitations to the CDC’s current surveillance data, Janssen notes.

For one thing, the data continue to be drawn from only a portion of the states, since the CDC relies on the 32 states with confidential, name-based reporting of HIV infection for its data.

Some of the states with the highest numbers of HIV-infected individuals are not included in the data, such as California, New York, Illinois, Maryland, Massachusetts, and Pennsylvania.

Other problems with analyzing the data involve public health trends, which can impact the number of people being tested and diagnosed, Janssen says.

Part of the problem is that HIV diagnoses is a result of HIV incidence and HIV testing, so an increase in one but not the other could show an increase in HIV reporting, he continues. "You could see more HIV reports among Latino MSM, but that doesn’t mean there are increases in new infections occurring in that group."

The CDC doesn’t have enough information to discern whether the increases are related to changes in testing, new infections, or both, adds Janssen.

In about a year, CDC officials expect to roll out the first nationwide incidence surveillance system, which will give real-time data about who is becoming infected and whether new infection rates are increasing overall or within specific populations, he says.

Nonetheless, CDC officials say they are concerned about the increase in HIV diagnoses among MSM because of other reports that indicate MSM increasingly are engaging in high-risk sex because of the success of antiretroviral treatment and the reduced threat of death from AIDS, Janssen says.

"We hope when we see new incidence, that should give us a much better sense of what’s going on," he points out.

Better-targeted testing programs

HIV diagnoses should show an increase next year due to the CDC’s new testing and prevention program that has put considerable effort into increasing HIV awareness and testing, Janssen says. "I’m hopeful we’ll see increases as a result of . . . better-targeted testing than what we have now," he says.

For instance, the CDC has provided grants to community-based organizations (CBOs) and state and local health departments to implement demonstration projects of targeted HIV testing. That includes using the Oraquick rapid test, testing in nontraditional sites, and the use of social networks and peer recruiters.

One of the demonstration sites, the Harlem United Community AIDS Center in New York City, had concentrated its prevention efforts on keeping HIV-negative people negative. But it changed its focus to a prevention for positives emphasis in response to the CDC’s targeting the positives population, says Tata Traore, program director.

"We create self-awareness and have clients understand their responsibility toward their community, and we also try to identify a risk factor that they’re engaging in and try to work on it," she explains

"We are seeing slow progress," Traore says. "When the program was funded, they wanted it to have a three-month cycle; and we extended it to six months because we didn’t think significant change could be noticed in under six months."

In Chicago, the Night Ministry has used rapid HIV testing with Oraquick since October 2003, as part of a pilot program that evolved into a CDC-funded demonstration project, says Jenny Tsang, MPH, rapid HIV testing coordinator.

Increase in % of clients who wait for results

So far, the testing initiative has found a 2% HIV-positive rate among those tested, and the rate of people who are tested and receive their test results has grown from 50% to nearly 100%, she says. Only two people out of 750 people tested did not stay for their results, Tsang adds.

"Our population really likes the rapid test," she says.

"We’ve had people come from the suburbs to get rapid tests from us, and we’re one of 10 to 15 sites that can do rapid testing."

The positive response largely is because of the convenience of the rapid test and the fact that it’s emotionally difficult to wait for HIV test results, Tsang notes.

Although no official data have been analyzed from the demonstration projects, some of the CBO officials in charge of the projects contend certain strategies are not well-suited for all populations.

For example, it has been difficult for the Southwest Louisiana Area Health Education Center in Lafayette to enlist the services of social network recruiters because of confidentiality issues in a small, rural community, says Robin Boyles, director of health education.

"We’re the only demonstration project that serves rural communities, and that makes us a little different," she says. "We’ve had challenges related to confidentiality that are a little greater than in larger communities because everyone knows everyone."

So if people volunteer to be peer recruiters for the center’s project, the community would know they were positive, and that has been the center’s greatest challenge in finding recruits, Boyles explains.

One solution has been to drop the title of recruiter, she adds. "Recruiter has negative connotations, particularly with the military climate right now, people recruiting for the military, to go to war."

Instead the center’s staff will say, We have this project, and we know you are concerned about people in the community, and we think you’d be good working with us to find people who are HIV-positive,’ Boyles says.

The social networking program also needs adjustments in some urban settings: For example, high-risk populations in San Francisco are sensitive to partner counseling and referral services because there’s resistance to name-based HIV reporting, says Cicily Emerson, MSW, director of prevention services at Continuum in San Francisco.

"It’s a struggle to establish trust to get people to come in for testing," she says. "I do see [social networking] being effective if you get the right recruiter."

Gifts also an incentive

Also, Continuum traditionally offers small gifts, such as $10 gift cards, as incentives to people who come in for HIV testing, Emerson says.

Some homeless and other high-risk people are regularly tested for HIV because they shop around for the incentives, she explains. "That’s part of their way of life."

"Where you have a highly transient population, it can be difficult to use the social network approach because the people who are stable and in recovery have left the old associates behind," Emerson adds. "The other challenge is around name-based reporting and the fact that most test counselors haven’t discussed disclosure with people before, so they don’t have that mindset."


1. Diagnoses of HIV/AIDS — 32 states, 2000-2003. MMWR 2004; 53(47):1,106-1,110.

2. UNAIDS, World Health Organization. AIDS Epidemic Update, December 2004. 1-87.