WHY THE U.S. HAS NOT STEMMED HIV

Activists Blame Infection Rate, Unchanged Since 1990, on Policies and Funding

The number of people in poor countries taking AIDS drugs -- about 1.4
million -- rises by tens of thousands every week. The spread of AIDS
in Africa seems to have peaked. Three countries there -- Uganda,
Kenya and Zimbabwe -- report declining HIV prevalence, largely thanks
to changes in people's behavior. Even in India, considered AIDS's
ticking time bomb, efforts to defuse the epidemic are paying off in
some places.

Amid these optimistic trends from around the world, however, is
another statistic that is stuck in time, right here at home.

The number of new HIV infections in the United States has been about
40,000 a year for the past decade and a half. It has not budged --
not with new drugs, new prevention strategies or new administrations.
Five years ago, the Centers for Disease Control and Prevention
launched an effort to cut it in half. It did not move.

The intransigence of the AIDS epidemic in the place where it emerged
- -- and where many of the strategies against it have been developed --
will be on the minds of many this week as 20,000 people gather in
Toronto for the 16th International AIDS Conference.

There is little question that, for public health experts and AIDS
activists, the fact that the HIV infection rate has not changed since
1990 is an embarrassment. At the same time, it is a testament to a
victory -- albeit one that happened long ago.

AIDS was first recognized in June 1981. Incidence of the disease --
the number of new cases in a period, generally a year -- peaked at
160,000 in the mid-1980s. With intensive effort to reduce risky
behavior in gay men and, to a lesser extent in injecting drug users,
it fell to 40,000 by 1990. It has remained there since.

"It's very much a glass-half-empty-glass-half-full situation," said
David R. Holtgrave, a professor at the Bloomberg School of Public
Health at Johns Hopkins University. "Prevention seems to work. But it
seems like we have a lot of work left to do."

In the eyes of Chris Collins, who wrote a new report on U.S. AIDS
policy for the Open Society Institute, "America is in many ways
failing its own citizens in its domestic response to the epidemic."
Government inaction has produced "needless mortality," he wrote.

But Grant Colfax, a physician at the San Francisco Department of
Public Health, said last week that "as someone who tries to figure
out new ways to reduce the number of infections, I don't sit here and
blame the CDC for this rate remaining at an unacceptable level for 15 years."

What does bother him, though, is the lack of money for prevention.
"As a society, there is just not enough commitment to addressing
this," he said.

The number of new HIV cases each year has not changed despite a
dramatic increase in HIV prevalence, the number of Americans infected
at a given time. That number stands at 1.1 million and is growing as
people on combination antiretroviral therapy live far longer than
AIDS patients used to. Deaths from AIDS in the United States dropped
from 52,000 in 1995 to 15,800 in 2004.

Normally, a rising number of infected people would lead to a rising
number of new infections each year, as more people are able to
transmit the virus. But that is not happening. One of the main
reasons is that HIV-positive people today are more likely to know
they are infected -- and to know to take precautions -- than was the
case in the past.

Consequently, a stable rate of 40,000 new cases a year is a "very,
very significant finding," Ronald O. Valdiserri, deputy director of
the CDC's HIV and AIDS activities, said last week. "We think it
represents some level of success in HIV prevention. We will not deny
that we have a ways to go."

What would it take to lower the infection rate?

Holtgrave, who worked at the CDC and at Emory University before
moving to Johns Hopkins, tried to answer that in 2002 and recently
updated his calculations.

He estimates that the number of new infections could be cut in half
if the 5 million Americans at highest risk of HIV -- 4 million
because of sexual activity and 1 million because of drug use --
received the full battery of proven interventions. Those include HIV
counseling and testing, free condoms, one-on-one or small-group
counseling sessions, and needle exchange.

The CDC now spends $720 million a year on HIV prevention. It would
need to spend $415 million more to reduce new cases by 50 percent,
according to Holtgrave's calculations.

He and his collaborators further estimated that the country would
need to prevent 12,000 infections each year to save money in the long
run. HIV infection is expensive to treat, and newly infected people
will need to be treated for decades -- a huge cost to the health-care system.

There is a lot of evidence that there is much more prevention to be done.

The CDC last month published a survey of 10,000 men who have sex with
men -- the term preferred by epidemiologists, as some such men do not
consider themselves gay or bisexual. They were questioned at bars,
dance clubs, gyms, raves, beaches and on the street in 17 cities
between 2003 and 2005.

The survey found that 77 percent had been tested for HIV in the
previous year. Testing is a crucial prevention tool. Studies have
shown that each year, 11 percent of people who do not know they are
infected transmit the virus to someone else, compared with 2 percent
of those who do know. Overall, it is estimated, about one-quarter of
infected Americans do not know their status.

Forty-seven percent of those interviewed said that in the past year
they had engaged in unprotected anal sex -- the riskiest activity.
Ninety-eight percent had gotten free condoms. But only 15 percent had
had one-on-one risk counseling, and only 8 percent had had peer-group
sessions -- two interventions found to change behavior.

The population most vulnerable is young black men who have sex with
men. In a study of five cities -- Baltimore, Los Angeles, Miami, New
York and San Francisco -- published last year, CDC researchers found
that 46 percent of people in that category were infected. Two-thirds
of them did not know it.

Many of those men are difficult to reach for testing and risk
counseling, and some organizations that work with that population
have found it increasingly difficult to get government money for their efforts.

"I think it's fair and certainly honest to say that over the past
several years we've gotten more stringent with our funding,"
Valdiserri, of the CDC, said last week.

Men of Color Motivational Group was a 14-year-old organization of gay
black men in Detroit with two missions: outreach to teenagers and
outreach to adults. It had a $1.2 million budget, with $650,000
provided by the CDC.

Last year, it lost that funding and closed.

"Over the years, there were ups and downs," said Mark J. McLaurin, a
New York AIDS activist who sat on the group's board. "But I don't
think there was any question that dealt the deathblow."

The strategy for reducing new infections many experts consider most
overlooked is needle exchange for drug addicts.

The CDC estimates that 17 percent of new infections each year come
from contaminated needles. Evidence suggests that 65 percent of those
could be prevented if every addict had access to a clean needle.
However, federal law prohibits using federal money for that purpose.

Nevertheless, there are 150 needle-exchange programs around the
country, including one in the District, supported by local budgets
and contributions. They have had dramatic effects.

In Baltimore, 60 percent of new infections came from drug use in
1994, the year before the city offered needle exchange. In 2003, 41
percent of new infections came from needle use -- and over that
period the total number of new infections, from all causes, declined.

Exchanging 2.2 million needles a year, Seattle is not just protecting
addicts. Most heterosexual transmission occurs between male drug
users and their female partners. In Seattle, very few women are
becoming infected that way, which in turn means that few pregnant
women are HIV-positive. That is part of the reason the city hasn't
had a baby born with the virus since 1997, said Robert W. Wood, the
physician who heads HIV-control efforts in the Seattle health department.

"Is prevention effective? We've spent a lot of money and a lot of
effort toward IV drug users, and I hope that's not for naught," he said.