Winning the Battle Against AIDS (web article)

HIV prevention programs have averted hundreds of thousands of HIV infections in the United States and research has developed a fine armamentarium against the disease, but we still have much work to do to get the infection rate to even lower levels, according to David Holtgrave, PhD.

Holtgrave, professor and founding chair of the Department of Health, Behavior and Society at the Bloomberg School, spoke December 7 at the Johns Hopkins Bloomberg School of Public Health. He said that in January 2001, the Centers for Disease Control and Prevention (CDC) set a goal of reducing HIV infections from 40,000 to 20,000 a year. The infection rate, he said, is still holding steady at roughly 40,000.

Holtgrave noted that the 20,000 persons a year who would escape the epidemic if more prevention programs were in place would amount to 130,000 people by 2010, with an estimated medical cost of an $18 billion.

On the other hand, he said, experts estimate that HIV infections could be halved in the U.S. for an additional $300 to $400 million a year but the money has not been forthcoming.  This is unfortunate because studies have shown that targeted HIV prevention programs not only save lives, they save taxpayers’ money by preventing the need for additional medical care expenditures.

Holtgrave asked rhetorically whether a lack of “skill or will” is impeding the AIDS fight. He then pointed to a number of funding and policy roadblocks put in place by the federal government—the ban on federal funding of needle-exchange programs, for example.

Still, Holtgrave is heartened by the fact that AIDS prevention programs have been working. In 1985, for instance, 25 percent of HIV-positive persons were transmitting the disease to others; by 2000, only 4 percent were spreading the virus.  Further, persons living with HIV who are aware of their infection transmit at only a 2% annual rate (as compared to a 9-11% rate for persons living with HIV infection but who are unaware).

Holtgrave believes that we must keep trying to halve the infection rate, and believes that we must commit to doing so by 2008. “But we mustn’t treat the HIV-positive population as a monolithic community,” he said. “Instead, we’ve got to target our prevention services to clients’ need, in part, by their HIV serostatus or risk behaviors.” Holtgrave suggested tailoring programs to the specific needs of the following groups:

•  HIV-negative persons who are at risk (through multiple sex partners, drug use or existing sexually transmitted diseases)—roughly 14 million people ages 15-44
•  HIV-positive and unaware of the infection—approximately 275,000 persons
•  HIV-positive, but aware of it and not engaging in risky behaviors—roughly 693,000 persons
• HIV-positive, aware, and risky behaviors—approximately 132,000 persons

Each of these subgroups, said Holtgrave, need a particular combination of prevention services. “We need to move people from unaware to aware, and from at risk to no risk,” he said.

There are prevention needs in the general population as well.  One ominous sign: “There’s been erosion of our basic knowledge about the disease,” he said, noting that in the late 1980s, about 90 percent of Americans could separate HIV myth from reality. They knew, for instance, that HIV couldn’t be contracted from mosquitos or a doorknob. Today, however, many people believe there’s a cure for HIV; and larger and larger numbers think HIV can be casually transmitted. And stigma is still a major issue; about 20 percent think that people with AIDS “got what they deserved.”

“In the 1980s there was an AIDS funeral every 15 minutes; today, there is one every 30 minutes. That’s better—but by no means nearly good enough,” Holtgrave said. “We know the tools we must use, now we must—in the words of Baltimore’s Rev. Debbie Hickman—‘scale up and intensify.’ ” —Rod Graham