Era of Sharp Declines in AIDS Cases and Deaths May Be Over
CDC Conference Highlights Continued Obstacles in AIDS Fight
August 27, 2001—Twenty years after the first cases of AIDS were reported, scientists and health officials continue to grapple with many of the same obstacles that have plagued them from the disease’s onset, including how to prevent high-risk behaviors, increase early virus detection, and target prevention messages to those communities at highest risk of infection.
In response to these questions, over 2,000 researchers, public health officials, and AIDS community representatives presented a wide spectrum of studies—some alarming and some encouraging—at the Second National Centers for Disease Control and Prevention (CDC) HIV Prevention Conference in Atlanta, August 12-15. amfAR's Vice President of Public Policy Jane Silver and Foundation Board member Kenneth Mayer, M.D., Director of Brown University's AIDS Program, were among the conference presenters.
Perhaps the most important study results reported at the CDC meeting is that the dramatic decline in the number of Americans acquiring AIDS and dying from it may have ended. Between July 1998 and June 2000, AIDS cases and deaths in the U.S. remained stable, signaling the end of the period of significant declines that began in the mid-1990s and were attributable largely to the advent of new combination or “cocktail” antiretroviral therapies. “The latest data suggest that the era of dramatic declines is over [and] there are a number of signs indicating that our progress in fighting the disease is in serious jeopardy,” said outgoing CDC Director Helen Gayle.
Ironically, the very success of combination therapy has fostered a widespread misperception that HIV no longer poses a serious risk, potentially undercutting the continued importance of HIV prevention behaviors. Other obstacles to achieving further reductions in AIDS-related mortality include the growing number of patients who are developing resistance to existing anti-HIV drugs and experiencing treatment failure, and the fact that many Americans still lack access to adequate health care. In addition, studies indicate that many physicians fail to provide adequate prevention counseling to their HIV-positive patients.
This year’s CDC conference also focused attention on the lengthy gap between initial HIV infection and eventual diagnosis—a gap that could pave the way for a resurgence in the AIDS epidemic. Because many Americans do not get tested
“We must reach these individuals at an earlier stage of infection for their own health and to prevent transmission to others.” —Ronald Valdiserri, CDC Deputy Director of HIV Prevention Programs
for HIV until they begin to feel sick, they often carry the virus for as long as ten years—the typical elapsed time between HIV infection and the onset of AIDS—before realizing they are infected. By that time, they have missed out on years of potentially life-prolonging medical treatment and could have inadvertently infected many other people. A study in 25 states found that 41% of people discovered they were infected with HIV within a year or less of being diagnosed with AIDS. Delayed testing for HIV has been observed in both men and women, in all racial and ethnic groups, and in all behavioral risk groups.
Because studies show that individuals who know they are HIV-positive may be less likely to engage in behaviors that might put others at risk of infection, this finding underscores the essential role that early testing and diagnosis will play in slowing the epidemic's spread. There are currently between 800,000 and 900,000 Americans living with HIV, and the CDC estimates that as many as 300,000 of them are unaware they are carrying the virus.
The Second HIV Prevention Conference also highlighted the changing demographics of the U.S. epidemic. Men who have sex with men (MSM) account for 42 percent of new HIV infections; those engaging in heterosexual contact make up 33 percent; and 25 percent are injection drug users. Several studies show increasing risk behavior among both HIV-negative and HIV-positive MSM of all racial and ethnic groups. A study in Seattle found that rates of unprotected sex among HIV-negative MSM had increased by 17 percent since 1994-1995, and the proportion of men reporting six or more sex partners in the last year rose by 28 percent. A second study, also in Seattle, found an increase in unprotected anal intercourse among HIV-positive MSM, following a two-year decline.
While gay men continue to account for the bulk of new HIV infections (42%), research shows that infections among heterosexual women are increasing more rapidly than among any other group. A recent
"In order to make further progress against AIDS, we continue to face formidable challenges, including re-energizing the fight to prevent HIV infections in the first place, getting more at-risk individuals tested for HIV, and developing new AIDS treatment options." —CDC Director Jeffrey P. Koplan
study of African American women found that nearly half did not use a condom during any sexual encounter in the previous two months, and 60 percent did not know if their partners had HIV. Another study revealed that nearly one in five young minority MSM who engage in high-risk behavior also had sex with a woman in the past three months, underscoring bisexuality’s possible role in putting women at risk of HIV infection.
Among the positive developments reported at the CDC conference were the lowest rates of AIDS cases among infants in nearly a decade and a significant reduction in HIV rates among injection drug users (IDUs). New York City researchers announced that needle exchange programs have served as the catalyst for reducing HIV infection rates among IDUs, from 50 percent in 1990 to 20 percent in 2000.
Announced earlier this year, the CDC’s strategic five-year HIV prevention plan aims to cut annual U.S. infections in half by 2005. Key goals of the plan include:
- Increasing the proportion of HIV-infected people who know they are infected from approximately 70 percent to 95 percent through voluntary counseling and testing;
- Increasing the proportion of HIV-infected people linked to appropriate prevention, care, and treatment services; and
- Decreasing by 50 percent the number of individuals at high risk of acquiring or transmitting HIV through targeted prevention interventions.
To review the CDC’s five-year prevention plan, please see the sidebar. For the full text of two of amfAR’s presentations at the conference, see below.