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New HIV cases stay steady in US over decade

Critics fault policies aimed at prevention

By Donald G. McNeil Jr.
New York Times / August 4, 2011

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NEW YORK - Despite years of great progress in treating AIDS, the number of new infections of the virus that causes it has remained stubbornly around 50,000 a year in the United States for a decade, according to figures federal officials released yesterday.

The US epidemic is still concentrated primarily in gay men and is growing rapidly worse among young black gay men.

That realization is causing a rift in the HIV/AIDS community. Activists say the persistent human immuno virus infection rate proves that the government prevention policy is a flop. Federal officials are on the defensive even as they concede that the epidemic will grow if prevention does not get better, which they know is unlikely while their budgets are being cut.

And some researchers believe it is impossible to wipe out an incurable disease when it is transmitted through sex and carries so much stigma that people deny having it and avoid being tested for it.

Looking back, epidemiologists at the Centers for Disease Control and Prevention believe that new cases peaked at 130,000 a year in the 1980s, sank slowly during the ’90s, and reached a plateau at 50,000 around the year 2000.

Larry Kramer, a longtime AIDS activist and the author of “The Normal Heart,’’ a play about the epidemic’s early days, said: “It means I don’t see an AIDS policy, and I don’t see anyone in charge. It’s so dispiriting that it’s hard to find something to say about it. How many times can you yell ‘Help!’ without ever getting anywhere?’’

Both Dr. Kevin Fenton, chief of AIDS prevention for the CDC, and Dr. Anthony S. Fauci, chief of AIDS research at the National Institutes of Health, took issue with Kramer’s interpretation.

While both agreed that 50,000 new annual infections is, in Fauci’s words, “a great concern,’’ both pointed to some areas where substantial progress has been made. They said that new studies are seeking ways to get more people tested and treated early in the course of the illness, which makes them less infectious and drives transmission rates down.

“The CDC is absolutely not resting,’’ Fenton said.

“It was a major accomplishment to drop infections from 130,000 to 50,000, and we’re dealing with an epidemic that is dynamic.’’

But, he conceded, 50,000 is an “unacceptably high level,’’ and without better prevention efforts, “we’re likely to face an era of rising infection rates.’’

Philip Alcabes, a public health epidemiologist at Hunter College in Manhattan, noted that 50,000 is close to the number of Americans who die in road accidents each year - almost 40,000 - “and in some ways, we consider dying on the road an ordinary thing.’’

By contrast, he said, nearly 1 million Americans a year die of heart disease and strokes.

“So it’s not clear that prevention is a failure,’’ he said. “But I agree with Larry Kramer that there has been a dearth of new policy ideas.’’

For most risk groups, infection rates are stable, with 61 percent of cases contracted through gay or bisexual sex, 27 percent through heterosexual sex, and 9 percent through drug injections.

But they are increasing rapidly in one subgroup: young gay black men.

Researchers said black teens often cannot move to gay-friendly cities such as San Francisco or New York, and often keep their sexuality hidden from relatives and friends, making it more likely they will have unsafe sex. They often lack health insurance, meaning they do not get checkups where a doctor might suggest testing.

And while new surveys find that they use condoms at about the same rate as young gay white and Hispanic men, sex tends to stay within racial groups, and more older black men, gay and bisexual, are infected. Also, untreated syphilis, whose sores open a path for HIV, is more common among blacks.

The National Institutes of Health is supporting studies in the Bronx, Washington, and other largely black urban areas seeking new ways to reach these men, Fauci said. Results will be ready in two or three years.

Prevention has worked for two groups, Fenton said. The number of women infecting their children at birth or through breast-feeding has dropped to 100 a year from about 1,300 two decades ago.

Also, the number of infections through drug use has dropped 80 percent, although that may be a result of changing practices among addicts, including a drop in the number who inject heroin.

Chris Collins, director of public policy for amfAR, the Foundation for AIDS Research, said the decadelong persistence of 50,000 infections “shows that we’ve failed to target prevention services adequately and have not gotten treatment coverage in many communities that would bring down community viral loads.’’

A recent study has shown that getting people on antiretroviral drugs early makes them 96 percent less likely to infect others, so there is a growing outcry for “test and treat’’ - shorthand for actively seeking out gay men and those injecting drugs and asking them to get tested, and then helping them find medical care if they have the disease.

Fauci and Fenton said there was no discussion now of making such tests mandatory - as, for example, syphilis tests once were for marriage licenses.

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