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HIV prevention efforts of the past two decades have scored two grades of "A," but there are even more "needs to improve" grades. Researchers and public health officials speaking at the Centers for Disease Control and Prevention’s 2nd National HIV Prevention Conference, held in Atlanta on Aug. 12-15, 2001, presented mixed news about the success of previous prevention efforts and hope for the future.
The latest CDC data show a leveling off of AIDS cases and deaths, and recent studies involving sexually transmitted diseases (STDs) among HIV-infected and at-risk individuals indicate the possibility of a future upswing in AIDS rates.
"Data continues to mount suggesting there is a true increase in risk behaviors," says Helene Gayle, MD, MPH, director of the National Center for HIV, STD and TB Prevention at the CDC. "Several studies show HIV-infected men getting other STDs, which is evidence of risk behavior in a population that already has HIV," Gayle adds.
On the positive side, mother-to-child transmission has been reduced to levels that haven’t been seen since the early years of the epidemic, a significant improvement from the peak rates of the early 1990s. Also, there is increasing evidence that a majority of men who have sex with men (MSM) are continuing to use condoms consistently, some two decades into the epidemic, notes Cynthia Gomez, PhD, of the Center for AIDS Prevention Studies at the University of California - San Francisco.
However, young MSM are not reducing their sexual risk behaviors as consistently, Gomez says. "This is a generation that has not received the intensive prevention message that the other men in their 40s have received, and it is not the same epidemic, so we can’t repeat what we did in the 1980s and expect it to be effective."
The younger generation of MSM is a much faster-moving and -acting group, and they receive a great deal of information through advanced technology. This leads to risk behaviors associated with meeting other MSM through Internet web sites.
For example, the CDC has observed that some recent outbreaks of STDs has been associated with people using the Internet to "hook up" with sexual partners, says Ron Valdiserri, MD, MPH, deputy director of the National Center for HIV, STD and TB Prevention. "The Internet is the 21st century version of anonymous sex, and it’s equally important to use that venue to provide information and reinforce messages about safer sex," Valdiserri adds.
In other good news, injection drug users (IDUs) residing in New York City have had a substantial decline in HIV incidence rates in recent years. That success story is directly attributed to legislative and funding changes that have made syringe exchange programs readily available to IDUs in most of the city’s boroughs.
"The HIV/AIDS epidemic among IDUs in New York City is one of the biggest local epidemics in the developed world, with over 50,000 cases of AIDS among IDUs, their partners, and their children, representing about 8% of all AIDS cases in the United States," says Don Des Jarlais, PhD, a investigator from Beth Israel Medical Center in New York City.
"That’s more cases than has occurred in any European country," Des Jarlais says. "It got started in the 1970s with the introduction of HIV into the injection drug-using population, and the percentage of infected injectors went rapidly up to about 50% by 1983 and stayed at 50% through 1991."
Early prevention work included illicit needle-exchange programs, but the HIV incidence rate remained at a high rate: 4% to 5% of HIV-negative IDUs became infected each year, he says. Then in 1992, the state legalized and funded needle-exchange programs. Prevention efforts, including voluntary HIV counseling and testing programs, began to show significant improvement in HIV rates.1 About 40% to 50% of injectors used the exchange programs, resulting in a substantial decline in risk behaviors. This, in turn, has resulted in a dramatic decrease in HIV infection rates, Des Jarlais says. "The percentage of IDUs infected has gone from 50% in 1990 to currently 20% of injectors who are infected," Des Jarlais says. "The new infection rate has declined from 4% to 5% per year in the 1980s to about 1% per year."
These data are based on a meta-analysis of 12 different studies with more than 6,000 person-years at risk. During the at-risk period, there were only 52 new HIV infections. The total percentage of IDUs infected is based on six studies with more than 11,000 participants.
Despite these two areas of positive prevention news, the overall picture regarding new HIV infection rates is grim, according to the conference participants. Other research presented in August showed a high HIV incidence among MSM ages 23-29 and resurgence of other sexually transmitted diseases, unprotected sex, and late HIV testing across various at-risk populations. All of these factors indicate that prevention efforts are not reaching everyone who needs to hear the message, CDC officials say.
"Men who have sex with men continues to be the highest-risk group, and we’re seeing troubling signs of resurgent epidemic among gay men, with increases in STDs and risk behaviors," Gayle says.
Worse, the declines in AIDS incidence and deaths are over until new treatment advances come to light, Valdiserri says. "Very significant numbers of people are learning they have HIV very late in the course of their infections, and even those who report risk to their doctors are often not getting the prevention and testing and counseling they need," Valdiserri says. "To make progress in reducing AIDS cases, as well as new HIV infections, it is essential to reach these individuals with earlier testing and better prevention and care, as well as prevention services tailored to meet their specific needs," he adds.
Several reports highlighted the problem of late HIV testing. For instance, the CDC reviewed behavior data from 12 states and local health departments participating in a supplemental HIV/AIDS surveillance project. The CDC found from 18,850 interviews that 40% of people diagnosed with AIDS from 1990 to 1999 first discovered they were infected with HIV within one year of the time they found out they had AIDS, says Michael Campsmith, a CDC investigator.
Late testing was common in all groups, regardless of age, ethnicity, gender, or HIV risk exposure category, Campsmith says. "Given that without treatment AIDS typically develops 10 years after infection, this means that many of these patients had gone as long as a decade without appropriate medical support or prevention services," Campsmith adds.
The large cohort interview found that 40% of men and 41% of women were tested late. About 46% of black and Hispanic men tested late, compared with 32% of white men. Also, 42% of black women and 44% of Hispanic women reported late testing, compared to 36% of white women. When divided by risk category, researchers found that 39% of MSM, 40% of IDUs, and 51% of people who were exposed to HIV through heterosexual contact were tested late, Campsmith says.
In a similar CDC study presented at the prevention conference, late testing was found to be especially true for men, certain ethnic groups, and people over age 30.2 That study showed that 45% of men had been tested late compared with 31% of women, and that 53% of people age 45 or older tested late compared with 26% of those who were under age 30.
Late testing was also the subject of a recent study by the Kaiser Permanente National Consortium Chair, which was formed by Kaiser Permanente of Oakland, CA. A large health care insurer, Kaiser provides health insurance to 12,000 HIV-infected people and used this database to determine best practices in HIV care.
"We identified all cases of HIV infection newly diagnosed in 1998 among Kaiser Permanente members who had been members for at least one year," explains Leo Hurley, MPH, a data analyst with Kaiser. After identifying 434 HIV cases nationwide, investigators reviewed these patients’ medical records for up to five years prior to diagnosis, looking for clinical events and patient characteristics that might have been expected to trigger an earlier test for HIV, Hurley says.
They found that nearly half of the cases had AIDS-defining CD4 cell counts at diagnosis, and these patients may have benefited from earlier detection.3 "We found that 44% of the cases had immunological AIDS at first diagnosis of HIV," Hurley says. "And 40% of the case had either risk factors or clinical signs of possible underlying HIV infection noted 12 or more months prior to diagnosis."
Also, according to chart notes, many of these cases had been identified as being at risk for HIV infection on one or more occasions, but not all of the people were subsequently tested for the virus. Some were tested and found negative, but others were offered HIV testing that they declined, and others were not offered testing, Hurley adds.
"Our third finding was that after diagnosis, it was determined that 80% of the cases belonged to the highest-risk category of male-to-male sex, and this was noted in the chart prior to diagnosis less than half of the time," Hurley says. "The bottom line of the study is that even among persons with reasonable access to quality health care, HIV may go undetected for several years after infection," Hurley adds. The study’s seven diagnostic clinical events were oral infection, pneumonia, unexplained fever, herpes zoster, seborrheic dermatitis, night sweats, and unexplained weight loss.
The CDC prevention conference highlighted a few programs that have successfully reached at-risk populations with testing, counseling, and treatment referrals. These include a North Carolina outreach project that targets the homeless and a Maryland HIV testing van program that visits areas where HIV prevalence is higher.
HIV-positive and at-risk individuals also fall through health care system cracks with regard to condom use counseling, according to some studies presented at the CDC conference. "People who are newly diagnosed with STDs may not know that they are at increased risk for transmitting HIV to partners," says Thomas Lampinen, PhD, an investigator from the University of Washington in Seattle. A solution might be for HIV clinics to regularly include a drug and sexual risk assessment on an annual basis and use this information to enhance and supplement prevention counseling, Lampinen says.
1. Des Jarlais D. Unexpected success in HIV prevention for injecting drug users in New York City. Abstract 565. Presented at the 2nd National HIV Prevention Conference, sponsored by the Centers for Disease Control and Prevention. Atlanta; Aug. 12-15, 2001.
2. Campsmith M, Burgess D. Race/ethnicity and gender differences in late HIV testing. Abstract 540. Presented at the 2nd National HIV Prevention Conference, sponsored by the Centers for Disease Control and Prevention. Atlanta; Aug. 12-15, 2001.
3. Klein D, Hurley L, Merrill D, et al. Early detection of HIV: The HEDS UP study. Abstract 838. Presented at the 2nd National HIV Prevention Conference, sponsored by the Centers for Disease Control and Prevention. Atlanta; Aug. 12-15, 2001.