Washington, D.C. has one of the highest incidences of HIV in the country. In fact, according to PBS NewsHour “if the nation’s capital were a nation in Africa, it would rank 23rd out of 54 countries in percentage of people with HIV, a higher rate than the Democratic Republic of Congo, Ghana, Rwanda, Ethiopia and 28 other African countries.” The incidence of HIV is so high that if Washington, D.C. was a country, it would be eligible for PEPFAR funds (The United States President’s Emergency Plan For AIDS Relief) a program initiated in 2003 by President George W. Bush to help save the lives of people suffering from HIV/AIDS in 15 of the most severely affected countries. That made D.C. a notable choice as host venue for the 19th International Aids Conference, held there in July 2012. It was also the first time since 1990 that the U.S. was chosen to host the International Conference. The choice by the IAS Governing Council to hold the Conference in the U.S. was influenced by the recent lifting of a 22 year HIV entry ban, which prohibited infected individuals from entering the United States.
Alongside the return to the U.S. of researchers and clinicians to discuss HIV/AIDS come calls for enhanced programs to combat the disease at home. In a recent Washington Post article, Robert C. Gallo, the scientist who proved in 1984 that HIV was the cause of AIDS, re-iterated his 2008 call for a PEPFAR-like program that would focus on the 12 U.S. cities in which the greatest number of HIV-positive Americans reside. New York City had the greatest estimated number of people living with AIDS in 2009, Los Angeles and Washington D.C. round out the top three Metropolitan areas. In 2007, the Bronx had New York City’s highest HIV death rate, and the prevalence of people living with diagnosed HIV in Bronx County at the end of 2009 was 2044 individuals per 100,000 – compare to 470 per 100,000 in Westchester Country. Bronx neighborhoods such as Hunts Point and Morrisania/Highbridge had prevalence rates of 2.5 and 2.6% respectively, comparable to rates in Haiti and Ethiopia. As part of the National HIV/AIDS Strategy, the Department of Health and Human Services announced in Feb 2011 The 12 Cities Project: ”an effort to accelerate comprehensive HIV/AIDS planning and cross-agency response in the 12 U.S. jurisdictions hit hard by HIV/AIDS.” The 12 Cities Project builds on the CDCs Enhanced Comprehensive HIV Prevention Plans (ECHPP) which among other things aims to identify public health strategies and interventions for the 12 Metropolitan areas most affected by HIV/AIDs.
The good news is that overall the incidence of HIV infection is decreasing. However, the majority of new cases of HIV in the U.S. disproportionately affect low income and black populations. This inequality was the topic of a recent Frontline PBS Special. The documentary traced the history of HIV/AIDS in the U.S. from the first cases in white homosexual males reported in the CDC’s Morbidity and Mortality Weekly Report (MMWR) in June 1981 through the last three decades highlighting increasing rates of transmission in intravenous drug users, to women (a reclassification by the CDC in 1993 to include invasive cervical cancer increased the number of women diagnosed with AIDS) and African Americans who, by race, currently face the most severe burden of HIV, in particular young black men who have sex with men (MSM).
Access to antiretroviral (ARV) therapy has significantly improved survival and quality of life for individuals diagnosed with HIV. In 1994, the ARV zidovudine was demonstrated to successfully prevent vertical transmission of HIV from mother to child, since then, rates of perinatal transmission in the U.S. have declined to less than 2% and there is optimism that transmission by this route will be abolished within a generation (in developed countries at least). Observational and ecological studies provided strong evidence that ARV treatment of infected individuals reduces rates of transmission to partners decreasing incidence of HIV. Over the last 2 years intervention studies have provided strong clinical data that ARVs decrease the risk of heterosexual transmission, these were discussed in a special HIV/AIDS issue of Science in Dec 2011. The HPTN 052 randomized clinical trial assessed the efficacy of early initiation of ARV therapy on transmission of HIV. This study, conducted in 9 countries (5 in sub-Saharan Africa; Brazil, India, Thailand and the U.S.) demonstrated a relative reduction of 96% in the number of linked HIV-1 transmissions resulting from the early initiation of ARV therapy, compared with delayed therapy. Due to its high efficacy this study was chosen by Science as its Breakthrough of the year in 2011. Truvada, a combination of the reverse transcriptase inhibitors emtricitabine and tenofovir, previously approved for pre-exposure prophylaxis for high-risk gay and bisexual men has been recommended by the CDC and approved by the FDA to be given to women and heterosexual men who are at high risk for getting the virus.
In spite of the great strides made in the past few years, the increasing incidence of HIV in the African American population, especially among young gay and bisexual men is a concern. Misconceptions about the risk of becoming infected, a general mistrust by many African Americans of the health care system (the unethical racial exploitation of African Americans during the Tuskegee syphilis study is one reason), the stigma associated with being homosexual and/or admitting to being HIV positive (especially in many religious communities where there remains a strong believe that HIV is a punishment from God) and low socio-economic status are major problems which contribute to the increasing incidence of HIV in young black people. Community outreach programs in Metropolitan areas such as the ones highlighted in the PBS documentary in Washington DC and the Bronx Knows target these high-risk communities to inform them about their risks, provide HIV screening, counseling and financial resources for coping with the cost of HIV treatment (the Ryan White Program was established in 1990 and provides HIV-related services to half a million people a year who do not have sufficient health care coverage or financial resources for coping with HIV disease). Some of the success of these outreach programs is a direct result of implementing interventions and strategies learned from programs in Africa funded by PEPFAR.