HIV Prevention for the Third Decade of AIDS
The Need for a Renewed Commitment
On June 5, 2001, the United States and the world mark an unhappy anniversary: the 20th anniversary of the report of the first cases of AIDS in the medical literature. On that date in 1981, the first cluster of unexplained cases of immune deficiency was officially announced in Morbidity and Mortality Weekly Report, a publication of the Centers for Disease Control and Prevention (CDC).
Since that time, the harm done by AIDS in the United States has been staggering: 711,344 AIDS cases have been reported as of July 1, 1999. Among these, three-fifths have died -- a death rate of more than 62 men, women, and children a day, or one every 24 minutes, for nearly two decades. AIDS quickly skyrocketed to become the leading cause of death for people between the ages of 25 and 44. In 1998, there were 17,047 AIDS deaths in the U.S. These illnesses and deaths occurred within a context of almost dizzying variability, among groups of nearly all ages, races, ethnicities, genders, sexual orientations, religions, and socioeconomic statuses and in the large metropolises, mid-sized cities, suburban towns, and rural regions.
From the outset, the battle against AIDS has been fought on two fronts. One front has been care and treatment for those suffering from symptoms of AIDS, the other prevention and education to reduce the further spread of HIV, the virus that causes AIDS. Treatment has always been a critical necessity, given that AIDS was first discovered among individuals who were already gravely ill. But HIV prevention has also always required an enormous investment of time and resources because, unlike chronic diseases such as heart disease, cancer, and diabetes, AIDS is caused by a transmissible agent.
In all, the nation's investment in HIV and AIDS has paid off tremendously. Advances in care and treatment have perhaps had the highest profile and the most media attention. At the start of the epidemic, all that was available for people with AIDS was palliative care and, later, prophylaxis for opportunistic infections. Concerted efforts in basic research and in clinical trials, however, have over time yielded insights into the functioning of HIV which have made possible the introduction of antiviral medications. Different classes of these antiviral medications used in combination have yielded dramatic results in suppressing viral replication and restoring many people with AIDS to improved health.
Although the treatment of HIV/AIDS remains highly problematic, and a "cure" remains distant, the progress has been remarkable. AIDS death rates dropped by more than two-thirds between 1995 and 1997, and new diagnoses with the serious immune damage associated with AIDS were down 30% during the same period. Although the rate of decline levelled off, and some people have failed on drug therapies, the impact of advances in antiviral treatments cannot be overstated.
Less well known are the equally dramatic advances made on the prevention front. The earliest AIDS cases clustered among a few clearcut populations, notably men who have sex with men (MSM), injecting drug users, and recipients of blood transfusions, particularly hemophiliacs. As the number of women with AIDS quickly increased, it became clear that HIV could also be transmitted heterosexually, as well as from mother to child. When HIV incidence was at its highest in the mid- to late-1980s, as many as 150,000 people were newly infected each year.
Prevention SuccessesThe first major breakthrough in prevention came with the development of a blood test for HIV antibodies, which could be used to screen the blood supply. Thanks to these tests, and other prevention measures, the number of new HIV infections due to blood transfusions has remained minimal since the mid-1980s. Likewise, the use of antiviral medications during pregnancy, along with other measures, has caused the number of HIV-infected newborns to tumble 74% since 1992. And the introduction of "universal precautions" has minimized the exposure both of patients and providers in health care settings. While none of these forms of prevention is perfect, they have cumulatively had an enormous impact in containing the spread of HIV.
No less impressive have been the strides made in preventing the transmission of HIV through sex and through injecting drug use. At the start of the epidemic, the number of new HIV infections was poised to expand exponentially, but a partnership between communities, agencies, and researchers soon determined the routes by which HIV is transmitted -- and those by which it is not. General education campaigns were launched to clarify to the population at large that they could not become HIV infected through "casual," "routine," or "household" contact, through the air, through mosquito bites, or through any other form of non-intimate contact.
While such general education campaigns were needed to quell unfounded anxieties and to reduce discrimination against people with HIV, carefully tailored campaigns were also required to reach the particular subpopulations most at risk. For instance, research soon made it clear that injecting drug users who shared needles with HIV-positive individuals were essentially inoculating themselves with the virus, virtually guaranteeing new infections. Despite a great deal of controversy, needle exchange programs and increased access to sterile syringes, especially in major urban centers, have significantly curbed the spread of HIV and often also serve as gateways to drug treatment.
Epidemiological data have also made it possible to discern a hierarchy of sexual risks, rising from the nonexistent/minimal, to the lower risk, to the highest risk. Prevention outreach has provided at-risk populations with a variety of strategies, including monogamy, abstinence from all sex, abstinence from certain sexual behaviors, and the correct and consistent use of condoms. Education and counseling, sometimes in the context of HIV testing, have empowered individuals to maintain sexual lives that are safer from risk of HIV infection. From this knowledge base, a wide variety of intervention programs has been developed, including condom education, skills-building, group discussion, condom promotion, and other interventions. What all these interventions share in common is that they have been rigorously proven successful using a control/comparison group methodology. In short, it is hard to reduce HIV transmission -- but it can be done.
A Shifting EpidemicThrough a variety of mechanisms, then, an epidemic expanding at a terrifying rate was stabilized. This stabilization of HIV incidence is a major victory in the prevention battle, no less impressive than the parallel strides made on the treatment front. Unfortunately, stabilization has occurred at a rate of new infections that remains far too high: 40,000 new cases a year -- or 110 a day, more than one every 15 minutes. The reasons for the continued high levels of HIV transmission are no less complex than the human activities in which they are embedded, and are far from new phenomena: unintended pregnancy, sexually transmitted diseases, and drug use are ancient problems which do not allow easy solutions.
Moreover, the AIDS epidemic is a constantly moving target. Although it was always an incomplete caricature, early AIDS was seen as a disease of middle class white men or of injecting drug users in the major coastal urban centers. And while it is true that this population remains a major focus (the majority of new HIV infections occur among gay men), the epidemic has long been multi-focal, making its presence known in every state and virtually every locality of the nation. Urban, suburban, and rural populations, heterosexual men and women, babies, children, teenagers, and older adults: all have been affected.
Yet certain concentrations of the disease in specific subpopulations and other general trends are clear, many of them linked to larger societal issues such as poverty, discrimination, racism, sexism, homophobia, homelessness, and other systemic problems. Most notably, HIV and AIDS disproportionately affect communities of color. While non-Hispanic African Americans compose approximately 13% of the overall population, they represent over 36% of cumulative AIDS cases and 45% of new HIV infections; similarly Hispanics who are about 12% of the national population represent 18% of cumulative AIDS cases and 22% of new HIV infections. Among these racial/ethnic groups, men who have sex with men continue to represent the largest number of new infections, with women infected by heterosexual contact a rapidly growing population as well. In addition, young people are disproportionately impacted.
The appropriate response to an expanding epidemic is an expanding response, not standing in place. However, approaches designed during an earlier, acute phase of the epidemic may no longer be applicable to an epidemic entering its third decade. Different communities require different strategies and messages. Advances in treatment have implications for prevention that must be factored into any rethinking of prevention. In all, previous victories on the prevention front must be sustained and expanded, amidst a renewed commitment to prevention.
Body Positive Editor Raymond A. Smith, Ph.D., was formerly Director of Research with the National Alliance of State and Territorial AIDS Directors (NASTAD) in Washington, DC, with whose permission this article was adapted for publication here.
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