"It's unacceptable, in a rich nation like ours, to have 40,000 new infections of what is a preventable disease," said Dr. Helene Gayle, director of the CDC's AIDS prevention center.
The higher HIV rate for African-Americans is accounted for by enduring socioeconomic disparities, including lack of access to medical care. African-Americans are also more likely than whites to live in areas with high rates of sexually transmitted diseases (STDs).
"Clients I see rarely have just HIV," says Patricia Kelly, executive director of Movers Inc., an AIDS outreach program in Miami. "It's HIV and substance abuse, HIV and domestic violence, HIV and my kids are in foster care, HIV and my family won't have anything to do with me, HIV and I'm in jail."
Blacks are also disproportionately represented in US prisons, where HIV infection rates are six times higher than in the general population.
In addition, black men who have sex with men are less likely to identify as homosexual and so miss prevention messages targeting gays. According to Kevin McGruder, executive director of Gay Men of African Descent, a New York nonprofit organization, black men are less likely to be public about being gay because fewer institutional support systems and medical clinics understand their background.
Finally, mistrust of the medical establishment endures among poor, black Americans because of a history of abuse, like the government-sponsored Tuskegee syphilis study that left patients diagnosed with the disease untreated even after the development of penicillin. Surveys show that eight of ten people at risk for HIV believe at least one HIV conspiracy theory.
According to Dr. Beny Primm, executive director of the Addiction Research and Treatment Corp., the best way to counter the mistrust that leads to high-risk behavior is to use HIV-positive counselors in high-risk neighborhoods. "This way," he says, "the misinformation is refuted by people who are trusted by the community." Such focused intervention can increase HIV testing and may serve as a blueprint for broader efforts.
"The numbers we're publishing right now are more like the findings you see in the '80s than the findings you see in the '90s," said the CDC's Linda Valleroy, who led the survey in which 3,000 gay and bisexual men were tested anonymously between 1998 and 2000 in Baltimore, Dallas, Los Angeles, Miami, New York and Seattle. The survey, timed to mark the 20th anniversary of the discovery of AIDS, is the government's most sweeping evidence yet of a resurgence in the disease among young gay men. The one-in-seven infection rate for young black gays and bisexuals is roughly the same as the current rate in South Africa, Valleroy said.
"People don't perceive that you get infected and you die in two months anymore," said Phill Wilson, executive director of the African-American AIDS Policy and Training Institute at the University of Southern California. "There's all these posters around that say you can climb mountains and do whatever with HIV and AIDS. There's not enough messages about the price you have to pay."
"We have to stop and take a look at the devastation that potentially could occur among these young men," said Dr. Helene Gayle, the CDC's AIDS chief. "These are precious and important lives." The CDC wants to cut the number of new US infections from the current 40,000 annually to below 20,000 in five years, chiefly by improving prevention, targeting at-risk groups and urging more Americans to be tested for HIV.
Jones felt a quilt would be a "comfortable middle-class symbol" that most people could accept. As it grew, the quilt earned a reputation as "the battle flag in the war against AIDS." Thousands of panels honoring gay white men were soon joined by others memorializing hemophiliacs, African-Americans, Latinos, children and women. In 1996, when the quilt was displayed for the fifth time in Washington, D.C., its 50-ton expanse reached from the Washington Monument to the doors of Congress.
Jones, whose HIV is now controlled by drugs, has officially parted ways with the quilt but not with activism. On Friday, June 1, in Washington, volunteers began reading the names of people who have died of AIDS. They continued the roll call night and day until Sunday, June 3, when the community that Jones helped create marched on Washington to demand increased access to AIDS drugs worldwide.
The genetic variation, called "Px," is present in about 12 percent of the population. It is only slightly different from other versions of a gene that acts as a critical part of the body's defenses against foreign invaders, such as HIV. The variation is benign in people who aren't infected with the virus, and it may even help by boosting the body's defenses against malaria, said study senior author Mary Carrington, an immunologist at the National Institutes of Health.
However, in the study of 850 people, the presence of the Px gene variation appeared to accelerate the onset of full-blown AIDS by four to five years. In the study group, it took only about seven years after infection for half of those with Px to develop full-blown AIDS, compared with about 11 to 12 years for those with other versions of the gene. One theory for this difference holds that the Px gene is "just sitting there and not doing its job" in AIDS patients, Carrington said. Another holds that "it may be actively damaging" to the body's defenses against the disease, she added.
Kaul and colleagues studied the immune responses of sex workers in Nairobi, Kenya: women who have more than 60 unprotected sexual encounters with HIV-positive men annually. Women new to the group show high rates of seroconversion in the first year, yet some remain HIV-negative for three years and longer. Researchers compared the immune responses of 91 HIV-negative sex workers from the cohort with those of 87 HIV-positive sex workers. The two groups of women both mounted HIV-1 specific CTL responses -- but often against a completely different set of epitopes. A few women who remained HIV negative for several years before seroconverting showed a switch in response from one set of epitopes to the other, according to a study by the same team published in the Journal of Clinical Investigation (2001; 107: 341-49).
According to Kaul, "the only way to demonstrate a true causal relationship between CTL responses and HIV protection is to induce these CTL in the setting of a vaccine trial." Phase I testing of a vaccine developed by Andrew Michael of the Weatherall Institute is underway in Oxford and Nairobi. "The vaccine in this trial does include the seronegative-specific epitopes, as well as epitopes known to induce a strong CTL response in HIV-positive workers."
Previous attempts to develop CTL-inducing vaccines have assumed that any CTL response could be protective, according to Jose Esparza, coordinator of the World Health Organization-UNAIDS HIV Vaccine Initiative. Future research should attempt to elicit protective CTL responses by taking into account the clade of HIV prevalent in the area to be targeted, and also should include epitopes tailored to the distribution of HLA types in the population, Kaul said. "The HLA types in Kenya have not been extensively studied but we are finding them to be quite different to those mapped elsewhere," said Kaul. Esparza agrees but cautions that "this would be particularly challenging in Africa, where both the genetic variability of the virus and of the host population is the largest."
Esparza expects interim results in one to two years from the first HIV-vaccine phase III efficacy trial -- the rgp120 HIV vaccine -- being tested in the United States and Thailand. "We do not know how effective that vaccine will be, or whether it will be effective at all. It may be prudent to prepare for the worst and to consider the use of a low efficacy vaccine while research continues to develop more effective products," he said.
The medications involved are three injectable drugs: Serostim, a growth hormone sold by Serono and used by AIDS patients; Nutropin, a growth hormone sold by Genentech; and Neupogen, a cancer drug sold by Amgen. All the brand name drugs carry a high price, which could be why the counterfeiters selected them. A 12-week course of Serostim, for instance, costs $21,000. The counterfeiters may have been able to find an easy market for their drugs since Serostim and Nutropin are sought by people who believe the drugs will help them lose weight, build muscle and smooth wrinkles.
Serono first realized that someone was counterfeiting Serostim late last year when patients in at least seven states began to complain that they had suffered a slight swelling or a skin rash after being injected. And last month, the FDA reported three more cases of counterfeit drugs involving Neupogen, Nutropin and a second fake batch of Serostim. In each case, the counterfeit drug looked nearly identical to the real product. For Serostim, the lot number, which is used to trace drugs, was a real number; only the expiration date had been changed from August 2001 to August 2002.
Shows focus on specific topics arranged in a series. A five-program series, for example, focused on names reporting and partner notification. "Nothing like this on the topic of names reporting-partner notification has been done before on television because we dealt with personal perspectives of people who are living with HIV-AIDS, what they feel about this topic and how it impacted them," said Barry Ansin, founder of Common Sensitivity.
The programs are scheduled to air before 13 million viewers across the United States this summer over local cable stations. "People mistakenly believe that AIDS can be treated as a chronic infection, and therefore prevention efforts have fallen by the wayside. That's unfortunate because the latest information from researchers is that drug therapies aren't what everyone thought they were going to be," said Ansin. That is why the show is so important. Education and information "are the best weapon that we have in the fight against HIV-AIDS," he added.
Heckman, an assistant psychology professor at Ohio University in Athens, said that some patients report being the only person in their community with the disease. "We hear from people who are severely discriminated against. And that, more than anything else, affects their overall quality of life," he said. One element of his study, called Project Connect, aims to break that isolation: The eight-week project linked HIV-positive people from around the nation on conference calls with mental health researchers. This forum enabled participants to offer advice and encouragement and share their experiences, Heckman said. Tim Parr, 43, a dairy farmer in Ohio, said that since learning he has HIV he has been deserted by his best friend; his AIDS-related mail from the health department has been tampered with; and he has been run off the road by men wearing white capes and driving pickup trucks. Even though "they told me to take my disease and move out," Parr said, "I'm much more of a fighter than that. I have just as much right to be here as anyone else."
"It's part of a bigger problem among the undocumented: As long as we don't acknowledge that they are here, we don't have to take care of them," said Pamela Donnelly, associate executive director for the AIDS Outreach Center in Fort Worth, Texas. Language is often a major barrier. In New York City, workers at the African Services Committee are often asked to relay a diagnosis in French or various African languages. Some HIV-positive people shun support groups, fearing they could be spotted by a native of their homeland who would tell relatives they are sick.
Unless an infected person is related to an American citizen or is coming for a short stay, US authorities may exclude him or her from getting a green card, as legal immigration status is not granted to those who may need public health or welfare benefits. "This is a medical problem," said Dallas immigration attorney John Wheat Gibson. "To the extent that it is an immigration problem, it is the same immigration problem anyone else who is illegally present faces -- fear of the consequences of seeking health care."
"The American people and the international community expect as much from the United States," Daschle said in a statement. "With more than 36 million people already living with HIV/AIDS, and 14,000 more contracting the virus every day, the secretary-general is right to call for a coordinated response. Governments, foundations and corporations throughout the world must work together to confront this humanitarian, economic and security crisis." The UN has called for global action on AIDS and is organizing a June special conference on the epidemic.
Annan visited legislators in Washington, D.C., just weeks after the United States was voted off the UN Human Rights Commission. Earlier Thursday Annan met with House of Representatives Minority Leader Richard Gephardt (D-Mo.) and Rep. Henry Hyde (R-Ill.), the chair of the House Committee on International Relations and an opponent of the UN.
Current spending on the three diseases is about $1.8 billion, according to Peter Piot, executive director of UNAIDS. The bulk of any new money will be spent on the AIDS epidemic in sub-Saharan Africa, home to 70 percent of the estimated 36-million HIV-infected persons worldwide. Contributions to the fund have been slow to materialize, however. The announced US donation of $200 million was criticized by AIDS activists as far too small. France has pledged about $127 million over the next three years, and Britain has promised an unspecified amount. No major foundation has offered money. There has been no US corporate response to Annan's personal appeal to the US Chamber of Commerce earlier in June. But UN officials insist they are not discouraged and that they still anticipate the money will be committed by mid-summer, following the UN General Assembly's special session on HIV/AIDS and the Group of Eight industrialized countries meeting in July. "I'm pretty sure that it's going to happen, and it's going to be a serious thing," World Health Organization Executive Director David Nabarro said on Thursday, June 7.
If adopted, the declaration would commit UN members to meeting a series of interim targets over the next 15 years. Among these are: development of national strategies and financing plans to combat HIV/AIDS by 2003, including businesses, grassroots groups and people with HIV/AIDS; adoption by 2003 of a set of time targets to achieve the goal of reducing HIV prevalence among youth by 25 percent by 2005; making prevention measures, including information and education, available in all countries while taking into account "local circumstances, ethnic and cultural values"; reducing the number of infants born with HIV by 20 percent by 2005 and by 50 percent by 2010 by providing treatment to HIV-positive pregnant women; and development of national programs to increase drug availability by 2003, and by 2005 demonstrating progress in implementing comprehensive health care programs. The proposed draft also calls for countries to initiate programs identifying groups most at risk for HIV infection by 2003; to implement programs for AIDS orphans by 2005; and to adopt legislation by 2005 that protects the rights of people living with HIV/AIDS.
In a keynote address to the World Health Assembly on May 14, Brundtland said, "The move towards wider access to life-saving health care is now unstoppable." Improvements in understanding the real global threat of tobacco use; high level recognition of the "dire consequences of malaria and tuberculosis in the poorest communities"; and the visibility of the "extreme damage caused by HIV" all point to great opportunities, she said.
But the challenges are great, and include a lack of funds. Brundtland proposed a slight increase in WHO's regular budget for 2002-3 to $842 million. While the voluntary budget rose by 40 percent last year, she said, the funds were short-term and WHO acted quickly to use them. The Global Alliance for Vaccines and Immunization had attracted $375 million since 74 developing countries submitted proposals last year for national vaccination campaigns, with vaccines being delivered since the beginning of this year.
But there is still great urgency. "We cannot wait another decade while HIV/AIDS affects more and more of the people from Africa, China, India, the former Soviet Union and Eastern Europe," Brundtland told the World Health Assembly. "If we do not act now, drug-resistant tuberculosis will have become far more widespread, requiring costly treatment that is difficult to provide. Malaria treatments will have lost their potency due to the increase in drug resistant strains."
But not all countries in Asia have approached the epidemic as openly. Malaysia doesn't have an anonymous HIV-testing program; rather, the government registers the names of anyone who tests positive for HIV and informs their sexual partners if they do not do so themselves within 48 hours. Such reporting, combined with the social stigma associated with AIDS, has made people leery of testing. Treatment for the country's 42,000 HIV-positive residents is difficult to find and costly. Although most AIDS drugs are available to them, many HIV-positive Malaysians cannot afford the $526 a month for treatment.
India already accounts for half of Asia's HIV-positive population with 3.9 million cases. China has about 600,000 cases, mostly among IDUs in interior provinces. But increasing overlap among IDUs and sex workers in China has made the problem particularly acute, as sexual activity could spread the disease to more populous coastal regions.
In Japan, where hemophiliacs comprised most of the early cases of HIV, men infected by prostitutes in foreign countries account for a growing percentage of the HIV-positive population, which the WHO has estimated to be about 8,100.