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Harold Jaffe, M.D., previously Director of the National Center for HIV, STD and TB prevention at the CDC, and now head of the Department of Public Health at the University of Oxford in the United Kingdom spoke with The Body's Myles Helfand about the state of the U.S. HIV epidemic.

Dr. Jaffe, you have been in Oxford now for a little more than a year. How has your view of the HIV epidemic in the United States changed during the time that you've been away?

I think, looking at the American epidemic, a couple of things strike you. The biggest thing is that [the HIV epidemic] isn't going away -- that even though it's certainly not something that the public reads about or thinks about a lot in the U.S., it's still here. The number of Americans who have been diagnosed with AIDS is approaching one million [since the beginning of the epidemic]. More than half a million people have died, and more and more people are in need of treatment.

In the 30-minute talk you gave this morning on the status of the U.S. HIV epidemic, one of the things you mentioned that was particularly striking was that HIV rates are 10 times higher in the United States today than they are in the United Kingdom, and two times higher than they are in Portugal -- which has the highest HIV rate of any country in Western Europe. Why do you think that is, especially considering the epidemic is as old as it is, and there has been such a history of activism and awareness in the United States -- at least in the 1990s -- that sought to actually decrease HIV rates a lot more?

If you look at who is [at] highest risk for HIV infection in the United States, it's really an epidemic that's being driven by infections in men who have sex with men, and in the African-American community. Men who have sex with men make up about half of all the new reported cases. Case rates in the African-American community are about eight times higher than in the white community. So I think there really needs to be a focus on what we can do to decrease infections in those two parts of our society.

In terms of what has been done to attempt to decrease infections, what has worked?

If we look back in time, we can see that infection rates in the gay community, which were very high at the beginning of the 1980s, dramatically fell in the late '80s. I personally think that was a result of fear. I think so many gay men knew somebody who was sick, somebody who had died, or [were] worried about themselves, that they took this very, very seriously.

I think now it's different. You look at it: It's a bad disease, but it's a treatable disease; it's a chronic disease. People look at it the way they would look at hypertension or diabetes. You don't want it, but if you do get it, it's not the death sentence that it was 20 years ago.

Then do you advocate fear as a method for HIV prevention?

I don't think exaggerating risks really gets you very far. I mean, people know what the risks are, and if you say it's worse than it is, they won't believe you. But the point is: A whole generation of gay men witnessed a terrible epidemic. Many of them died. A younger generation of gay men is now getting infected, and they're getting sick. They are not dying, because they fortunately have access to treatment, but they're going to live difficult lives.

What would you suggest then actually be done to get advocacy back up to the level that it needs to be at? For instance, what can clinicians and healthcare workers do to help curb what appears to be a steady rise in HIV infections, particularly in men who have sex with men and in African-Americans?

Well, one thing that clinicians and other providers can do is to routinely test their patients. The testing model that we have had in the past is one that's called an "opt in," where a patient had to request the test because they were worried, or a doctor recommended it because they thought the person might be infected.

We think it makes a lot more sense, in areas of the country with high HIV rates, to simply say it is the policy of this practice, this hospital, this clinic, that we test everybody between ages, say, 15 and 60 ... unless they say they don't want to be tested. But normally, we do [test for HIV].

We know from a number of studies that that approach will find large numbers of people who didn't know that they were infected, who could potentially transmit to others, and are at risk for very serious illness.

I take it that you are a clear fan of the new CDC recommendations that suggest routine HIV testing for everybody between the ages of 13 and 64, almost regardless of their risk level.

I think the issue with routine testing is that, in a sense, it says to clinicians, "Don't try to make that judgment anymore. Don't try to say, 'Well, I think Patient A is gay and I think Patient B is a drug user.' You're not very good at that. Why not just say, 'I think everybody in my practice should be tested for their own health?'"

What would you say to people who are skeptical of routine testing? The recommendations have been out for about half a year now, but the implementation has been extremely slow, and I've heard various physicians saying that to actually ratchet that kind of thing up requires a level of resources and commitment that many clinics and many hospitals might not necessarily have.

I think that change in testing will be a slow process because, from the very onset, HIV testing was viewed as different from all other testing -- that we routinely check hematocrit, we check for syphilis, we check for this and that -- but HIV was set aside as something different.

Now, the attempt is to make it more mainstream. I think once there are examples of practices, hospitals, clinics and emergency rooms that have done this successfully, it will be a lot easier.

What about HIV prevention advocates and people living with HIV? What can they do to try to stem the number of new HIV infections when, despite their active efforts, they don't quite seem to have the same impact that they did back in the '90s?

One of my concerns is that the focus of advocacy has changed. That's understandable. A lot of the advocacy now is based on access to treatment, and that's perfectly understandable. But at the same time, we're sort of conceding that large numbers of people are going to get infected, and then we're going to treat them. It would certainly make a lot more sense, from both a medical and public health perspective, to say the real goal is to prevent people from getting infected in the first place. We need a lot more activism, based on not getting infected, rather than getting access to treatment.

I think infected people can do a lot. They can be leaders. They can say, "Don't get infected; it's not fun. I'm not dying, but I don't like taking these pills." I think they can also kind of adopt the model of the San Francisco program, "HIV Stops With Me," to say, "I am infected but I don't want to infect anyone else." That's really important.

Correct me if I'm wrong. But wasn't it during the time when you were director of the CDC HIV STD TB Prevention Center, that the CDC began a "prevention for positives" campaign, focusing on the need for HIV-positive people to be more active about preventing other people from getting infected. How much of the responsibility for HIV prevention do you feel falls with people who already have HIV, compared with people who are HIV-negative?

I think the downside of focusing too much on HIV-infected persons is the issue of blame, to say what's your fault. I don't think that's a useful message for anybody. But I think the personal responsibility message makes a lot of sense. All HIV infections start with a transmission from an infected person to an uninfected person. There are a lot fewer infected people than uninfected people. So I think it does make sense, as long as you avoid the blaming-the-victim kind of mentality, to put a lot of resources into helping infected people not transmit, and even become advocates for prevention.

Sounds fair enough. Part of the responsibility of ensuring that there isn't that level of stigma is going to fall to the government. We've talked about the clinical aspect of HIV prevention, and the HIV-positive people and advocacy aspect. What about the government? How much can clinicians or HIV-positive people or advocates really do without a significant amount of federal government support for their efforts?

I think the federal government [has] multiple role[s]. It's to do research to find out what actually does prevent HIV transmission. It's to have monitoring systems in place to see, when these systems are implemented, whether they do any good or not. So the government's role isn't necessarily the same as a community advocate. It's really to figure out what works, put the money where it belongs, and then see what happens.

What do you say to policies like abstinence-only education, which the Bush administration is a staunch supporter of but which, as you have said in your talk, and as research has shown, really doesn't seem to work very well?

There's certainly very little, if any, evidence that abstinence-based education decreases the risk of [becoming infected with] HIV, or any other STD [sexually transmitted disease], for young people. I believe it largely reflects a religious conservative agenda of the current administration.

You worked at the CDC for quite a long period of time. You saw many administrations come and go. When you transitioned from one administration to the next -- and I guess, particularly for our audience, it would be the Clinton to Bush transition -- did you see a change in the culture and the overall take on how to tackle HIV in the United States?

Certainly, when the [most] recent Bush administration came into office, it became very clear that abstinence-only was a major message. We were told that in a variety of ways, in a variety of venues. And it showed. I mean, for example, the CDC condom fact sheet was taken off the CDC's Web site for quite a long time, because it was seen as too supportive of the role of condoms in HIV prevention. Well, if you say condoms prevent HIV, you're really knocking out one of the arguments for abstinence-only. So that kind of thinking certainly was there while I was at CDC, and I have to assume it's still there.

That doesn't sound a very promising note for the next couple of years, although I suppose with the Democrats in power in Congress there might be some ability to effect a change there. But if you don't feel advocates are getting the message across in quite the way that it needs to be done, and clinicians have a relatively limited power to make an impact, and the federal government doesn't support it, do you feel positively or negatively about the ability of the United States, in general, to be able to tackle the HIV epidemic over the years to come?

I think the point is that the epidemic is not over by a long shot in this country. Why is it that it's OK [to ignore the HIV epidemic in the United States]? It isn't OK for more than 40,000 people to develop a life-threatening disease every year. Why is it OK for 17,000 people to die from it [AIDS-related causes]? It isn't OK. [Y]et the level of attention, both in the community at large and in the advocacy community, just seems not to be there the way it was before. Maybe it's because people see the international epidemic as more interesting, as something more deserving of their time and effort. And it is important. But it's not the case that the U.S. epidemic has gone away ... quite the contrary.

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