The Centers for Disease Control and Prevention (CDC) announced a new HIV prevention strategy at an April 17 telephone news conference. It aims to reduce the number of new infections each year.
Current estimates are that close to a million Americans are infected with HIV, and perhaps a quarter of them do not know it. The CDC's estimate of new HIV infections has held steady for the last decade at 40,000 per year.
The CDC's previous prevention campaign, a five-year plan introduced in January 2001 after much public comment, had set the goal of cutting new HIV infections by half within those five years. There have been no reductions in estimated new infections, and in fact the CDC has issued repeated fears of increases in new infections because of increases in other sexually transmitted diseases.
'I'm thrilled that they are talking about HIV,' said Terje Anderson, executive director of the National Association of People With AIDS (NAPWA), and he is pleased with some of the content, but 'some of the details are troubling.'
'There was no consultation with the community on this,' said Anderson, it was largely done on the inside with CDC staff. 'That has aroused a tremendous amount of suspicion and distrust that people are going to do things to us, not with us.'
He called it a 'political' document 'designed to protect them [CDC] downtown' at the Department of Health and Human Services and in Congress.
In presenting the prevention initiative, CDC Director Julie Gerberding said, 'One of the barriers is access to diagnostic HIV testing.' She is removing the requirement of pre-testing counseling 'because many clinicians either don't know how to do that kind of counseling or simply don't have the time to squeeze it into a very brief office encounter.' This will make HIV testing a 'routine' part of medical care.
'Removing the link between counseling and testing is a mistake,' said David Harvey, executive director of the AIDS Alliance in Washington, D.C. 'Receiving an HIV diagnosis is a life changing event. It can result in estrangement from family, loss of job and housing. We cannot give people an HIV positive diagnosis without information and counseling.'
A second element in the CDC plan will fund demonstration projects using the recently approved OraQuick antibody test that gives results in twenty minutes. It can be used in the field, away from labs.
'Expanded testing makes absolute sense,' said Craig E. Thompson, executive director of AIDS Project Los Angeles. 'However, we cannot just test everyone, tell them they are HIV positive and send them home without counseling, care, or drug treatment.' He criticized the Bush administration for underfunding all aspects of HIV prevention and treatment.
A third component will focus prevention education messages on people already diagnosed with HIV and their partners. It will put increased emphasis on partner notification. This likely will lead to shifting prevention funds away from service organizations that target groups to ones that provide medical and social services.
Mark Ishaug, executive director of the AIDS Foundation of Chicago, called the initiative both 'very exciting and very troubling.' He is concerned by the 'apparent retreat on counseling and risk-reduction services—such as condom distribution and outreach programs—[which] represents a significant step backwards in our efforts to help high-risk communities respond to the AIDS crisis.'
'Preventing IV infection is everyone's responsibility,' he said. 'Both HIV-positive and HIV-negative individuals need accurate and science-based HIV prevention education and access to prevention supplies such as condoms and sterile syringes so that they may safeguard their health and the health of others.'
A fourth CDC initiative focuses on reducing mother to child transmission of HIV, approximately 300 cases a year. The CDC is recommending 'the opt-out approach' where testing a pregnant woman for HIV will be included within a routine package of exams rather than separately. Mothers can decide not to have the test, but if they do, 'then we want to make sure that their children are tested after birth,' Gerberding said.
Mother to child transmission constitutes a fraction of 1% of all new infections in the U.S. Most observers saw this fourth point as a sop to the far right, but it will costs millions of dollars a year in unnecessary HIV testing of pregnant women.
In an April 18 letter to Gerberding, NAPWA wrote, 'By focusing solely on interventions that deal with individual behaviors of people living with HIV/AIDS, CDC will immediately lead many to assume that government is moving toward a policy of blaming people living with HIV/AIDS for new infections.'
'They forget that this [new infections] occurs in a social context,' said Anderson. The success that Uganda has achieved in reducing new infections did not occur within a medical context, but through social interventions.
Anderson's biggest fear is that 'they are going to completely change the guidance they give to states' on prevention programs. 'It's very clear to me, no more talking dirty' will be allowed, even if it has been proven to be an effective intervention.
OMISSIONS
The new plan suffers from many of the same flaws and omissions as the old one and there is little reason to believe that it will significantly reduce the number of new infections. The Bush administration has been a strong supporter of abstinence-only prevention programs and has made it more difficult to include condoms as a part of total prevention activities.
Injection drug use continues to be a major route of transmission and needle-exchange programs have demonstrated success in reducing transmission of HIV. Yet this administration, as have all previous administrations, opposes federal funding of needle-exchange programs.
But perhaps most importantly, the CDC continues to ignore primary HIV infection (PHI). PHI is that window of about 90 days from exposure to the development of antibodies when viral load skyrockets into the millions, before settling back into the thousands of copies as the immune system exercises some control over the infection.
The likelihood of transmission of HIV increases with the viral load, as has been demonstrated in the lab and in population studies in Africa. Many researchers believe half of the new infections in the U.S. occur during the window of PHI. But the CDC offers no plan to deal with this route of infection.
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