HIV/AIDS Rate in D.C. Hits 3%
Considered a ‘Severe’ Epidemic, Every Mode of Transmission Is Increasing, City Study Finds

By Jose Antonio Vargas and Darryl Fears
Washington Post Staff Writers
Sunday, March 15, 2009; A01

At least 3 percent of District residents have HIV or AIDS, a total that far surpasses the 1 percent threshold that constitutes a “generalized and severe” epidemic, according to a report scheduled to be released by health officials tomorrow.

That translates into 2,984 residents per every 100,000 over the age of 12 — or 15,120 — according to the 2008 epidemiology report by the District’s HIV/AIDS office.

“Our rates are higher than West Africa,” said Shannon L. Hader, director of the District’s HIV/AIDS Administration, who once led the Federal Centers for Disease Control and Prevention’s work in Zimbabwe. “They’re on par with Uganda and some parts of Kenya.”

“We have every mode of transmission” — men having sex with men, heterosexual and injected drug use — “going up, all on the rise, and we have to deal with them,” Hader said.

In addition to the epidemiology report, the city is also releasing a study on heterosexual behavior tomorrow. That report, funded by the CDC, was conducted by the George Washington University School of Health and Health Services.

Among its findings: Almost half of those who had connections to the parts of the city with the highest AIDS prevalence and poverty rates said they had overlapping sexual partners within the past 12 months, three in five said they were aware of their own HIV status, and three in 10 said they had used a condom the last time they had sex.

Together, the reports offer a sobering assessment in a city that for years has stumbled in combating HIV and AIDS and is just beginning to regain its footing. A more accurate accounting of the crisis offers a chance to contain what is largely a preventable disease.

So urgent is the concern that the HIV/AIDS Administration took the relatively rare step of couching the city’s infections in a percentage, harkening to 1992, when San Francisco, around the height of its epidemic, announced that 4 percent of its population was HIV positive. But the report also cautions that “we know that the true number of residents currently infected and living with HIV is certainly higher.”

The District’s report found a 22 percent increase in HIV and AIDS cases from the 12,428 reported at the end of 2006, touching every race and sex across population and neighborhoods, with an epidemic level in all but one of the eight wards. Black men, with an infection rate of nearly 7 percent, carry the weight of the disease, according to the report, which also underscores that the District’s HIV and AIDS population is aging. Almost 1 in 10 residents between the ages of 40 and 49 has the virus.

The report notes that “this growing population will have significant implications on the District’s health care system” as residents face chronic medical problems associated with aging and fighting a disease that compromises the immune system.

Men having sex with men has remained the disease’s leading mode of transmission. Heterosexual transmission and injection drug use closely follow, the report says. Three percent of black women carry the virus, partly a result of the increase in heterosexual transmissions.

“This is very, very depressing news, especially considering HIV’s profound impact on minority communities,” said Anthony Fauci, director of the National Institutes of Health’s program on infectious diseases. “And remember: The city’s numbers are just based on people who’ve gotten tested.”

Ron Simmons, who is black, gay and HIV positive, said he’s not shocked by the study’s findings. “You have a high incidence of HIV among African Americans, and a lot of African Americans live in the city,” said Simmons, who is a member of a black gay support group. “D.C. also has a high number of gay men, and HIV is high among gay black men.”

Charlene Cotton, a D.C. resident who got an HIV positive diagnosis five years ago, said breaking the taboo on discussing HIV is the key to moving forward. “You need to start at home and talk about it,” Cotton said. “It’s so hush-hush.”

Mayor Adrian M. Fenty (D) said he is aware that some advocates have called on elected officials and others to more aggressively and publicly address the crisis. He praised the city’s recent efforts, however, and expressed his frustration about the struggle ahead.

“In order to solve an issue as complex as HIV and AIDS, you have to step up,” he said. “It’s the mayor and certainly other elected officials. But it’s also the community. You have this problem affecting us, and you tell people how serious it is and it literally goes in one ear and out the other.”

David Catania (I-At Large), chairman of the D.C. Council’s health committee, said that although the District’s testing and monitoring have improved in the past two years, the AIDS office is still playing catch-up. The city was in the forefront of the crisis when it created the office in 1986, but it fell far behind. Hader took control in 2007. She is its 12th director and the third in five years.

“Frankly, there can be no excuse for the state of the HIV/AIDS Administration that I found in 2005,” Catania said. “I cannot speak to why it was not a priority previously. For years prior to 2005, mayors and previous individuals allowed things to exist in an unacceptable way. And I do blame this government for part of the epidemic we’re confronting.”

Until recently, the District’s AIDS office lacked a fully staffed surveillance unit to collect, analyze and distribute data. Inevitably, the office lost credibility, and although it has received millions in federal and local funds — $95 million this year — some care providers questioned whether resources were being properly allocated.

Critics also say congressional control over the District had restricted the AIDS office’s ability to combat the virus among drug injection users by banning the use of local tax dollars for a needle exchange program. After almost a decade, the ban was lifted last year.

The study is the most precise count to date, according to the authors. The document is an update of a breakthrough 2007 report, which brought into clearer focus a picture of a city in the grip of a complex and “modern epidemic” that had traveled from a mostly gay population to the general one and disproportionately hit blacks.

For years, District HIV/AIDS workers depended on estimates that put the rate at 1 of 20 living with HIV and 1 of 50 living with AIDS.

The current study notes that its tracking occurred as the city made a switch from a code-based counting system to a name-based one. The surveillance unit interviewed medical providers to find unreported cases, pressed providers who did not consistently report to the administration and searched databases for unreported cases.

More than 4 percent of blacks in the city are known to have HIV, along with almost 2 percent of Latinos and 1.4 percent of whites. More than three-quarters — 76 percent — of the HIV infected are black, 70 percent are men and 70 percent are age 40 and older.

Heterosexual sex was the principal mode of transmission for blacks with the disease, 33 percent. Men having sex with men was the chief mode of transmission for white residents, 78 percent; and Latinos, 49 percent. Black women represent more than a quarter of HIV cases in the District, and most, about 58 percent, were infected through heterosexual sex. About a quarter of black women were infected through drug use.

The companion study, “Heterosexual Relationships and HIV in Washington, D.C.,” is a detailed look at those whose social networks include individuals at high risk of infection and aims to analyze people’s choices and actions before they set foot in a clinic or get HIV.

The 750-participant study targeted four areas in wards 1, 2, 5, 6, 7 and 8 with both high rates of AIDS and poverty. Salaries of a majority of participants — 60 percent — were under $10,000 yearly; a similar percentage had never been married; and 43 percent were unemployed.

The survey’s methodology — interviewing those with connections to high-risk networks rather than those who exhibit high-risk behavior themselves — highlights a shift in the direction by the CDC, which developed the survey protocol.

There is good news in the AIDS office’s report: More people are getting HIV diagnoses early, while they are still healthy, as a result of a policy of routine testing implemented by the city in mid-2006. Publicly supported HIV testing expanded by 70 percent.

Walter Smith, executive director of the DC Appleseed Center for Law and Justice, praised the study but also lamented that it did not offer more current data on new infections. The report said that detailed information on new HIV cases is not included because the transition from the code-based tracking system to a name-based one takes five years to be mature, according to the CDC.

“I’m not criticizing them for that,” he said. “But we’ve had more testing, more needle exchange programs. We don’t have, at this moment, any understanding about what impact the new programs have had.”

Staff writers Jon Cohen and Jennifer Agiesta contributed to this report.

A January 2008 article in a new journal Future HIV Therapy makes the most persuasive case for male circumcision being rolled out on a much, much wider scale in sub-Saharan Africa. We have blogged about the importance of male circumcision before (see here, here, and here).

This new piece is by Jeffrey D Klausner, Richard G Wamai, Kasonde Bowa, Kawango Agot, Jesse Kagimba & Daniel T Halperin. They start their paper by asking “What would the reaction of the international public health community have been if a year ago scientists had announced the discovery of a vaccine or chemical gel that, in three separate clinical trials, had reduced the risk of heterosexual HIV infection in men by at least 60%?”

They answer that question by noting that male circumcision (MC) provides that kind of risk reduction potential and also one which potentially provides an “‘African solution to African problems.”

Here are some choice quotes:

Currently, MC is the only modality for preventing sexual HIV transmission that has been proven to work by the highest standards of scientific evidence; specifically, findings from multiple randomized controlled trials. In fact, it appears that the actual protective effect of MC is probably somewhat higher than the official 60% estimate cited by WHO and UNAIDS, especially among higher-risk men.

In fact, it appears that the actual protective effect of MC is probably somewhat higher than the official 60% estimate cited by WHO and UNAIDS, especially among higher-risk men. In part, this is because some men who were randomly assigned to the circumcision arm in each trial did not show up for their appointment and, more importantly, a larger number of men who were randomly assigned to noncircumcision decided to get circumcised on their own during the trial period. Hence, the ‘as-treated’ protective effect, taking into account the actual MC status of participants, was a 76% HIV reduction in the trial in South Africa (where HIV prevalence was highest) [19]; and averaging across the three trials it was 65% [12].

The ultimate population-level impact of MC would be further amplified by a ‘herd immunity’ phenomenon if a sufficiently large proportion of men were to become circumcised in the population.

Modeling suggests that widespread circumcision in the rest of sub-Saharan Africa could avert up to 2 million new HIV cases and 300,000 deaths over the next 10 years, and 3.7 million infections and 2.7 million deaths in the following 10 years, many of those among women [27].

What about the cultural acceptability of male circumcision? Is this not cultural imperialism? This article largely puts that notion to bed.

A dozen acceptability studies conducted in different parts of Africa where MC is no longer traditionally practiced have found that the majority of uncircumcised men want the procedure performed, and generally an even higher proportion of women in those regions would prefer to have an uncircumcised partner.

Male circumcision was historically practiced in nearly all of Africa, but 19th century European missionaries condemned the widespread traditional initiation ceremonies, which included circumcision, as pagan practices

In a 2006 household survey of Swazi men in both urban and rural areas, 87% said they would want the procedure if it helped reduce the risk of HIV infection. In January of that year, the media reported on a ‘circumcision riot’ when over a hundred men in the capital city were turned away because not enough physicians were available at a ‘free circumcision Saturday’ event.

The authors are incredulous that there has been a delay in rolling out male circumcision on a broader scale.

So the question must be asked: why the continuing delays in the implementation of MC? Why do some prominent officials, nongovernmental organizations, Ministries of Health and international organizations vacillate as thousands become infected every day, preferring to debate over cultural imperialism, the ‘rights’ of the foreskin, the ‘real world’ validity of randomized trials and so on?

We understand the very real operational challenges, implementation logistics, safety concerns and the enormous task of scaling-up a surgical procedure so that it is readily available for millions of impoverished people.

They make their own personal case:

Two of the authors (Wamai and Agot) are from Kenya and have witnessed first-hand the devastation in the part of the country (Nyanza Province) where the virus has flourished due in large part, we now realize, because that is the one province where MC is not a cultural norm. Another (Bowa) is a Zambian urologist who has struggled to make safe MC available at the University Teaching Hospital in Lusaka; due to funding limitations, the demand for services has far outstripped supply and the waiting list has grown up to 8 months long. Another (Kagimba) was one of the original architects of the now famous ‘Zero Grazing’ behavior change (partner reduction) strategy in Uganda, and seeks to add MC to the ‘ABC’ prevention approach.

They conclude with a call for action:

Now, 25 years after the pandemic was first identified, we have an important additional tool, the knowledge to help bring life back, to give people some hope. We need the rallying cry; above all, we need accountability. We need you – the reader, the media, the viewer, the voter, the caring man or woman on the street – to say not whether but when. When will there be widespread, safe and affordable MC services available in Africa? Every day we are counting and watching.

Immediately, the front page of every major newspaper and other broadcast media around the world – certainly those in southern Africa – should report on the great impact that implementation of MC could bring.

The latest estimates, due to be released publicly Tuesday, put the number of annual new HIV infections at 2.5 million, a cut of more than 40 percent from last year’s estimate, documents show. The worldwide total of people infected with HIV — estimated a year ago at nearly 40 million and rising — now will be reported as 33 million.

For example, the United Nations has cut its estimate of HIV cases in India by more than half because of a study completed this year.

There is some suggestion that the epidemic has crested, that fears of a potential global epidemic in places like China and India are overblown. I thought the line in the story about India was interesting in that India has been thought to have the largest number of AIDS cases, even if a small proportion of the total populace. This suggests the disease is much less of a problem in India than initially feared.

What does this mean for policy? The study quotes some other experts who think 33mn is still too high. I think in time this might mean more emphasis on health systems (broadening the health emphasis beyond HIV) and perhaps more targeted efforts to southern Africa and vulnerable populations in other countries.

It’s interesting to think about Oster’s thesis, and I’m not sure it sits that well with Epstein’s recent book. If Oster is right, then it may be harder to replicate Be Faithful programs around the continent through conscious efforts. It may be harder for people to be faithful if commodity prices increase and give people more income to be able to afford to support more sexual partners.

However, I’m not sure if Oster’s thesis is internally consistent. If people have more money, then, according to Oster, a cost-benefit ratio over the long-term would suggest they have more to live for, so they shouldn’t wreck it by being risky. On the other hand, she also finds that a large proportion of the variance in AIDS rates is explained by variations in export revenue. With higher export revenue, AIDS prevalance goes up. What gives? Am I wrong or are these two conjectures at odds? I believe there may be a correlation there with declining export revenue and prevalance in Uganda, but is the causal connection between walk around money and how many girlfriends men could support right?

Postscript: Oster’s old paper is the one that made the claim that richer people should be more risk averse because they have more to live for. Her newer paper makes the claim that higher export earnings are correlated with higher prevalence levels. It seems to be driven by volume and the time truckers are away from home rather than individual earnings power. More exports means more time demanded of truckers to be away from their families. However, that must also mean more money in their pockets which should mean that, as any forward thinking rational animal, truckers should put a sock on it. Sounds like they don’t which sits uneasily with Oster’s previous work, as far as I can tell.

Postscript 2: I had a good interchange with Oster about this issue, and she sought to reconcile it by talking about long-term vs. short-term behavior change. She wrote that the subject of her first paper was how making people richer over their whole lives could motivate behavior change. It wouldn’t happen overnight, as it relied on shifts in people’s expectations about the future, and she noted that the effects were small.

Whereas the first paper relied on long-term behavior change, she suggests the export story in her new paper is really short-term, as trend data has been explicitly removed. With more exports she says, there are more truck drivers. They have more sex partners, driving epidemic rates up. Over the long-term, high exports could make the country richer, leading people to protect themselves, but in the short-run, the issue is one of more exports–>more truckers–>more risky sex–>more HIV.

The more I read her paper, and from her e-mail, it’s really not about income, but it’s about export volume and the presence of more truckers on the road. She disputed the notion that export volumes in the short run would necessarily mean more income. But, unless truckers have more pocket money, how are they able to enter into these sexual relationships?

I think the mechanism influencing the number of sexual partners needs more elaboration. Do truckers’ change their number of sexual partners in response to education/information, income, or time away from home. It seems like Oster’s thesis comes down to the third explanation. Guys are away from home, and no matter how much money they have in their pocket, they will engage in risky sex. The fact that Uganda experienced a a decline in prevalence wasn’t because the truckers got information or even that they had less money, but there were simply fewer of them on the road. This may be a hasty read of her argument, but I still think it needs some tweaking/refinement.

CHITUNGWIZA, Zimbabwe — It’s not only the prices of bread and eggs that are out of control in Zimbabwe, land of 4,000 percent inflation. For the man inclined to cheat on his wife, these are trying times. Keeping a mistress, visiting a prostitute or even taking a girlfriend out for beers is simply becoming too expensive, men say.

But their strain is Zimbabwe’s gain in its fight against AIDS. Alone among southern African countries, Zimbabwe has shown a significant drop in its HIV rate in recent years. A major reason, researchers say, is the changing sexual habits of men forced to
abandon costly multiple relationships…

Read the full story on the Washington Post

Researchers have discovered that cells in the mucosal lining of
human genitalia produce a protein that “eats up” invading HIV –
possibly keeping the spread of the AIDS more contained than it might
otherwise be.

Even more important, enhancing the activity of this protein, called
Langerin, could be a potent new way to curtail the transmission of the
virus that causes AIDS, the Dutch scientists added.

Langerin is produced by Langerhans cells, which form a web-like
network in skin and mucosa. This network is one of the first structures
HIV confronts as it attempts to infect its host.

Copyright © 2007 ScoutNews, LLC

Yesterday, the NIH announced that it was suspending male circumcision trials. Because the trials were so successful, the NIH determined it was unethical to continue with additional rounds of treatment and control groups.

The trial in Kisumu, Kenya, of 2,784 HIV-negative men showed a 53 percent reduction of HIV acquisition in circumcised men relative to uncircumcised men, while a trial of 4,996 HIV-negative men in Rakai, Uganda, showed that HIV acquisition was reduced by 48 percent in circumcised men.

Amy Patterson in her recent book on AIDS in Africa raises an interesting issue about male circumcision. She suggests that male circumcision represents a search for “technical solutions” and a broader failure of policymakers to address the political and economic structures that contribute to HIV vulnerability” (11).

Specifically, she is referring to the recurrent patterns of gender inequality that expose women to unequal power relations vis a vis male sexual partners, from the broad system that makes women economically vulnerable and dependent on men to coerced sex and a lack of willingness by men to use condoms.

While I agree with her broader concerns about gender inequality, it is pretty clear that both patterns of long-term concurrent sexual partners, low condom use, and systemic gender inequality are not going to be easy to change in the short-run. While women may enter into unequal sexual relations in years to come, if they do so with circumcised men, at least their risk of exposure to HIV should go down significantly. That, in my view, is a very good thing.

“Trials in Kenya and Uganda Stopped Early”

The National Institute of Allergy and Infectious Diseases (NIAID), part of the National Institutes of Health (NIH), announced an early end to two clinical trials of adult male circumcision because an interim review of trial data revealed that medically performed circumcision significantly reduces a man’s risk of acquiring HIV through heterosexual intercourse. The trial in Kisumu, Kenya, of 2,784 HIV-negative men showed a 53 percent reduction of HIV acquisition in circumcised men relative to uncircumcised men, while a trial of 4,996 HIV-negative men in Rakai, Uganda, showed that HIV acquisition was reduced by 48 percent in circumcised men.

“These findings are of great interest to public health policy makers who are developing and implementing comprehensive HIV prevention programs,” says NIH Director Elias A. Zerhouni, M.D. “Male circumcision performed safely in a medical environment complements other HIV prevention strategies and could lessen the burden of HIV/AIDS, especially in countries in sub-Saharan Africa where, according to the 2006 estimates from UNAIDS, 2.8 million new infections occurred in a single year.”

…

Both trials reached their enrollment targets by September 2005 and were originally designed to continue follow-up until mid-2007. However, at the regularly scheduled meeting of the NIAID Data and Safety Monitoring Board (DSMB) on December 12, 2006, reviewers assessed the interim data and deemed medically performed circumcision safe and effective in reducing HIV acquisition in both trials. They therefore recommended the two studies be halted early. All men who were randomized into the non-intervention arms will now be offered circumcision.

…

For more information on the Kenyan and Ugandan trials of adult male circumcision, see the NIAID Questions and Answers document at  [CLICK FOR COMPLETE ARTICLE]