Grab That Bull by Its Horns: HIV/AIDS in the Capital of the Richest Country in the World

Sunday’s Washington Post’s headline news: “HIV/AIDS Rate in DC Hits 3%.”. We are indeed in the midst of a “generalized and severe” HIV/AIDS epidemic in the Nation’s capital. Shocked? You should be. From a report of a study that was released today, sexual transmission, followed by intravenous drug use, is the key mode of transmission in our city.The report has just been posted but the news article mentions a few features of the study design: Study sample size: 750 and Methodology: Developed by CDC, a survey conducted with study participants from four targeted areas—Wards 1, 2, 5, 6, 7 and 8—with high HIV infection rates and poverty. Participants were interviewed “with connections to high-risk networks rather than those who exhibit high risk behaviors themselves.” Further details about the study design such as calculation of the sample size or the survey sampling method will allow for more detailed comments on the statistical power and validity of the results but a common sense read of the published results in the news tell us a few things about the HIV/AIDS epidemic in DC and what it means for DC and the rest of the world:• It’s affecting our city’s residents across the board: black, white, Hispanic, gay, straight, man, woman (with varying rates, but all alarmingly high) and notably high in age groups 40-49 and 50-59. A glimmer of hope is that young people interviewed are relatively less affected, but nonetheless getting infected as we speak. These are cross sectional numbers so we have no idea about new infections (incidence) and where these are occurring, but this snapshot does tell us how the infection rates are distributed at the time of the study.• High prevalence rates in DC could be due to lower number of deaths due to AIDS (because of treatment), and/or an increase in new infections but it is clear that our city officials have not been able to grab the bull by its horns ever since the DC AIDS program started in 1986 and its time to do this! Last September I commented on connections between the domestic (U.S.) and global response to AIDS and the need to move beyond preventing sexual behavior (as in promoting abstinence, ignoring MSM) and in this case IVDU, to preventing HIV transmission both in the US and globally. I’m especially interested in learning more about the prevention programs that will be designed to address these high levels of infection and if and how they will be evaluated. Given that HIV is being transmitted through multiple modes in DC (as is typical of a generalized epidemic), prevention approaches that combine different interventions to address multiple drivers of infection will need to be put in to place. “Combination prevention” programming is a topic that is being hotly debated in the global health policy world. See letter in Lancet (subscription required) by Daniel Halperin: “As with HIV treatment regimens, prevention elements should be combined, but their combined effectiveness must be demonstrated. Trials of standard combination prevention approaches in Africa have thus far been unsuccessful (and, in one, HIV incidence was higher in the experimental group). Like treatment, prevention must be deployed with scientific rigor.”• As Shannon Hader, Director of the city’s HIV/AIDS Office mentions in the article, DC is now among the ranks of countries in East Africa, but the difference is that Washington, DC is NOT in Africa. It is the capital city of the world’s largest economy (well at least for now, and if you don’t count the EU!) which you would think guarantees a few conditions for an effective HIV/AIDS program:

• Financing: It isn’t clear from the article how much money has been poured in the District’s AIDS office, but the news article says that this office has “received millions in federal and local funds--$95 million this year-- some care providers questioned whether resources were being properly allocated.” Where did this money go? If the U.S. government is encouraging its partner countries in the Global AIDS program to be accountable for the funds they receive, this must start at home.• Health System: It’s embarrassing but not surprising that our city’s health system (can anyone describe this clearly?) has not managed to keep its citizen’s free of HIV/AIDS with all the resources supposedly available to it, relative to countries in east and southern Africa—financing, capacity, infrastructure.

CGD’s HIV/AIDS Monitor examines how global donor programs support the AIDS response in Uganda, Mozambique and Zambia. We are conducting research to understand how the design, delivery and management of these programs can improve the effectiveness of aid for HIV to make a real impact on the epidemic in these countries. The DC AIDS office should be commended for doing this study and looking forward DC could be a perfect case study for many at home and abroad who are trying to find out how prevention, treatment and care programs can work in a generalized epidemic, when you have all the right conditions and leadership in place. Shannon Hader as Matador, an ex-CDC official (with experience under much tougher conditions in Africa), offers us some hope to do this. While animal activists and bullfight aficionados fight over whether bull fights should exist, here is one bull the city’s HIV/AIDS office can grab by the horns and try put to rest without debate.Update: For an interesting Q & A with Shannon Hader on the reasons behind the statistics and the approach of the DC Government going forward see:http://www.washingtonpost.com/wp-dyn/content/discussion/2009/03/13/DI2009031302713.html?sid=ST2009031402211