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Susman, Ed

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National HIV Prevention conference, Atlanta

Office of National AIDS Policy

Scott Evertz looked out at the 2000 participants at the National HIV Prevention Conference in Atlanta. Ga., and asked: ‘‘How many of you thought that I wouldn't come here and say: ‘Men who have sex with men'; ‘commercial sex workers and their clients', ‘injection drug users.’’’ The audience exploded with clapping and laughter, indicating the level of suspicion with which the HIV/AIDS community views the commitment of George W. Bush's Administration to fighting the disease.

Evertz, the director of the Bush Administration's much-maligned White House Office of National AIDS Policy, took pains to assuage the perception that AIDS policy is off the administration's radar screen. ‘‘My presence here is really the best way to convince you that the Bush Administration really does care about HIV/AIDS,’’ Evertz said. ‘‘All I ask is that you give me some time to prove that to you. I'm here to listen.’'

Evertz said the White House office has retained on its advisory board members who were appointed by President Clinton and whose terms have not expired. He also said his office now has staff to help him. He challenged attendees to buttonhole him during the meeting and offer suggestions. However, calls to his office for comment on specific programs were not returned.

Needle exchange reverses epidemic

Researchers at the conference said that use of needle exchange programs in New York City had changed the face of the epidemic among injecting drug users in the city. ‘‘Large scale syringe exchange and HIV voluntary counseling and testing programs appear to have ‘reversed’ the HIV epidemic among injecting drug users in New York City,’’ said Dr. Don Des Jarlais, Ph.D., professor of epidemiology and social medicine at the Albert Einstein College of Medicine of Yeshiva University, The Bronx, New York.

Although illegal in many states, some municipalities allow needle exchanges, in the belief that such exchanges will prevent spread of disease. In New York City, that is apparently what has occurred. Des Jarlais said that at the peak of the epidemic among injecting drug users 50 000 people were infected. The epidemic began in the late 1970s and swept through the needle-sharing population of the city. By 1983, he said, as many as 50 percent of the 200 000 drug users in New York City were infected with HIV. That number remained constant through 1991, Des Jarlais said. A needle and syringe exchange program was initiated in 1992. About 40 to 50 percent of the injecting drug users took advantage of the program. When Des Jarlais and colleagues analyzed the latest data, they found that about 20 percent of the drug users are infected. Until the initiation of the needle exchange program, about 4 to 5 percent of the drug users were becoming infected each year, he said. Now, he said, new infections are down to about 1 percent a year. (Unexpected success in HIV prevention for injecting drug users in New York City. Des Jarlais D, et al. for the National Development and Research Institutes. National HIV Prevention Conference. August 2001, abstract 565, p. 300).

Patients tested late in the game

In the US, as many as 300 000 of the estimated 900 000 people living with AIDS are unaware they have the disease because they haven't been tested. Yet a number of those people either have risk factors that would make them candidates for testing or have shown symptoms of the disease. Even so, in a new study, doctors said that 4 of 10 people aren't tested for the disease until years after becoming infected.

The failure to test people for HIV infection and to treat them in a timely manner, researchers said, may also mean that patient are spreading AIDS unknowingly through contacts with others. ‘‘It takes about 10 years for signs of disease to occur,’’ said Dr. Ronald Valdiserri, MD, deputy director of the National Center for HIV, STD and TB Prevention at the Centers for Disease Control and Prevention (CDC).

In a study presented at the conference, Leo Hurley, a researcher at Kaiser Permanente, Oakland, Calif., reported that 40 percent of patients diagnosed with AIDS were first tested for their disease within a year of coming down with AIDS-defining illnesses. About one in five of the patients – 18 percent – were diagnosed with an AIDS-defining illness within 1 month of testing, Hurley said. About 30 percent of the patients were first tested within 3 months of developing disease symptoms, and 34 percent were tested less than 6 months from the time of receiving an AIDS diagnosis. ‘‘About half the patients sought an AIDS test because they were feeling ill,’’ Hurley said. He noted that about half of the patients when diagnosed had depletion of CD4-positive cells. Eighty percent of the patients who were diagnosed with AIDS fell into high-risk categories: they were men who had sex with men, or were injecting drug users or both. (Early detection of HIV: The HEDS UP Study. Klein D, et al. National HIV Prevention Conference. August 2001, abstract 838, p. 441).

Silence on safer sex messages

And often when patients are diagnosed with AIDS, their primary care doctors fail to provide a prevention message. Almost one-fourth of HIV-infected men said their doctors never discussed with them methods of safer sex – even in cases where the men were being treating for another sexually-transmitted disease. ‘‘Health care providers are not consistently talking to HIV-seropositive patients about safer sex,’’ said Andrew Margolis, a CDC project manager, and lead author of a study presented at the conference. ‘‘We are speculating,’’ Margolis said, ‘‘but we think that time and money are the reasons that doctors do not perform this counseling as part of the routine patient treatment. Doctors are under a lot of pressure to see patients and may not have the time to spend in counseling efforts. And then there is the question of reimbursement for the doctor's counseling time. Right now they are not reimbursed.’'

Margolis recruited 250 gay and bisexual men in San Francisco and New York and asked them to complete a confidential questionnaire and interview. He found: about 23% of the men said their current healthcare provider had never spoken with them about safer sex practices such as condom use; 37% of participants had unprotected anal intercourse with a partner who was HIV negative or whose serostatus was unknown; men who were at greatest risk for transmitting HIV were no more likely to have been counseled than men not reporting risky behaviors; contracting a sexually transmitted disease since HIV diagnosis was not associated with having received safer-sex counseling. (Many health care providers are not counseling hiv-seropositive patients about safer sex. Margolis A, et al. National HIV Prevention Conference. August 2001, abstract 3598, p. 190).

US epidemic on a plateau

The estimated number of new cases of HIV infection remained constant in the US for the third straight year at 40 000. Dr. Helene Gayle, MD, director of the National Center for HIV, STD and TB Prevention at the CDC, said the plateau achieved in the epidemic in the US is no reason for complacency. ‘‘I believe the United States is at a critical juncture in the battle against HIV,’’ she said. ‘‘The type of progress made to date is in jeopardy if efforts are not intensified and in fact accelerated.’’ Gayle said that new statistics that cover the epidemic through December 2000 have found that 765 559 cases of AIDS have been reported in the US since the disease was first reported in 1981. Of that number, 442 882 people have died of AIDS. Death from AIDS – which peaked at 40 000 a year in 1995 has now fallen to around 16 000 a year.

While citing progress in fighting the disease, Dr. Anthony Fauci, MD, director of the National Institute of Allergy and Infectious Diseases, said ‘‘we are in the midst of a still accelerating epidemic. It is not time to congratulate ourselves on some of our advances but to look at some of the challenges that remain.’’ (Overview of the epidemic: epidemiology and major program responses. Gayle H. Presented at the National HIV Prevention Conference. August 2001 p. 33).

Helene says good-bye

The conference represented Gayle's last meeting as the head of the National Center for HIV, STD and TB Prevention. She moves to take a position with the Bill and Melinda Gates Foundation, one of the world's leading contributors to the fight against the disease.

In her emotion filled closing remarks to the conference, Gayle said, ‘‘We have come a long way together and we have come together because we believe in prevention. We are here because we believe this battle is about all of us, about our humanity and because we believe that together we can win. As we leave here let's remember the power that we all have to make change occur. Times have changed. The epidemic has evolved. What hasn't changed and shouldn't change is our belief that we can make a difference. In the end, all change starts with individuals, spreads to communities and in turn alters nations and ultimately the world.’'

Ed Susman

Websites of interest:

White House Office on National AIDS Policy

Log Cabin Republicans

© 2002 Lippincott Williams & Wilkins, Inc.