Bay Area Reporter - November 16, 2000
Terry Beswick

But given the fact that rates of HIV infection among heterosexuals appear to be falling û at a time when infection rates among gay and bisexual men are either stable or on the rise û researchers at the University of California, San Francisco are saying enough is enough.

In "HIV Prevention: U.S. Priorities," published in the October 28 issue of Science, Joseph A. Catania, Ph.D., and other researchers with UCSF's Centers for AIDS Prevention Studies called for a major shift in priorities based on cost-effectiveness grounds.

In the paper, the researchers assert that it would be far more efficient for federal prevention resources to be directed toward gay and bisexual men, rather than toward populations where HIV is clearly on the decline.

"The cost-effectiveness of prevention efforts depends on the prevalence in the field," said Catania, speaking with the Bay Area Reporter.

But after Catania and his colleagues at CAPS conducted an extensive analysis of HIV risk reduction funding from the federal Centers for Disease Control and Prevention and the National Institutes of Health, they determined that funding priorities are being misplaced. Resources are being allocated based on old AIDS case data that looks at where the epidemic was going in the past, rather than the best available HIV surveillance data that shows where the epidemic is going today.

Men who have sex with men (MSM) accounted for 46 percent of AIDS cases in 1999 and yet received only 28 percent of HIV risk reduction funding, noted the researchers. Meanwhile, risk reduction for heterosexuals accounted for 31 percent of the spending even though heterosexual transmission accounted for just 17 percent of the cases.

"The allocations would make more sense if one believes that the HIV epidemic is declining among men who have sex with men," said Catania.

"HIV prevalence and incidence declined during the 1980s for urban MSMs.

However, HIV incidence plateaued for MSMs over the past decade, and incidence and prevalence generally remain at very high levels. In contrast, heterosexual prevalence levels, which have always been very low (<1%), have declined over the past decade, suggesting that incidence has decreased during this time period," wrote Catania and his co-authors in the Science paper.

The researchers called for a shift from the current focus on AIDS and HIV case-based reporting which gives a "window on the past" to an emphasis on sentinel surveillance systems that could provide "a much needed window on the future."

"All the AIDS case data has become completely useless," Catania noted.

"I'm not the first person to realize that."

"If you look at AIDS cases, there is a decline in cases among MSMs and an increase in heterosexual cases. However, if you look at the incidence of HIV, meaning the rate of new infections, and the prevalence of HIV, meaning the proportion of individuals in a population infected with the disease, you get a different picture. There seems to be a decline among heterosexuals and stable or increasing rates among MSMs," said Catania, the paper's lead author and an assistant professor of medicine with UCSF CAPS. "Unfortunately, our focus has been on AIDS cases, which give a picture five to 10 years out of phase with the epidemic. Frankly, we've lost track of the disease.

"This is my frustration, is that we don't have high quality data, and we can't get the NIH and CDC to fund this research," Catania said. "What we need is four good surveys in every high risk population over the next 10 years."

A developmental psychologist, Catania said he also worries about the complete lack of information or research on the population at greatest risk: young people.

"The challenge is really to focus on gay children and gay adolescents who really need a lot of nurturing and care to deal with their emerging sexuality," Catania said.

But the researchers said that now is the time for the federal government to catch up with the science and try to get ahead of the ball, if for no other reason, than simply to save money that would otherwise have to be spent on preventing more infections and caring for more people with HIV down the line.

"The financial costs of collecting probability-based samples and biological data present barriers to many local communities. However, oral HIV testing and 'detuned' assays are methodological developments that reduce data collection costs. In addition, the high costs of obtaining probability samples can be decreased," said the CAPS researchers.

"The United States has yet, however, to finance long-term HIV surveillance systems of high risk populations that are based on current advances in scientific sampling," the paper concluded. "Unfortunately, greater emphasis is placed on HIV case-based reporting than on sentinel surveillance. The former is a window on the past, while the latter is the much-needed window on the future."

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