Bay Area Reporter - July 31, 2008
Bob Roehr

A trio of reports on the state of HIV/AIDS in the United States and around the world tumbled out in back to back telephone news conferences Tuesday, July 29. Together they painted a picture of significant accomplishment and remaining challenges.

They offered a backdrop to President Bush signing the five-year, $50 billion reauthorization of the U.S. international AIDS effort known as PEPFAR, and set the stage for the International AIDS Conference in Mexico City, August 3-8.

According to a new report by the Black AIDS Institute, there are more black Americans living with HIV than the total HIV populations in seven of the 15 countries that are the focus of the PEPFAR program. If black America were its own country, it would rank 16th in people living with HIV; 105th in life expectancy; and 88th in infant mortality worldwide.

That damning case was made in " Left Behind! Black America: A Neglected Priority in the Global AIDS Epidemic." The report praised the country's international effort but said the U.S. has neglected the epidemic here at home.

"If black America were a separate country, it would elicit major concern and extensive assistance from the U.S. government," said Phill Wilson, executive director of the institute. "Instead, the national response to AIDS among black Americans has been lethargic and often neglectful."

The report noted that HIV prevalence among middle-aged black men in Manhattan is almost as high as it is in South Africa, the heart of the epidemic. It chastised the U.S. for not having created a national strategic plan to address the domestic epidemic, something that it demands of countries receiving PEPFAR funds.

Blacks constitute about 12.5 percent of the entire U.S. population but more than half of all HIV infections. Wilson said current prevention policies and programs "are fundamentally flawed" and need to be reoriented.

The report argues that HIV has become a generalized epidemic within the black community, with significant transmission of infection beyond the initial core groups of injection drug users and men who have sex with men.

It calls for a substantial increase in funds to addressing those needs. The programs should be a mix of prevention programs that target high-risk populations, plus a broader based initiative that mobilizes entire communities to address issues of concurrent partnerships within social networks.

UNAIDS

The ramping up of access to antiretroviral therapy and prevention "are now producing measurable effects in terms of mortality and declines in new infections," said Dr. Paul De Lay, director of monitoring and evaluation at UNAIDS.

Those changes were documented in the 250-page " 2008 Report on the Global AIDS epidemic." The biennial report by UNAIDS uses 25 indicators to track progress and allow comparisons between countries. The governments of those nations supplied the data.

De Lay said that over the last two years there has been "a tripling of HIV prevention efforts in some countries for populations most at risk." Prevention education has been integrated into 90 percent of primary school education in sub-Saharan Africa, compared with 65 percent worldwide.

"Young people are waiting longer to become sexually active," he said. For example, in the African nation of Cameroon, the percentage of young people having sex before the age of 15 has dropped from 35 percent in 2005 to 14 percent in 2007. Worldwide, use of antiretroviral therapy to prevent mother to child transmission of the virus has increased from 14 percent to 33 percent in just two years.

As a result of increased activities such as these, the number of new infections in persons under the age of 15 has declined from 410,000 to 370,000.

There has been a dramatic increase in access to antiretroviral therapy in middle and low income countries, "an increase of 1 million just in the last year alone," increasing that total to 3 million people, said De Lay. Because of that the number of people who died of AIDS declined from 2.2 million in 2005 to 2 million in 2007.

"However, there are still five new infections for every two people who are newly started on treatment. Clearly we are not pushing back the epidemic ... AIDS continues to be the leading cause of death in Africa and it is among the top 10 leading causes of death globally," said De Lay.

The U.S. did not provide data for this report, though it has in previous years. When asked about this De Lay said that was "a disappointment," but declined to elaborate.

The Centers for Disease Control and Prevention has played coy with its estimates of new infections since last fall. Reports were that they have revised those numbers upward, perhaps substantially, but Kevin Fenton, the head of HIV programs at the CDC, has declined to release them pending peer review and publication. They will be released Sunday at the conference in Mexico City.

Advocate's report

The International Treatment Preparedness Coalition released its sixth annual report, "Missing the Target #6: HIV/AIDS Response and Health Systems: Building on success to achieve health care for all."

A substantial portion of the report was devoted to refuting charges from those who have asserted that international efforts such as PEPFAR have come at the expense of more traditional health care. The report was based upon extensive interviews with patients, policy, and health care workers in targeted countries hardest hit by the epidemic.

It concluded that the HIV effort "has had far-reaching positive impacts on health care in many settings; building infrastructure and systems, raising the bar on quality, extending the reach of health care to socially marginalized groups and engaging consumers."

"HIV services have been an oasis in the middle of a collapsing health delivery system" amidst the political and economic turmoil of Zimbabwe, said co-author Matilda Moyo.

"To me, the scale-up of antiretroviral therapy has been the most ambitious public health undertaking of our lifetime," said co-author Gregg Gonsalves. "We can be the catalyst for building comprehensive primary care for poor people around the world."

Jim Kim with the Harvard School of Public Health said, "HIV is the reason why we have so much more money to do more for health" in the developing world. He saw the report as a way to help design better health care delivery systems in the countries hardest hit by AIDS.

All three reports are available online at the sites of the respective organizations.

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