Chicago Tribune - July 11, 2004
Judith Graham, Tribune staff reporter

The strategy essentially shifts the focus of federally financed prevention from its previous target--minorities, gays and drugs users who don't have the AIDS virus but are at high risk of becoming infected--to people who already have the virus and might transmit it to others.

Supporters say the change of direction, spearheaded by the Centers for Disease Control and Prevention, is needed because the nation's fight against AIDS has stalled.

Critics say the CDC could be undermining community programs sponsoring frank discussions about drugs and sex by imposing new requirements and in some cases, terminating government support.

Preventing AIDS will be a major topic of discussion this week in Bangkok, as scientists, policy experts and political leaders from across the world meet to discuss how to contain the epidemic, which has killed 20 million people since 1981.

In the U.S., arguments have erupted over how the CDC's new policies will affect efforts to contain the AIDS epidemic, particularly in minority communities. The government says outreach to such communities remains a high priority.

Last month, Sen. Dick Durbin (D-Ill.) wrote to Health and Human Services Secretary Tommy Thompson expressing concern that "two-thirds of the HIV/AIDS prevention organizations that previously received funding through the CDC will no longer be funded," even though many serve racial and ethnic populations "disproportionately affected" by the disease.

Dr. Rob Janssen, director of the CDC's HIV/AIDS prevention division, defends the government's new policies, noting that they reflect stark realities.

With the advent of anti-retroviral therapies in the mid-1990s, people with HIV are living longer and remaining sexually active, increasing the risk that AIDS could spread further, he said. Seven out of 10 people with HIV are sexually active.

Past prevention programs largely ignored the 900,000 people living with HIV/AIDS, Janssen said. It's especially important to reach the more than 200,000 people who are infected with undiagnosed HIV and play a major part in transmitting the infection to others, he said.

To this end, the CDC is encouraging much more widespread testing for HIV/AIDS in medical settings and other areas, using relatively new tests that can deliver results in as little as 20 minutes. The government has significantly expanded the number of providers authorized to administer the tests. More efforts also will be made to track down partners of people with HIV, already a common practice with other sexually transmitted diseases.

A major goal of the new strategy is reducing new infections. Although prevention efforts have helped dramatically cut the number of new HIV infections nationally from a peak of more than 160,000 in 1985, the current rate of 40,000 infections a year largely has held steady for a decade.

"We need to do a better job," Janssen said.

In Chicago, 15,900 people have HIV/AIDS; 56 percent of those are African-Americans. Between 1999 and 2002, the most recent year for which data is available, new AIDS diagnoses have hovered between 937 and 1,009 a year in the city. Since Chicago started tracking new HIV infections, they have been relatively stable at about 1,100 a year.

AIDS organizations agree the issues that concern the CDC need attention. The problem, they say, is that federal funding for AIDS prevention has remained at about $750 million a year, and devoting resources to these priorities means there will be less funding for preventing infections in high-risk populations, including minorities, gay men, injectable-drug users, and women.

"We are very concerned about how resources are being allocated, what populations they are going to, and whether high-risk populations will continue to be reached," said Leo Rennie, director of prevention programs for the National Alliance of State and Territorial AIDS Directors, based in Washington.

Also generating concern are proposed CDC guidelines for AIDS prevention published June 16 in the Federal Register. The guidelines require that educational materials used in prevention programs promote the benefits of abstinence, explain the potential risks of condom use, and not be considered obscene by "an average person."

"We think it's overkill, and even worse, that it could have a chilling effect," said David Munar, associate director of the AIDS Foundation of Chicago.

Exercising responsible oversight of AIDS prevention programs and striking a balance among priorities is challenging, Janssen says.

But he says the most effective intervention for preventing HIV/AIDS is informing people they're infected--not handing out condoms or educational materials, strategies employed by many programs.

The Chicago Department of Public Health is adopting a "wait and see" posture toward the new CDC initiative, said Christopher Brown, assistant commissioner for the division of HIV/AIDS.

"We'll be watching closely to see how this plays out," he said.

California's experience gives reason for some optimism.

Six years ago, the state started a project in 12 communities designed to show that people with HIV/AIDS could be persuaded to modify their behavior with counseling and support. Social workers worked intensively with small groups of men and women considered at the greatest risk of transmitting the virus.

The project showed "dramatic" reductions in risky behaviors such as substance abuse as well as dramatic improvements in condom use and other safe-sex practices, said Drew Johnson, chief of the education and prevention branch for California's office of AIDS policy.

In Chicago communities, though, some AIDS experts are skeptical about the CDC's new approach.

"Essentially, what this CDC plan is saying is, `We'll wait until you become HIV-positive and then we'll pay attention to you,'" said Jim Pickett, 38, a community activist and writer who learned he was infected nine years ago. "I think it's exceptionally cruel."

At Jelani Unified Men's Project on the West Side, Executive Director Vaughn Taylor worries that the CDC is emphasizing a medical model of "test and diagnose" in its new prevention strategy and de-emphasizing the behaviors that can lead to HIV infections.

The Jelani Project specialized in outreach to gay and transsexual black men on the West Side until last month, when it lost $233,890 in annual CDC funding and fired most of its staff. In Chicago, four agencies lost CDC funding, four had previous grants renewed, and three received new grants.

It's not enough to preach "safe sex" in the disadvantaged West Side neighborhoods where the Jelani Project operates, Taylor suggested.

"Sex is a currency to get goods and services in poorer populations," he said. "You have to find out what people's emotional response to sex is--Is it about power? Do they do it because they're bored? Because it makes them feel better? Under the influence?--if you have any hope of getting them to think about changing their behavior."

But Dr. Arthur Moswin, medical director for HIV programs at Michael Reese Hospital's Research and Education Foundation, thinks the CDC's new prevention program makes "intuitive sense."

For the first year, the Michael Reese program will draw clients from the hospital's clinics, but in later years it hopes to expand on the South Side through alliances with other organizations.

"These are very vulnerable, hard-to-reach populations," Moswin said.

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