Newsday - September 28, 2000
Laurie Garrett, Staff Writer

For more than a decade, the Centers for Disease Control and Prevention has estimated that the same number of people-about 40,000- has been contracting HIV annually. The institute, the nation's highest independent medical science body, questioned the validity of those numbers and of the CDC's HIV surveillance system.

Even if the numbers are accurate, the report added, such a plateau would constitute public health failure, since some poor countries have made strides in rolling back their epidemics.

The report, commissioned by the CDC, considered many factors potentially responsible for failure to bring new infection rates down, including lack of a clear strategy for HIV control, weak federal leadership and inappropriate allocation of resources.

But of primary concern are the numbers. No disease prevention effort can be judged successful unless the number of people newly infected declines as a result of an intervention. The institute said in strong terms that it doubts the reliability of the CDC's estimates of how many Americans are acquiring HIV each year.

"One of our concerns is getting accurate data to see if we have a handle on how serious the epidemic is," Dr. Michael Merson, dean of the Yale School of Public Health, said in an interview. Merson was one of 16 experts involved in preparing the institute's report. "One of the key recommendations in the report is that CDC create a surveillance system that can provide accurate estimates of the extent of the epidemic."

Since 1986, the CDC has said that the same number of Americans has been getting infected with HIV each year. That number isn't based on hard data, nor could it easily be, as most people who are infected don't realize they are HIV-positive until they, or their sex partners, become ill. And for reasons of confidentiality, many states do not require that doctors report HIV diagnoses. Fewer, still, report HIV cases by name, the most reliable way to track the incidence of any disease. The number, then, is a guess.

"The 40,000 number has always been a rough estimate-and that's an understatement," said Dr. James Curran, dean of the Rollins School of Public Health at Emory University in Atlanta. During the 1980s and early '90s, Curran headed the CDC's AIDS control efforts, and it was under his leadership that the 40,000 figure was originally derived. Back in 1986, Curran recalled, the U.S. prevalence was reckoned by extrapolating from the numbers of Army recruits who tested positive each year, allowing for an assumed lower rate of homosexuality among military volunteers as compared with the general population. Because the infection rates in 18-year-old Army recruits have consistently stayed quite low, the extrapolation to 40,000 hasn't wavered for 14 years.

But Curran, and the institute's panel, insist it's time to conduct widespread HIV surveillance studies to get a truer picture of the scope of America's epidemic.

"We do agree with the finding that having a more reliable surveillance system in place would be desirable," said Dr. Helene Gayle, Curran's successor at CDC. But she hastily added, "We don't think the [40,000] estimate is unreliable. It's been done using standard epidemiology."

The institute was also critical of how AIDS resources were spent. Deciding where to spend the $775 million AIDS prevention budget-8 percent of total 1999 federal HIV-related expenditures-calls for strong national leadership. And there, again, the institute was critical.

"The Clinton administration has not done any worse or better than any previous administration," Merson said, noting Secretary Donna Shalala's Health and Human Services Administration has demonstrated "insufficient coordination, and no single point person for HIV prevention."

The White House did not respond to telephone requests for a comment yesterday on the institute's charge.

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