SEPTEMBER 1998

NUMBER ONE

Money Talks
Programs work, but politicians don't care.

Over the past two years, the arrival and quick success of HIV combination therapy has overshadowed prevention efforts. That's the view taken by prevention experts, who have called for increased funding for prevention and risk-reduction programs and more action around these issues by community HIV advocates. While federal money for AIDS housing and substance-abuse programs increased, prevention advocates criticized the "flat funding" of HIV prevention programs this year and denounced the ban on federal funding for needle exchange (see "Clinton Flip-Flops on Needle Exchange").

While declining among whites, HIV continues to target black and Latino communities disproportionately. Youths make up half of all new infections in the U.S., with African-American teens again particularly vulnerable. Many young black women are getting HIV from sexual partners who use IV drugs; often they are unaware of their partners' HIV status. Gay and bisexual black and Latino teenagers are also at high risk.

In the February issue of the American Journal of Epidemiology, New York City Health Department officials reported a 35 percent rate of HIV infection among bisexual Hispanic and African-American men attending STD clinics between 1988 and 1993. Many of them didn't use condoms often and had multiple male and female sex partners. HIV transmission from bisexuals may be an under-recognized route of transmission, the study suggests. Other groups ignored by prevention advocates are transsexuals and sex workers, including male prostitutes, according to recent reports at the World AIDS Conference in Geneva.

Looking at the big picture, HIV has fallen in some groups but is rising again within other high-risk communities after a serious decline during the first decade of the AIDS epidemic. At Geneva, a new debate flared up about reports suggesting that some gay and bisexual men, especially young ones, were slipping back into unsafe sexual behavior, perhaps lulled by the false security of new HIV therapies. In some groups, HIV infection rates have jumped by as much as 10 percent, says Daniel Zingale, executive director of the AIDS Action Council. There is also a pressing need for a microbicide to protect women. At Geneva, advocates blamed lack of funding, not science, for the gap.

While safer sex and condom use have greatly increased among the general population, many people do not practice what they have learned. Knowing about a condom and using one are quite different things. For years now, prevention programs have stressed condom use and safer sex, clean needles, and harm reduction as tools to halt HIV. Targeted prevention efforts that use peer education remain the most successful and innovative. That approach also works for injection drug users and prisoners, who are at the highest risk for HIV and are sometimes the hardest to reach.

In U.S. prisons, infections continue at a staggering rate six times higher than in the rest of the country, with few education or prevention dollars, few programs, and few condoms to help inmates. New studies continue to document that prisoners are at extremely high risk for exposure to HIV, along with other STDs, hepatitis B and C, and tuberculosis-but across the board, inmates lack access to basic prevention information, as well as condoms, bleach, and clean needles. Today, no federal prisons and only two state and four city jails in the U.S. provide condoms for inmates-a shocking statistic given the scope of the epidemic. The problem continues after prisoners are released: There are few follow-up prevention or risk-reduction programs to help discharged prisoners.

Within prisons, sharing of shaving, tattooing, and piercing equipment poses additional risks. A high percentage of prisoners are drug users, but needles are so hard to come by that many prisoners share works or improvise with crude injection implements like pens and glass. Studies at the recent Geneva conference highlighted model outreach programs involving ex-addicts, or those in recovery, who are trained and hired as HIV prevention advocates and community role models and who work with professional nurses. The same peer-education approach works inside prisons, but few states have adopted such programs. Strong advocacy is badly needed to turn the tide.