The capital of one of the richest nations in the world is beset by an HIV epidemic that rivals those seen in some developing countries
By Regina McEnery
Twenty-nine years ago, the US Centers for Disease Control and Prevention (CDC) issued a brief report in its Morbidity and Mortality Weekly Report about an unusual cluster of pneumocystis pneumonia infections among five gay, otherwise healthy men from Los Angeles. A month later, 46 more cases were reported in Los Angeles, San Francisco, and New York City.
Today, the majority of new HIV infections in the US still occur in men who have sex with men (MSM)—approximately 77% of all infections among men and slightly more than half of all new infections overall occur in MSM. Although the prevalence rate of HIV/AIDS in the US is high in subgroups such as MSM, the overall HIV prevalence rate among adults is estimated to be less than 1%, according to the Joint United Nations Programme on HIV/AIDS (UNAIDS). As such, UNAIDS considers the US to have a concentrated HIV epidemic, primarily among MSM and injection drug users (IDUs), rather than a generalized epidemic such as South Africa’s, where more than 1% of the entire population is infected with HIV and mere geography becomes a risk factor for acquiring the virus.
However, there is now growing evidence that a more generalized HIV epidemic has emerged among heterosexuals in poor, urban neighborhoods stretching across the US from Boston to Seattle. Nowhere is it more evident than in Washington, D.C. The capital of one of the richest countries in the world has an HIV prevalence rate comparable to those in developing countries (Health Affairs 28, 1677, 2009). In 2007, an estimated 3% of the District of Columbia’s adult population was infected with HIV, a higher HIV prevalence rate than Rwanda, Angola, and Ethiopia, and just slightly lower than Nigeria and the Democratic Republic of Congo.
Other estimates suggest the HIV prevalence in Washington, D.C. may be even higher. A George Washington University (GWU) study based on data collected from December 2006 to October 2007 for the National HIV Behavioral Surveillance (NHBS)—a community-based study funded by the CDC and the District of Columbia Department of Health—estimates that the HIV prevalence rate in the district among a particular subset of heterosexuals at high risk for HIV infection is as high as 5.2% (AIDS 23, 1277, 2009). The study’s authors said this was “the first estimate of HIV and risk behaviors among urban, low income, and African Americans in the nation’s capital.” The HIV prevalence among women in this study was 6.3%, similar to the prevalence among women in Tanzania (7.0%) and Uganda (7.1%).
One reason D.C.’s HIV prevalence is the highest in the nation is the district’s size. The city’s population of roughly 590,000 residents is small compared to other urban areas with significant epidemics, such as New York (population 8.3 million) or Los Angeles (3.8 million). But a number of troubling epidemiological, social, and political factors are also to blame. Poor disease reporting, a lack of laws to support syringe-exchange programs for IDUs, and poverty, among other factors, have all contributed to the burgeoning epidemic in the US capital. While fighting the epidemic there is still an uphill battle, the city’s public health officials have made some significant strides in recent years to understand the epidemic and to adjust prevention programs accordingly.
The roots of the epidemic
Evidence of a generalized epidemic in D.C.’s poor, urban neighborhoods reflects what seems to be happening nationally within economically disadvantaged neighborhoods. A poster presented by the CDC at the XVIII International AIDS Conference in Vienna in July showed that the HIV prevalence between September 2006 and October 2007 is estimated to be 2.1% among 23 urban poverty areas in the US, including parts of Washington, D.C. that the NHBS now tracks on a regular basis. Poverty areas are defined as those where at least 80% of residents have household incomes below the US poverty level. A family of four is considered to be living below the poverty level if their household income is below US$22,000 in the 48 contiguous states or Washington, D.C., $25,000 in Hawaii, and $27,500 in Alaska. Because the study was designed to study the potential link between poverty and HIV risk, the NHBS sample analyzed by researchers excluded other risk groups such as MSM, IDUs, and commercial sex workers (CSWs) living in the 23 urban areas.
The CDC found that HIV prevalence among individuals who were surveyed in the urban poverty areas was inversely proportional to socioeconomic status—the lower the income level the greater the prevalence of HIV—and that unlike overall HIV prevalence in the US, HIV prevalence in urban poverty areas did not differ significantly by race or ethnicity. “Poverty isn’t itself the direct cause of HIV infection,” says Jonathan Mermin, director of the CDC’s HIV/AIDS prevention program that presented the paper in Vienna. “Most people get HIV from having unprotected sex. But poverty sets up an environment that increases the possibility that someone will be having unprotected sex.”
In addition to poverty, several other factors are driving the epidemic in Washington, D.C. One is a scattershot HIV/AIDS surveillance system that until 2006 failed to collect or report data on a timely and consistent basis. Only recently, in 2008, D.C. converted to a confidential name-based reporting system that the CDC has used since the early 1990s, and recommended states and dependent areas begin using in 2005, to collect data on HIV infections and monitor the epidemic more effectively (see A Static Epidemic, IAVI Report, May-June 2008).
The lag in reporting HIV cases has made it difficult for both public health departments and privately run AIDS agencies to fully appreciate the status of the current epidemic, which in turn has hampered efforts to develop effective responses to control it. DC Appleseed, a non-profit organization based in the US capital, has been issuing annual report cards on the district’s response to HIV/AIDS for the past five years and says that the lack of access to timely epidemiological data has delayed the implementation of prevention plans that determine how much money should be spent and where the resources should be allocated. “Accurate and complete HIV surveillance data are essential to plan HIV prevention programs and allocate healthcare resources,” DC Appleseed noted in its inaugural report in 2005. “Although the HIV/AIDS Administration (HAA) has collected HIV data for the past three and a half years, it has not yet publicly disseminated a report on HIV data.”
The political structure of Washington, D.C., a federal territory that despite being the capital has less legislative representation than the 50 states and falls under the jurisdiction of the US Congress, has also created tensions between local and federal officials that have made it difficult to effectively tap resources that might be used for HIV prevention and care for people with HIV/AIDS living in the city.
Some critics also blame the district’s high prevalence rate on federal laws that have barred the public funding of syringe exchange programs, which a number of studies have shown are effective in reducing HIV transmission among IDUs (see A Static Epidemic, IAVI Report, May-June 2008). Until this year, the US government banned federal funding for programs that provided IDUs access to clean needles because needle exchange programs were viewed as being supportive of illegal drug activity. Like many states and cities, Washington, D.C. had been relying on privately funded needle exchange programs, but the district’s effort was only able to reach about a third of the city’s IDUs, according to DC Appleseed’s 2005 Report. In 2008, D.C. was granted Congressional approval to use district funds for needle exchange programs.
The high HIV prevalence in the district is also being blamed on the absence of a comprehensive counseling and testing policy and weak HIV education programs in the public schools.
Mermin says the social determinants of health—the circumstances in which people are born, grow up, work, and age, and the systems in place to deal with illness—are also drivers of the epidemic. “Syringe services can be effective in reducing the likelihood that people who inject drugs will acquire HIV. Having access to accurate information about HIV transmission can help people avoid acquiring HIV,” says Mermin. “But it would also be beneficial for HIV prevention if there were no poverty in these areas. Homelessness, low household income, lack of education, lack of employment are also independently associated with [an] increased risk of HIV.”
The US’s first National HIV/AIDS Strategy, which was released in July by US President Barack Obama’s administration and created to provide clarity and coordination in the prevention and treatment of HIV, seems to reflect Mermin’s view (see Vaccine Briefs, IAVI Report, July-Aug. 2010). The 60-page document noted that it is important to employ a holistic approach to HIV prevention and care that extends beyond risk behaviors of the individual to “contextual factors” such as joblessness, homelessness, and sexual- and drug-use networks. “Although there have been some successful efforts in this regard, such as interventions that examine the link between homelessness and HIV risk behavior, there are too few proven models associated with reducing HIV incidence that have had a community-level impact,” according to the report.
Robert Fullilove, a professor of clinical social sciences at Columbia University, has studied the US epidemic in urban communities for more than 20 years. He agrees with Mermin that poverty has driven the epidemic in the US as much as, if not more than, risky behavior. Fullilove says structural factors such as unemployment, incarceration, racism, and neighborhood violence have created an environment that has put people living in these communities at greater risk for HIV. And, he says, black men and women are disproportionately affected by HIV because a higher percentage of blacks live in poverty.
“A number of us have written about this extensively,” says Fullilove. “We’ve felt that people were paying much too much attention to individual risk factors and not enough to the geography of the epidemic, which is mostly urban and mostly confined to poor urban communities of color.”
The geographical risk of HIV infection in the US was evident in a 2006 study that set out to determine the risk factors for HIV among blacks in North Carolina by comparing recently HIV-infected individuals with a matched control group of HIV-uninfected individuals. The researchers, including Fullilove, found that while most of the individuals reported either high-risk behaviors such as crack-cocaine use or having sex partners that injected drugs or used crack cocaine, about 30% of the HIV-infected volunteers and 69% of the uninfected volunteers denied any high-risk sexual partners or behavior. Instead, the risk factors for these individuals were lack of a high school education, concerns about not having enough food to feed their family, and having a partner who was not monogamous (J. Acquir. Immune Defic. Syndr. 41, 616, 2006).
D.C. fights back
While the situation in Washington, D.C. is the worst in the nation, the capital city has made some significant strides in recent years. For one, the district has greatly expanded the quality of data about residents who are either at risk of or are already infected with HIV, and its eventual goal is to develop a database that collects and stores information, in real time, from all consenting HIV-infected individuals undergoing care and treatment at major clinics throughout the city.
Shannon Hader, who was appointed director of HAA in 2007 and left in May to join the international development firm Futures Group, says the improved data collection is allowing the district, for the first time, to develop policies that directly address the epidemic.
“For many years the district had been dysfunctional, unable to collect, process, and disseminate data, much less apply a national surveillance system,” says Hader, who is widely credited with turning around the failing administration. “If you don’t have data you fund programs and prioritize activities based on anecdotes and impressions. Now that we have the data the numbers really speak for themselves. The numbers tell us we have a serious and extensive epidemic in the capital that affects many groups and all modes of transmission. Despite the heavy perception that HIV is under control in the US, that it’s Africa that has the problem, it’s just not true. We are a hotspot. We have a high rate of HIV across our city.”
The district also boosted the number of HIV tests from 16,776 in 2004 to 92,748 in 2009—a dramatic 368% increase. In 2008, the district also instituted a syringe-exchange program that removed 130,000 used needles from the streets during its first six months and referred more than 40% of the 900 clients who used the program to drug treatment centers. Condom distribution also increased by more than 130% between October 2008 and July 2009, when roughly 2.3 million condoms were handed out at sites ranging from barbershops and nail salons to restaurants and bars.
The severity of the epidemic in Washington, D.C. has also prompted some unusual collaboration between the DC Department of Health and the National Institute of Allergy and Infectious Diseases (NIAID), a division of the US National Institutes of Health (NIH). In D.C., about a 30-minute drive from NIAID’s headquarters in Bethesda, Maryland, NIAID has partnered with the GWU School of Public Health and the DC Department of Health to study what Carl Dieffenbach, the director of NIAD’s Division of AIDS, describes as “the strongest, most complete example of a domestic urban epidemic in the US.”
The collaboration has translated into a number of projects that could have wide-ranging impact on control and prevention of HIV, both locally and nationally. Notably, the NIH allocated $26.4 million to form the D.C. Partnership for HIV/AIDS Progress, a two-year research collaboration between the NIH and the DC Department of Health that is designed to find ways of reducing infections, improve the health of D.C. residents living with HIV/AIDS, and strengthen the response to the epidemic. The money is being funneled through both NIAID and the Office of AIDS Research, which oversees all government research dollars for HIV/AIDS.
NIAID, through its collaboration with the D.C. Partnership for HIV/AIDS Progress, is also conducting two multi-site observational studies with the HIV Prevention Trials Network (HPTN). In HPTN 061, a two-year study that began last year, trial investigators are collecting sexual and social networking information from black MSM. Volunteers in HPTN 061 are tested for HIV and other sexually transmitted infections, and asked about HIV risk behaviors, substance abuse, mental health problems, and homophobic violence to assess the impact these factors have on HIV incidence and related risk behaviors. HPTN 061 has enrolled men in six US cities, with 266 from the D.C. site. Manya Magnus, the DC site investigator for HPTN 061 and an associate professor at GWU, said this feasibility study’s primary objective is to obtain information about the black MSM community that will be used to develop a much larger, community-wide, randomized, controlled trial to test the impact of behavioral and structural interventions.
A second observational study, HPTN 064, will attempt to estimate HIV incidence among high-risk women living in areas with high rates of poverty and HIV. HPTN 064 is also a two-year study and has enrolled women from six cities, including 210 from Washington, D.C.
Another proposed intervention referred to as test and treat, which calls for universal testing and immediate antiretroviral treatment for anyone who is HIV-infected, is also being studied in Washington, D.C. (see Test and Treat on Trial, IAVI Report, July-Aug. 2009). NIAID is now funding a study to test the feasibility of test and treat in one of Washington’s high-risk communities (see Vaccine Briefs, IAVI Report, Sep.-Oct. 2009). The study, which began this summer, is also being conducted in the Bronx in New York City.
Rochelle Walensky, an associate professor of medicine at Harvard Medical School, who developed a mathematical model of test and treat in Washington, D.C., found that an expanded test and treat program would increase life expectancy of HIV-infected individuals. But her models showed only a modest impact on HIV transmission over the next five years (Clin. Infec. Dis. 51, 392, 2010). Walensky thinks test and treat is a viable strategy in places like Washington, but worries that the public health community may have unrealistic expectations about what it can accomplish. “I wholeheartedly believe in frequent testing in high-risk populations and I wholeheartedly believe in universal treatment,” says Walensky. “But I think we have to think of prevention as we think about antiretroviral therapy, chemotherapy, and the treatment of most other diseases. Test and treat isn’t a magic bullet, but one page of the playbook.”
Whether or not these interventions help the district gain control of the epidemic and bring about a dramatic decline in HIV incidence remains to be seen. “Despite the fact that it is grounded by trappings of wealth and ought to be a showpiece for the US, I cannot think of a more dramatic contrast or a starker example of the failure of public policy,” says Fullilove.