High case rates make D.C. the nation's HIV/AIDS capital

Washington -- One in 20 Washington, D.C., residents is HIV-positive, and one in 50 has AIDS -- both numbers underscore the staying power of this disease and the importance of refining efforts to control its spread, according to a new report compiled by the District of Columbia's Dept. of Health. Experts say an examination of this local epidemic's scope and complexity holds lessons for the rest of the nation.

The "District of Columbia HIV/AIDS Epidemiology Annual Report," released in November 2007, revealed that the District of Columbia's case rate is the highest in the United States -- 128.4 cases per 100,000 people in D.C. The figure nationally is 14 cases per 100,000.

Moreover, these statistics could foreshadow the direction of other trend lines. Specifically, the Centers for Disease Control and Prevention is reviewing data that may show a national increase in the number of people newly infected with the virus, and the current U.S. estimate of 40,000 new infections per year may have to be revised, perhaps to 60,000 per year.

The signs are clear that AIDS continues to grip many segments of the population. And the message to communicate beyond the beltway: "If you don't pay attention ... and aggressively try to implement prevention measures, it can get as bad as Washington," said D.C. resident Anthony Fauci, MD, director of the National Institute of Allergy and Infectious Diseases. He has spent much of his career working to stanch the disease.

With the failure of the latest experimental AIDS vaccine, prevention becomes even more important. "I think we have to be prepared for a long, long journey toward a vaccine," Dr. Fauci said. "And there is no guarantee we are even going to get a vaccine."

As for why Washington's case rates are so high, Dr. Fauci pointed to a constellation of factors that include those found in most big cities: A large minority population, poverty and injection drug use. Plus, the nation's capital also faces some more unusual variables. It has experienced a high turnover among administrators of its HIV/AIDS office, resulting in gaps in leadership. Plus, as part of its unique status as a federal district, Congress controls its budget.

In the past, federal lawmakers have forbidden the city from spending money on needle-exchange programs, which have been shown to prevent the spread of the disease in injection drug users. The AMA also encourages such program.

The city has a needle-exchange program funded with private money, which health officials want to apply more widely. That could happen. As of mid-December 2007, the prohibition against needle exchange was not in D.C. budget legislation.

The appointment last October of Shannon Lee Hader, MD, MPH, as the new HIV/AIDS administrator is seen as a sign that the city may be on the cusp of making inroads regarding its infection rates. Dr. Hader is an epidemiologist and directed the CDC's Zimbabwe Global AIDS Program.

The city's mayor, Adrian Fenty, who took office last year, and Dr. Hader grasp the depth of the problem, Dr. Fauci said. "So I hope we are going to start seeing a turnaround."

Dr. Hader brings to her post the experience of fighting the disease in this country and in Africa. She was part of a team that reduced new HIV infections in Zimbabwe enough to result in the prevalence rate dropping from 24% to 17%. "That's where we need to be going everywhere," she said.

"One of the lessons for us is that this is a modern epidemic in D.C., in its scope and its diversity, in terms of who is getting infected and how they are getting infected," Dr. Hader said.

Designing a locally appropriate program is important, she noted. "There is no cookie-cutter model." She welcomes the data in the new report as a guide. "We've known we had a big problem with HIV for some time. But we didn't have the details to really give us a snapshot of where it was and who was getting infected. Having all these data is a huge tool. We know what we've got and where to go from here."

Dr. Hader strongly advocates adopting the CDC's recommendation to administer HIV tests routinely. "We have a lot of lessons that show us when a doctor has to predict who has HIV and who does not, and who is going to be adherent with their medicines and who is not -- that our predictions are not very good."

Thus, routine HIV testing, which the AMA also endorses in a number of settings, including physicians' offices, will be an important focus. "Whenever people seek medical services, whether in the emergency room or when delivering a child or during a primary care visit, we want to make sure we are routinely thinking about HIV and addressing it," she said.

She would like HIV testing to be thought of as a standard of care. "What does it mean if I had any contact with an emergency room or a medical provider in the last year and they didn't offer me an HIV test? That was a lost opportunity for preventing me from getting sick. I would say that is not standard of care."

Kevin Frost, CEO of amfAR, the Foundation for AIDS Research, based in New York City, suspects that there has been an increase in the number of new HIV cases in the nation and that Washington is on the leading edge of that trend because it lacks programs that could serve as a "firewall" to halt the disease's spread.

In contrast, New York City has in place programs that address underlying issues such as drug use and abuse and violence in the home that can lead to heterosexual spread of the disease, he said. Both New York City and New York state have been in the lead in developing programs that provide clean syringes to drug users, he said.

Frost also recommends that the prevention message be recrafted to move beyond raising awareness of the disease to heightening perception of risk.

"One of the things we have tried to do for many years was create awareness with the belief that if people have the right information, then they will act in appropriate ways. But we should know better. After decades of work on smoking, while showing progress, we have still found it enormously difficult to get people to not start or to quit."