HIV/AIDS in the Year 2000 and Beyond

In the last years of the twentieth century, the United States experienced an estimated 40,000 new cases of HIV infection annually, the equivalent of 110 per day or more than one every 15 minutes. Although this figure represents a stabilization rather than an expansion of the incidence of HIV infection, such rates are generally agreed to still be unacceptably high. Further, as AIDS deaths decline, the total population of HIV-infected people grows, increasing the total number of sexually active people with HIV. Troubling evidence has also emerged of increases in sexually transmitted diseases such as gonorrhea and syphilis, as well as hepatitis C, a serious viral infection that is on the rise among people who inject drugs. Because these diseases are transmitted in many of the same ways as HIV, they can serve as markers for HIV risk activities.

There is also concern that the existence of antiviral drugs may be contributing to a false sense of security among both HIV-negative and HIV-positive people. Indeed, risky behaviors may be increasing among those who believe that an "undetectable" viral load means that a person is less infectious, as well as among those who have a diminished sense of fear of HIV infection or AIDS. This false sense of security--the feeling that AIDS is no longer a "big deal"--is particularly prevalent among young people who have never witnessed firsthand the effects of AIDS, or known people who have died of HIV-related causes.

These facts underscore the need for changing public health approaches to HIV prevention, since preventive strategies developed at earlier phases of the epidemic may no longer be relevant. For instance, some safer-sex approaches from the 1980s (designed as stopgap measures pending the quick discovery of a cure) may be ill-suited as lifelong strategies. Evidence of relapses into unsafe sex, particularly among some gay men, has sparked debate over how to reframe the challenge of HIV prevention. One strategy receiving a great deal of attention has been "negotiated safety," an approach developed in Australia. Reflected in the capsule phrase "talk-test-test-talk," negotiated safety encourages couples to discuss HIV issues openly, take an HIV test together, retest after six months of sexual monogamy, and then discuss whether or not to abandon the use of condoms and other forms of safer-sex practices.

More than one third of the AIDS cases in the United States have resulted directly from injecting drug use (IDU) or from sex with an injecting drug user. Of the nearly 50,000 new cases of AIDS reported in 1998, more than 15,000 were IDU-associated. Nonetheless, U.S. states and localities have been slow to organize needle-exchange programs or to provide legal access to clean syringes. Further, the federal government has continued a policy of pursuing a "war on drugs" and thus refuses to fund needle exchange programs, despite documented evidence that they reduce the number of new HIV infections without increasing drug use.

Early in the epidemic, AIDS was generally considered to be a disease of middle-class, white, gay men, or of people who injected drugs, and was thought to be confined to major urban centers. While it is true that many new HIV infections in the U.S. continue to occur among gay men, the epidemic has long been multi-focal, making its presence felt in suburban and rural areas as well as cities, among heterosexual men and women, and among babies, children, teenagers, and older adults. Nonetheless, certain concentrations and general trends are now clear, and many are linked to larger societal issues such as poverty, discrimination, racism, and homelessness.

Most notably, HIV and AIDS disproportionately afflict communities of color. Although African-Americans constituted approximately 13 percent of the population of the United States in 1998, they accounted for 36 percent of all AIDS cases and 45 percent of all new HIV infections. Similarly, Latinos, who constituted 12 percent of the population of the United States, accounted for 18 percent of all AIDS cases and 22 percent of new HIV infections. Within these communities, the percentage of people with HIV/AIDS who are women also continues to rise. These statistics indicate an urgent need for messages that are specifically directed to these communities and for innovative approaches in reaching high-risk people, some of whom have historical and personal reasons for being distrustful of the scientific and medical establishments. In addition, harsh immigration policies may drive away increasing numbers of undocumented Latinos and other "illegal aliens" from the health care system. The continuing trend towards the entrenchment of HIV/AIDS in communities of color has sparked an increased focus on HIV/AIDS among grassroots organizations, such as African-American and Latino churches and civic organizations, as well as among government bodies such as the Congressional Black Caucus and the Congressional Hispanic Caucus.

Younger people are at particular risk for HIV. By 1998, 27,860 AIDS cases had been reported among young people between ages 13 and 24, the age group that has shown the lowest decline in AIDS rates despite the availability of new treatments. It is estimated that more than half of new HIV infections occur among people under the age of 25. Among new HIV cases diagnosed in people aged 13 to 19, nearly two thirds (62 percent) were among females. African-Americans account for more than half (56 percent) of all HIV cases among young people. Further, the majority (51 percent) of all AIDS cases among people aged 13 to 24 were among young gay and bisexual men.

School-based HIV prevention programs have been demonstrated to be the most effective form of intervention. For youths who are not in school, including highly vulnerable runaways and "throwaways" (those forced to leave home), programs are needed in settings such as shelters, detention centers, and community-based organizations. Ideally, such programs provide comprehensive education on such topics as sexual abstinence, safer-sex practices, sexual orientation, drug use, prevention of sexually transmitted diseases, contraception, and general reproductive health.

Although AIDS first emerged predominantly among gay men and male injecting-drug users, women have been affected by HIV and AIDS since the onset of the epidemic. An estimated 120,000 to 160,000 women in the United States were living with HIV at the end of 1999. By 1997, women accounted for nearly 20 percent of all people with AIDS, with increases occurring most dramatically among women of color. Although African-American and Latina women account for less than one quarter of all American women, they represent more than three quarters of female AIDS cases in the U.S. Younger women are particularly vulnerable, making up nearly half of all HIV diagnoses in the 13 to 24 year age range.

Many women are unaware of their partners' HIV risk factors and therefore of their own vulnerability to HIV infection. These are also the women least likely to be identified as being "at risk" by their health-care providers, and thus they may go untested. Both biomedical and behavioral strategies have been proposed to help women avoid HIV. The female condom is now widely available in the United States, and vaginal microbicides (anti-HIV creams and gels) are in development, although their efficacy has yet to be conclusively proven. Interventions have been undertaken to inform women of the availability of the female condom and to enhance women's ability to negotiate safer-sex practices, particularly when they are in relationships of unequal power.

Because of its severe consequences and the stigmatization it has provoked, AIDS has from the outset of the epidemic been treated differently from other diseases, an approach known as "AIDS exceptionalism." The core of this exceptionalism is the "voluntarist consensus," in which it was broadly agreed that HIV testing, prevention, and treatment would be conducted on an entirely voluntary basis. In practice, this has meant that, in order to safeguard their privacy and shield them from discrimination, people would not be tested for HIV or compelled to undergo treatments against their will.

As HIV/AIDS has become more treatable and less "exceptional," a number of government bodies have begun to diverge sharply from the concept of voluntarism toward more coercive policies. For instance, New York State has passed laws requiring the compulsory testing of newborns without the consent of mothers, despite the fact that this amounts to proxy testing of the mother (the only person from whom the baby could have acquired the virus). A number of U.S. states have also passed laws requiring all newly diagnosed individuals with HIV to have their names reported to state health authorities (for statistical purposes), and some states have mandated that these individuals' sexual and drug-using partners be notified that they may have been placed at risk (although partners are not told the name of the person who tested positive). Similarly, "wilful exposure" laws, which criminalize intentional transmission of HIV by HIV-positive individuals, have received increased attention, with the circumstances that require disclosure of HIV status and the definition of "intentionality" varying from jurisdiction to jurisdiction, but the burden of disclosure always on the HIV-positive individual.

Even as HIV/AIDS has begun to stabilize and, in some ways, "normalize" in the U.S. and other parts of the developed world, the epidemic has expanded with ferocious speed in parts of the developing world. The reasons for this expansion are many, but include widespread and worsening poverty, increased prostitution and injecting drug use, weak educational systems, inadequate health care systems, and high rates of sexually transmitted diseases. All of these, and other, factors overlap within an environment in which information about HIV prevention is often nearly nonexistent and effective treatment options are prohibitively expensive. The spread of HIV is further exacerbated by the economic need of many individuals to migrate to find work or food, and by large population displacements of refugees fleeing warfare and civil strife. The illnesses and deaths caused by HIV/AIDS, particularly among people in their prime working years, further the cycle of poverty by undermining already-struggling economies and creating new generations of "AIDS orphans" (of whom there have been an estimated 11.2 million globally).

At the end of 1999, the United Nations estimated that the number of HIV-positive people in the world had increased by 5.6 million to a total of 33.6 million, with all but 5 percent of the new cases occurring in the developing world. In addition, some 1 million men, 1.1 million women, and 470,000 children, a total of 2.6 million people, were thought to have died of AIDS in 1999. These figures brought the total global death toll to 16.3 million. While scientific advances could potentially save the lives of many of these people, the annual cost of potentially life-saving medications is often many times the per capita income. To cite but one statistic, antiviral medication for one person typically costs about $12,000 to $15,000 per year, but the entire annual health budget of some African countries is less than $6 per person. In some of these areas, poverty is so extreme that even if medications were provided free of charge, the food and clean water and the health infrastructures needed to take them are often not available.

By far the hardest-hit region of the world is sub-Saharan Africa, where the number of people believed to have HIV is 23.3 million, with an average rate of 8 percent (more than one person in 12) of adults having HIV, and some countries in the south of the continent having as many as 25 percent or more of their population infected. With 70 percent of the world's AIDS cases, sub-Saharan African populations have seen sharp drops in their life expectancies and their overall quality of life due directly to AIDS. Other heavily impacted regions include South and Southeast Asia (6 million cases) and Latin America (1.3 million cases), where the epidemic could potentially reach African proportions. While the Caribbean does not have a heavy caseload in absolute numbers, due to its comparatively small population, it has the second highest percentage of its population (2 percent) infected with HIV. Similarly, rates of new HIV infections in Eastern Europe and the former Soviet Union have begun to skyrocket, with the region considered the next great point of expansion for the epidemic. (By contrast, fewer than 0.5 percent of North Americans have HIV, and fewer than 0.25 percent of Western Europeans.) Attempts are underway to make generic versions of antiviral medications more widely available and to devise more effective means to prevent transmission. However, for the most heavily impacted developing regions, HIV prevention, education, and the development of an effective, affordable vaccine must be the top priorities.