The announcement that the government underestimated HIV incidence--the rate of new HIV infections--by 40 percent is less surprising than you might suppose. One might conclude that the epidemic is getting worse, or that CDC screwed up. But neither is right. HIV incidence has actually been stable over the past decade. It’s just hard to know how many infections are occurring. We’re always driving by the rearview mirror in a changing epidemic.
One-quarter of Americans living with HIV do not know it. People can be infected for a decade or more before symptoms become obvious or they get tested. Most new infections appear to be transmitted by people who don’t know that they are infected. HIV risk behaviors are stigmatized and covert. We don’t really know how many American men have sex with other men. We know even less about the population of heroin and crack users and commercial sex workers. Epidemiologists have long distrusted the circuitous compilations required for the prior estimates. Bench scientists and statisticians of the HIV Incidence Surveillance Group deserve great credit for surmounting these problems.
Their findings show the failure of our government and society to confront a deadly epidemic that has killed more than 10 times as many Americans as died in combat in Vietnam. An unknown, unknowable number of these half-million deaths could have been avoided. Appalling failures flow back to the Reagan Administration, which showed conspicuously tepid concern for those at risk. Yet our poor response reflects more than the cruelty of social conservatives. It reflects our continuing inability to execute the most important matters of public health. The problem goes back a quarter-century. The failures of the current Bush administration are especially palpable.
Our next President will inherit a beleaguered public health system that has deteriorated during the Bush years. We’re all aware of the headline-grabbing ideological disputes: abstinence-only education, condom distribution, syringe exchange. The National Academy of Sciences has put out truckloads of reports that try to place public policy on an evidence-based footing, to little apparent effect.
Less familiar is the impact of the Bush Administration’s Katrina-esque disdain for the practical craft of governing. The Atlanta Journal-Constitution has chronicled CDC’s astonishing difficulties over the past seven years, which have prompted the exodus of many noted scientists and officials from the country’s flagship public health agency. Five former directors--who had served under Democratic and Republican administrations--publicly stated that serious morale problems and questions of scientific integrity threaten CDC efforts. In a federal employee survey released in 2007, CDC ranked 189th out of 222 agencies in worker morale.
In Saturday’s press release, CDC Director Julie Gerberding says, “We as a nation have to come together to focus our efforts on expanding the prevention programs we know are effective." If only her bosses had listened. Despite rising overall HIV prevalence and rising incidence in key populations, CDC’s inflation-adjusted budget for domestic HIV prevention has actually declined by about 20 percent since 2001.
Budget cuts matter. In January 2001, CDC officials announced an ambitious five-year HIV prevention strategic plan. But the funds were never allocated to expand HIV prevention efforts. David Holtgrave, former director of CDC’s HIV prevention efforts, has presented a widely-cited estimate that the agency must nearly double its HIV prevention outlays, to about $1.3 billion, to meet identified but unmet needs for prevention services across the United States. The needed additional funds amount to 0.04 percent of the federal budget. That is less than it costs to buy four F-22 fighters, which Defense Secretary Robert Gates doesn’t want anyway.
Things are no better within the alphabet soup of lesser-known public health agencies. Accounting for inflation, federal spending has declined for the Substance Abuse Prevention and Treatment block grant, Ryan White services to persons living with AIDS, primary care physician training grants, and other safety-net programs that support HIV prevention and care. Surprise: The underfunded agencies responsible for implementing these programs rank 219th and 191st, respectively, in employee morale.
The marginalization of public health shows up in other ways. In 2006, CDC announced recommendations for broad HIV screening in hospitals, emergency departments, and other care settings. The idea enjoys strong support from clinicians, who know that many infected patients are missed. Yet CDC encountered angry pushback because the federal government did not provide resources to conduct screening or to treat patients found to be HIV-infected. Adding insult to injury, Medicare, Medicaid, and the nearly 190 other health plans that provide coverage to federal employees do not reimburse HIV screening performed in accordance with CDC recommendations.
At some level, most citizens and policymakers know this makes no sense. Most would like to see a health care system in which public health and prevention receive equal priority with tertiary care. Sadly, these priorities don’t survive the jostling for resources. Within a $2.1 trillion medical economy and a $3.1 trillion federal budget, it is surprisingly hard to find the rounding-error funds required to maintain many public health functions at the levels appropriated when President Bush took office.
This is a hard time for HIV prevention. Recent trials of microbicides gels, cervical diaphragms, and pre-exposure prophylaxis have proved disappointing. Vaccines remain years away. Researchers are increasingly skeptical of behavioral interventions that reduce self-reported risks. One prominent scholar expressed the sentiment of many to me: “I want to see infections averted. I'm tired of knowledge, attitudes, and self-reported behavior at 3 months ... Almost thirty years into the epidemic, I'm entitled to some longer-term outcomes.”
Where do we go from here? The new findings confirm that men who have sex with men and nonwhites bear the brunt the epidemic. High-risk heterosexuals and injection drug users remain vulnerable, yet incidence has actually declined in both groups, by 80 percent in the case of injection drug users. These trends make the steady, 15-year rise in incidence among gay and bisexual men even more frightening. Gay and bisexual men now experience about 30,000 new infections every year. Particularly among young men, prevention messages are not getting through. One of many depressing statistics: Among uninfected men who did not know the HIV status of their male partners, 21% report having unprotected anal sex in their last encounter.
Some public-health experts want to set priorities among outreach, counseling and testing in high-risk groups, population screening, syringe exchange, and substance abuse treatment. Each of these approaches is valuable and cost-effective. Each merits substantially increased resources. Still, after many years in operation, none is executed particularly well on a broad scale.
Our next president will soon be taking the car keys after a reckless eight-year run. He must increase HIV prevention spending, and put these efforts on an evidence-based footing. New CDC statistics refine but do not alter what must get done. We once hoped that education and services to uninfected persons would slow the epidemic. We can’t give up on primary prevention, but it is not enough. We need more aggressive targeted and population-wide screening to find and treat infected people earlier, and to link them with effective prevention services. We must make better use of medical settings, jails and prisons, homeless shelters, and other places that attract individuals at greatest risk. We must ensure that public and private insurers reimburse providers for appropriate public health services. We must ensure that persons living with HIV and AIDS have proper insurance coverage, and we must ensure that federal agencies coordinate their efforts.
This is not rocket science. It is a big challenge just the same. As President Bush has shown, not everyone is up to it. The task requires skilled and attentive management from the top to get things done. Omar Bradley is reputed to have said: “Amateurs study tactics. Professions study logistics.” Maybe he’s available.
Harold Pollack is a public health policy researcher at The University of Chicago’s School of Social Service Administration, where he is faculty chair of the Center for Health Administration Studies.
By Harold Pollack