BLUMENTHAL/SHIVE: AIDS amnesia in America

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There is a city where 1 out of 20 people are infected with HIV, the virus that causes AIDS, but it is not located in the developing world. It is Washington, D.C., where the infection rate is higher than that of Ethiopia, Rwanda and Nigeria. In fact, every 10 minutes an American is newly infected with HIV, and 34 percent of them are under 30 years old.

A report released last week by the Centers for Disease Control and Prevention (CDC) revealed that 56,000 people become infected with HIV annually in the United States - 40 percent higher than previously estimated. For the last 15 years, the CDC has told us the number of newly infected people with HIV was stable at an estimated 40,000 people annually, down from a peak of 130,000 in the mid-1980s. This apparent plateau of annual HIV infections has contributed to a complacency about HIV/AIDS in America with the mistaken assumption by many that medical advances had stopped the disease's growth.

In recent years, America has shifted its attention overseas, epitomized by the closing of the White House Office of National AIDS Policy. The establishment and recent expansion of the lifesaving President's Emergency Plan for AIDS Relief (PEPFAR) and other important global initiatives have brought important resources to the developing world and required that recipient countries establish national plans to address their epidemics.

The CDC's new statistics, however, provide dramatic evidence that HIV remains a major public health problem in America that requires a national strategy. There are more than 1 million people who are HIV-positive in the United States and 25 percent are unaware of their status. From its discovery in 1981 until the end of 2005, AIDS has infected more than 1.5 million people in the United States and 500,000 people have died.

The CDC report also reveals that ethnic minorities and men who have sex with men (MSM) are disproportionately affected. The majority of new HIV cases in 2006 - 53 percent - were among MSM. These numbers are an ominous flashback to the situation when the epidemic first emerged, but now many of these men are black or Hispanic. Forty-five percent of all new HIV infections occurred among blacks in the United States, though they comprise 12 percent of the population. In fact, the number of blacks living with HIV in the United States exceeds the number of HIV infected people in seven of the 15 focus countries of the PEPFAR initiative.

Furthermore, women account for an increasing proportion of the epidemic, growing from 8 percent of cases in 1985 to 28 percent in the United States and 50 percent of those affected worldwide.

The CDC's revised estimates are the result of many technical factors, including the use of a new test that distinguishes between recent and chronic infection, better statistical methods and calculations, federal regulations that push states to collect data on new HIV infections, and increases in HIV testing and reporting. However, this week's upward revision in infection rates highlights the need to further evaluate and strengthen the HIV/AIDS surveillance system in the United States.

The CDC statistics also underscore that HIV infection is on the rise among youth aged 13-24. This population faces unique risk factors and a widespread lack of awareness and education. Young Americans have grown up viewing AIDS as a treatable chronic disease rather than a frightening terminal illness. Absent are memories of the fear and panic, the mass demonstrations for greater policymaker attention to the disease, and the death sentence that a diagnosis conferred.

With studies revealing American youth engage in sexual behaviors at early ages and with a rising percentage of HIV-infected youth, it is imperative that evidence-based HIV/AIDS education initiatives are supported to stem the epidemic.

Yet research and prevention funding has been inadequate in recent years to address the domestic epidemic and has often been hindered by ideology and politics, as in the case of ineffective abstinence-only programs.

A recent Kaiser Foundation study found only 4 percent of the $23 billion spent on American HIV/AIDS programs supports prevention. When adjusted for inflation, there has been a decrease in the CDC HIV/AIDS prevention budget by 19 percent since 2002. Similarly, flat funding of the National Institutes of Health has resulted in an 18 percent decline in the agency's ability to fund scientific studies.

AIDS cannot be fought with medicines alone; our country desperately needs the same kind of leadership and commitment at home that our country has shown with its assistance programs to the developing world. The next president of the United States should establish a domestic science-based PEPFAR that would create a national strategy to eradicate HIV/AIDS at home.

Progressive policies are urgently needed that recognize HIV/AIDS as an emergency in America as well as overseas. That means creating a national plan and providing necessary funding to increase research, implement evidence-based prevention programs that target vulnerable groups, address issues of stigma, discrimination and poverty, and improve access to lifesaving treatments and health care to eradicate this disease.

The dedicated work of many people in the public and private sectors has led to a decline in death rates and many important advances in fighting AIDS in the United States over the last 25 years. But last week's report of a 40 percent higher infection rate in America than previously estimated and 14,000 deaths annually should serve as a wake-up call from the AIDS amnesia surrounding the domestic epidemic in recent years. Let us remember the public health lessons from the beginning of the epidemic and ensure an emphasis on the power of prevention as well as the importance of effective treatment and care.

With a national action plan to address this major public health issue that mobilizes all sectors of our society, combined with continuing global investment and leadership, perhaps one day people have to turn to the history books to learn there ever was a disease called AIDS.

Susan J. Blumenthal, M.D., is a retired rear admiral in the U.S. Public Health Service and is senior policy and medical adviser at amfAR, the Foundation for AIDS Research. She was assistant surgeon general of the United States and is a clinical professor at Georgetown School of Medicine. Melissa Shive, a former research assistant at amfAR, is a medical student at the University of California-San Francisco.