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HIV Update International View HIV Incidence and Prevalence by Country For past issues of HIV International Updates and HIV (Domestic US) Updates, see: http://www.childrensaidsfund.org/doclist.asp?section=N01 Volume 4, Number 29 In this edition: President Bush Signs Into Law $15 Billion Global AIDS Bill The law, authored by Representative Henry Hyde (R-Illinois), authorizes $3 billion a year for five years to international HIV/AIDS programs, with up to $1 billion in fiscal year 2004 going to the Global Fund to Fight AIDS, Tuberculosis and Malaria. The law endorses the "ABC" HIV prevention model-- abstinence, be faithful, use condoms, in that order of priority-- which has had success in lowering HIV prevalence rates in Uganda. The package directs at least 55 percent of direct aid go to treatment programs and recommends that 20 percent be spent on programs aimed at preventing HIV infections. Ten percent is directed to programs assisting children who have lost one or both of their parents due to AIDS-related causes. The measure also specifically allocates one-third of the bill's HIV prevention funding for abstinence). In a signing ceremony at the State Department, Bush said, "In the face of preventable death and suffering, we have a moral duty to act, and we are acting" to address "one of the most urgent needs in the modern world." He added, "The United States of America will take the side of individuals and groups and governments fighting HIV/AIDS in Africa and other parts of the world. We'll provide unprecedented resources to the effort. And we will keep our commitment until we have turned the tide against AIDS." Bush also said that he would "challenge" other nations to "follow our lead" by contributing to the fight against HIV/AIDS during the G8 summit next week in Evian, France, reminding them that "time is not on our side." During the ceremony, U.S. Secretary of State Colin Powell said, "HIV is one of the biggest killers on the face of the earth. It is more devastating than any army, any conflict, or any weapon of mass destruction. Responding to HIV/AIDS is not only a humanitarian and a public health issue; HIV/AIDS also carries profound implications for prosperity, democracy and security." The following are some of the reactions to the new law: Mark Isaac, vice president of the Elizabeth Glaser Pediatric AIDS Foundation said "There is no question that this represents a whole new day" in the United States‚ fight against AIDS. "The bill is unprecedented in the size of its commitment, its unanimous support from Congress and its innovative approach to the use of debt relief in exchange for a countries' commitment to domestic health care," according to an AIDS Action release. "This is just the kind of leadership that the HIV/AIDS response needs," Dr. Marsha Martin, executive director of AIDS Action, said. "President Bush said this effort will be judged by how many lives are saved, and we couldn't agree more. We deeply appreciate the president's commitment, which he repeated today to work closely with community organizations here and abroad," AIDS Healthcare Foundation President Michael Weinstein said. In addition, AHF calls for funding from the bill to be swiftly appropriated in Congress as well as for a "quick scale-up" of antiretroviral clinics in Africa and the Caribbean. Focus on the Family "applauded President Bush for putting people before politics" in his support of the bill. The group is "pleased" that the legislation made abstinence-based prevention programs a "priority," Tom Minnery, vice president of public policy, said. World Vision President Richard Stearns commended Bush and Congress for their "unified, compassionate and generous response" to the AIDS epidemic and expressed hope that the measure would encourage other world leaders to step up their commitment to fighting the disease. The president and Congress are also to be commended for the "unprecedented" speed with which the bill was passed, Stearns said. Many with HIV Do Not Disclose Their Status Before Engaging in Unprotected Sex "It's not uncommon that people reported that with certain partners there was no disclosure," said lead author Dr. Daniel H. Ciccarone of the University of California at San Francisco. "(And) from a public health point of view this is where transmission could happen-- these are the relationships we're most concerned about." The researchers stressed that although the disclosure of HIV status has not been conclusively linked to an increase in condom use, prevention efforts that stress the importance of disclosure for anyone who is sexually active might promote safer sex. "Most HIV-positive people are doing right," Ciccarone said. "But it's not just on the HIV-positive person. It's also their partners who need to be asking and sharing." In 1998, Ciccarone and his research team interviewed nearly 1,400 HIV-positive men and women from across the U.S. who were at least 18 years old. The researchers asked the participants about their sexual behavior during the previous six months -- oral, anal and vaginal sex as well as abstinence. In the June issue of the American Journal of Public Health, the authors report that abstinence rates were high among all HIV-positive individuals-- ranging from 28 percent among gay and bisexual men to 39 percent among heterosexual men. Women of all orientations reported a 34 percent abstinence rate. The survey showed that approximately half of all the sexually active HIV-positive men and women regardless of sexual orientation reported having sex with a partner whose status was either unknown or negative. About 13 percent of people who had sex with a partner who was HIV-negative or of unknown status had unprotected vaginal or anal intercourse. Ciccarone and his colleagues also noted that for all HIV-positive individuals most such unprotected‚ sex without disclosure appeared to involve mutual non-disclosure-- namely neither partner revealed his or her status to the other. Among HIV-positive individuals who were sexually active, gay and bisexual men were much more likely to have any sex-- either with or without a condom-- without disclosing their status to their partner. Forty-two percent of gay and bisexual men reported having sex without disclosure, compared to 19 percent of heterosexual men and 17 percent of all women. The survey also found that among those HIV-positive individuals having sex without disclosure, gay and bisexual men were much more likely to do so in casual relationships than in monogamous relationships, whereas heterosexual men and women of all orientations were equally likely to do so in either an monogamous or non-monogamous relationship. However, the researchers found little difference among all HIV-positive individuals regarding the likelihood of having sex with a partner whose status was either unknown or negative. HIV Increasing Among Seattle-area Gay Men HIV cases diagnosed in public health clinics rose 40 percent last year and are projected to increase by another 60 percent this year, "the most dramatic increase since the beginning of the epidemic" more than 20 years ago, said Dr. Robert Wood, director of AIDS control for the Seattle-King County Health Department. The agency's clinics reported 94 new HIV infections in gay men tested last year, and testing through April indicates there could be more than 150 cases by the end of this year. "The new information is frightening. It's astounding," Wood said. Officials estimate there are 400 to 500 new HIV infections in the county each year, including those found at private clinics. Lacking a count from private clinics, however, the overall increase in HIV infections remains unknown. Last year there was an increase of about 11 percent in the number of gay men tested for HIV in public clinics, which Wood said was encouraging but could not account for the increase in infections. He estimated about 8,400 county residents are HIV-positive, including about 3,000 with full-blown AIDS, compared to 7,500 individuals with HIV two years ago. Gay and bisexual men account for about 85 percent of the AIDS cases in the state's most populous county. As in other large cities, reduced fear of AIDS because of new medications and burnout on "safe" sex messages have resulted in riskier sexual behavior, health officials said. Health officials and AIDS-oriented community groups are urging gay men to be tested for the virus, disclose their status to sexual partners and practice "safe" sex. "We need to take HIV out of the closet. It's the responsibility of all guys who are sexually active to be talking about it-- and don't be afraid to talk about it if you have it," said Jack Johnston, program coordinator for Positive Power, a group that helps HIV-positive men. To encourage testing, the county agency last Friday began a pilot project offering a new HIV blood test that gives results in about 20 minutes, instead of the week required for a conventional test. Volunteers are recruited along Broadway on Capitol Hill for the test, called OraQuick, in a nearby private office with an "incentive" of $10. Counseling is provided before and after results are known. The test is quite accurate but remains subject to confirmation by a conventional test, Wood said. Wood, who has battled AIDS for years but is relatively healthy now, said that if the project is successful in the next year, health officials hope to expand it to gay bathhouses and sex clubs. "One of the most important things you can do in HIV prevention is make sure people know if they are positive or negative," he said. "Studies have shown that people make major changes in behavior when they learn their status." Rapid HIV Test Offers Opportunities for Prevention and Treatment, But Still Concerns Some AIDS Groups The local health department hopes that the trial run using the test, called OraQuick, will lay the groundwork for a larger program to offer the test in gay bathhouses and sex clubs. The health department has drafted protocols for using the rapid test in public settings, and it currently offers the traditional HIV test, which can take up to a week to get results, in gay venues. The tests are offered in private rooms and administered by health care workers. Since 1998, the health department has tested 1,200 men in three gay venues in Seattle. Of the 56 men who tested positive-- 4.7 percent of the total number tested˜23 percent, or 15 men, did not return for their test results the next week. "If we had been using a rapid test, those ... people would have at least received preliminary positive results and would have been informed of the need to return to our clinic for confirmatory results," Frank Chaffee, HIV/AIDS program manager for the Seattle-King County Department of Public Health, said. The Centers for Disease Control and Prevention in April released a revised HIV/AIDS prevention strategy, which targets the estimated 200,000 people in the United States who are HIV-positive but are unaware of their status. The agency urged local health departments to use the rapid HIV test-- which was approved by the Food and Drug Administration in November 2002 for use in about 40,000 hospitals and clinics with laboratories-- in all federally funded clinics, as well as places such as homeless shelters, jails and substance abuse treatment centers. In February, President Bush announced expanded availability for OraSure Technologies‚ OraQuick HIV test, which offers results that are 99.6 percent accurate within 20 minutes, to more than 100,000 doctors‚ offices and public health clinics. AIDS groups had advocated for making the test more widely available to the general public. The CDC also recommended simplifying the pre-test counseling process. However, the CDC does not yet have recommendations on the use of the rapid test or what type of counseling should accompany the test, leaving such decisions up to local health authorities. A CDC official, speaking on the condition of anonymity, said that although the agency is rethinking counseling strategies, it still believes the process is important. The CDC plans to conduct research over the next year to determine the best ways to combine counseling with the rapid test. The speed and portability of the new HIV test means that some people may find out they are HIV-positive in places where counseling and other services may not be immediately available, Fred Swanson, executive director for Gay City Health Project, said. Local health officials say that they can successfully combine counseling and testing in public locations. The health department has drafted its own protocols for using the rapid test. "Our big challenge, and one of the big goals for the Centers for Disease Control, is to try to increase the number of people with HIV infection who know that," Chaffee said, adding, "One, because people who have HIV and don't know it are losing the benefits of good medicine. ... And two, we know from a variety of studies that when people know they have HIV infection, they are much more careful with their sexual and needle-sharing partners." Although Washington state law requires pre- and post-test counseling, the law is not specific as to what the counseling should entail. "Are recipients of positive test results going to be able to internalize the information they've received around the (new) test when they don't have any time to mull the information over?" Paul Feldman of Seattle's Lifelong AIDS Alliance asked. Swanson said that although he is worried about possible negative effects of using the rapid test in public settings, he said that he is reassured by the fact that the rapid testing will not occur immediately in gay bathhouses and sex clubs. "What's exciting to me is that the local health department recognizes that there may be some challenges, and as such is doing a trial run," he added. Stopping a New and Deadly Mix of Syphilis and HIV Why this worry over a centuries-old scourge that's easily treated with penicillin? Because medically, syphilis boosts the chances of giving or getting HIV by up to five times. And HIV is much tougher to treat and impossible to cure. A rise in syphilis raises the frightening specter of a new AIDS epidemic. That specter is now taking shape. Syphilis cases have tripled in and around Tucson, Arizona, over the past year. Massachusetts has found an 87 percent increase between 2001 and 2002, and the upward trend is continuing. Case reports have risen 67 percent in Minnesota, 50 percent in New York City, and 27 percent in Los Angeles. And across 25 states, HIV infections have registered their first increase since 1993. The STD outbreaks seem driven by people on society's margins-- gays, drug addicts, prostitutes-- who are somehow beyond the reach of standard health services. This situation has grown so distressing that the Centers for Disease Control and Prevention has sent workers across the country to find new intervention strategies. "We know that [syphilis outbreaks] mean HIV is being transmitted," says Emily Erbelding, an infectious-disease specialist at the Johns Hopkins University School of Medicine and clinical director of Baltimore's sexually transmitted disease program. "It has been unrelenting," says Peter Kerndt, who runs the Sexually Transmitted Disease Program of the Los Angeles County Department of Health Services. "We haven't seen the end of it. We haven't seen it peak." In March, a CDC team touched down in Broward County, Florida, which has seen syphilis rates soar by 88 percent. Howard Sommers, acting director of the county's STD program, says the CDC and his staff together hatched plans for more vigorous outreach: getting clinics to do more syphilis screenings and a hospital to run an after-hours men's health clinic. They must act fast: Almost all the men Sommers sees with syphilis also have HIV. The actual uptick in syphilis is small-- in the United States there are just over 6,000 cases-- but the trend shows that people at high risk are slipping back into Œunsafe‚ sexual behaviors. They are poised to become a breeding ground for the next round of HIV. "Many [of the men] are HIV positive and on medical regimens," says Kontar Mosi, 28, from the Health Education Resource Organization, the Baltimore nonprofit that runs the syphilis-screening van. "They are close to 100 percent healthy, so they are lapsing back into non-condom use. That is really hurting prevention." Mosi knows firsthand the damage such attitudes do. An unscrupulous partner infected him with HIV several years ago. Thus Mosi trolls the streets for HERO, bringing men to the van for screening. This program has helped slash the city's syphilis rate by 80 percent. Other cities are trying different forms of outreach. In wired San Francisco, public-health workers post syphilis information in an Internet chat room. Study Finds Wives of Substance-abusing Men Are Unknowingly Being Placed at High Risk for HIV In most cases, wives in the study were not having sex out of their marriage, were unaware of their husband's high-risk behavior and did not know that they, in turn, were being placed at high risk. The study, involving 362 drug-abusing men entering outpatient treatment and their wives, found that 40 percent-- or 144-- of the husbands had during the year prior to entering treatment engaged in "unprotected" penetrative sexual intercourse with a person other than their spouse or engaged in risky needle practices, such as using a used syringe. With all but six of the wives in the subgroup reporting that they had sexual intercourse with their spouse during the same time period, 78 percent-- or 108-- of the wives reported that condoms were not used regularly when they had intercourse with their husband. Seventy-one percent-- or 77-- of the 108 wives reported they were not aware of their husbands' high-risk behaviors. Thirty-one wives were aware of their husbands' high-risk behaviors, but still engaged in "unprotected" sexual intercourse with them. Results of the study were reported in Drug and Alcohol Dependence. William Fals-Stewart, PhD, lead researcher on the study, said it identifies a "hidden" at-risk group-- non-substance-abusing women indirectly and unknowingly exposed to HIV, sexually transmitted disease and hepatitis by having "unprotected" sexual intercourse with their husbands. "This population is under-recognized as being at risk," said Fals-Stewart, a clinical psychologist who is a senior research scientist at RIA and research associate professor in the department of psychology in the UB College of Arts and Sciences. Women are the fastest-growing group infected by HIV in the U.S. HIV infection is the fifth-leading cause of death among American women ages 25-44 and the number 3 cause of death among African American women in that age group. The U.S. Centers for Disease Control estimates that among women, about 40 percent of new AIDS cases and 75 percent of new HIV infections are due to heterosexual transmission. Eighty-two percent of the 362 men in the UB study abused and were dependent on alcohol, and other drugs also were involved. Sixty-nine percent were dependent on cocaine, 64 percent were dependent on opiates. Couples in the study had been married on average for 6 years. More than 70 percent of participants were white; fewer than 20 percent were African American. Couples were not included in the study if a partner reported he or she was HIV-seropositive. According to Fals-Stewart, "The majority of the husbands engaging in extramarital relationships were doing so with very high-risk women. These women either used intravenous drugs and/or had multiple sexual partners." In contrast, the wives in the study reported no drug use and less than 2 percent reported extramarital relationships. Fals-Stewart said the researchers could not breach confidentiality by informing wives in the study of their husband's promiscuity. HIV Rates Four Times Higher Among Female Prison Inmates Overall, 3.6 percent of women in federal or state correctional systems are living with HIV compared to about 2 percent of male prisoners, according to "Serving Women in The Corrections System Through Ryan White CARE Act Programs." While national statistics are alarming enough, in some cities and states, the problem is far worse. In the District of Columbia, 41 percent of women inmates are HIV positive. Other states with high HIV incidence among women prisoners are New York, 18.2 percent; Nevada, 12.4 percent; Maryland, 9.8 percent; Florida, 9 percent; Connecticut, 8.1 percent; New Jersey, 6.8 percent and Vermont, 5 percent. Ten million or more people cycle out of prisons and jails each year, according to the guide. Correctional systems can provide an opportunity to get HIV positive women diagnosed and/or connected to care "Reaching women in prison can help end the cycle of addiction and HIV transmission," said David C. Harvey, AIDS Alliance executive director. "Because many women come out of the correctional system, there is a significant benefit for public health when these women know their status and are in treatment." Juvenile Offenders at High Risk of HIV Such risk-taking by young offenders, researchers say, could spur problems that stretch well beyond youth detention centers. "Once these kids are back in the community they may continue with behavior that causes the disease to spread," said Dr. Linda A. Teplin, a legal health expert at Northwestern University. "They do not stay in jail for very long." In a report published in the American Journal of Public Health, Teplin and colleagues call for corrections officials to do more about preventing the spread of HIV. "These kids may be too busy skipping school to learn about HIV, and they don't have much parental support in their lives," Teplin said. "The best chance to educate these kids may actually be in prison." Teplin's team based its conclusions on interviews with 800 youth offenders held at the Cook County Temporary Detention Center in Chicago. The participants, who ranged from 10 to 18 years of age, were asked about their sex life and use of drugs. The responses came as no surprise, Teplin explained, but they were "alarming," nonetheless. Ninety-five of the juvenile detainees said they had at some point engaged in at least three behaviors that could put them at risk of HIV, and roughly two-thirds of them reported 10 or more behaviors that upped their chances of contracting HIV. The most common risk factors were Œunprotected‚ intercourse and getting a tattoo with a potentially dirty needle. And while such risky behavior was more widespread among older teens, the younger ones were close behind. More than half of girls ages 10 to 13 said they were sexually active, and most admitted to using marijuana and alcohol-- which, Teplin said, could impede their judgment. "The problem with using these drugs is that you tend to engage in risky behavior because you're intoxicated," she said. "Kids may handle these situations even less responsibly." Still, the study also had its brighter spots. Very few detainees said they injected drugs or shared needles. And while many reported sometimes having sex when they were drunk or high, the majority also said they had used condoms in recent times. Teplin said that younger kids, who have yet to develop as many risky habits, may offer the best hope for HIV prevention. "If we start early enough, we can influence their behavior before it possibly gets more dangerous," she said. Some correctional facilities do offer educational programs on HIV, but Teplin contended that much more needs to be done. She and her colleagues point out that many kids at particular risk of HIV/AIDS-- such as runaways, drug users and teens who trade sex for money-- "cycle through" youth detention centers, causing a broader problem once they are released. Last year, close to a half-million juveniles spent time in jail, providing an important forum for education, according to Teplin. "We can target a lot of high-risk kids in detention centers," she said. "Intervening could have big pay-offs for the community." HIV Deaths and Heroin Overdoses Increase in Massachusetts The report indicates the increase in drug deaths is consistent with a national trend and said Massachusetts has joined 11 other states in examining the increase. A report is due out later this year. Of the deaths by drugs and other poisons, 61 percent were among people ages 25 to 44, the report said. For the first time since 1994, HIV deaths increased, from 226 to 249, but officials said the numbers are not statistically significant and don‚t necessarily show a trend. Preventive Medicine Group Recommends Widespread Screening for Chlamydia "While chlamydia has become the nation's most common bacterial sexually transmitted disease, it can in fact be controlled by aggressive public health efforts," said Dr. Katerina Hollblad-Fadiman, the lead author of ACPM's recommendation. "Not only can effective screening programs result in the diagnosis and treatment of chlamydia in currently infected persons, but they can greatly reduce transmission of the disease to unsuspecting sexual partners," she said. Chlamydia affects more than 4 million Americans each year. Seventy percent of all reported cases occur in women under age 25. Widespread screening is necessary since up to 70 percent of infected women and 75 percent of infected men are asymptomatic. Treatment for chlamydia, once detected, is effective and simple. Cervicitis is the most common reported manifestation of chlamydial infection in women. Pelvic inflammatory disease occurs in up to 30 percent of untreated women, leading to possible ectopic pregnancy and/or tubal infertility. Chlamydial infection also increases the likelihood of both transmitting and acquiring HIV. The full American College of Preventive Medicine Practice Policy Statement, "Screening for Chlamydia Trachomatis," is published in the American Journal of Preventive Medicine (2003;24(3):287-292) and may be accessed online at www.acpm.org. New HIV Drug Forces Tough Call in North Carolina Fuzeon, developed by Trimeris Inc. of Durham, is the first in a new class of HIV-fighting drugs. Doctors believe it is a remedy when older drugs fail. One study-- published this week in The New England Journal of Medicine-- found the amount of HIV in the blood of Fuzeon-treated patients decreased almost 10 times more than in patients treated just with standard antiretroviral medications. Fuzeon "is highly effective," said Dr. Joseph Eron of UNC Chapel Hill, the study's co-author. It's also highly expensive. The wholesale cost for one patient's yearly supply is about $20,000. Many HIV patients take drug regimens that cost $10,000 to $12,000, and doctors say Fuzeon must be used in combination with the other meds to be effective. That means the wholesale cost of treating some HIV patients could triple. Which brings us back to Sherman, coordinator of the North Carolina AIDS Drug Assistance Program (ADAP). The program buys HIV medications for low-income patients who can't get them through Medicaid or other insurance. Current enrollment is 2,820, or 15 percent of the state's residents known to be living with HIV. ADAP's budget is $24 million. That doesn't go a long way in the world of HIV, and North Carolina officials had to make hard decisions to control costs. They restricted eligibility to people with very low incomes-- no more than $11,225 for a single person and $23,000 for a family of four. That ceiling is the nation's lowest. South Carolina's ADAP, in contrast, takes single people who make up to $26,940 and families of four with incomes up to $55,200. Still, the N.C. program has had more eligible patients than it could handle. In late 2001, it froze enrollment and started a waiting list that grew to more than 800. The waiting list ultimately was pared, partly because some enrollees got jobs, died, or became disabled to the point of qualifying for Medicaid. Last month, the waiting list hit zero. When federal regulators approved sale of Fuzeon earlier this year, the N.C. Medicaid program decided to pay for Fuzeon, as did most other public and private insurance programs. But that state's ADAP has a tighter budget, so while ADAP will offer Fuzeon, the number of patients receiving it will be limited to 25, Sherman said. Patients will be selected based on the order they sign up and on whether they meet medical eligibility guidelines. Because Fuzeon is most appropriate for a small fraction of HIV patients, Sherman hopes, a cap of 25 will be enough. The HIV Update is a weekly report of articles, studies and other information related to HIV/AIDS, sexually transmitted diseases and related risk behaviors compiled from various news sources by the Children's AIDS Fund. For additional information contact Roland Foster at (703) 471-7350 or via e-mail at rfoster@childrensaidsfund.org. The Children's AIDS Fund is a non-profit, non-partisan organization dedicated to helping limit the suffering of HIV-impacted children through direct assistance and resources, as well as through technical assistance for their parents and care-givers Previous Editions of the HIV Update |