DR. COLBY: Dr. Valdiserri will discuss with us the HIV epidemic in the United States and he is uniquely qualified to address this subject from the U.S. Welcome and thank you, Dr. Valdiserri.
DR. RON VALDISERRI: Because of the widespread use of combination antiretroviral therapy in the U.S., AIDS cases and deaths in adults and adolescents have dropped substantially between 1996 and 1998. But since mid-1998, AIDS cases have remained roughly stable at approximately 10,000 AIDS’ diagnoses per quarter. Through June 2001, we have seen no dramatic changes in this pattern. Now, whether cases will continue to stabilize throughout 2001 remains to be seen; with only two quarters’ worth of data, it’s too soon to tell.
Additional progress against HIV/AIDS will clearly require expanded efforts to get people tested early and into care. Recent estimates suggest that about half of infected individuals -- that’s 400,000 to 500,000 Americans -- remain undiagnosed, untreated or both. However, for reasons that I will shortly explain, this seeming stability may not tell the whole story.
Looking at trends in HIV diagnoses by risk group, one observes slow but steady increases among heterosexuals with reported HIV diagnoses -- that’s the green line in this slide -- increasing 10% between 1998 and 2000. In these 25 states, diagnoses among injection drug users -- that’s the blue line -- continued to decline between 1998 and 2000, at a rate of 6%. Finally, HIV diagnoses among gay and bisexual men -- the red line -- were roughly stable between 1998 and 2000.
As this pie chart shows, men who have sex with men accounted for the largest proportion of HIV diagnoses in these 25 states throughout the entire study period. Of the nearly 129,000 HIV diagnoses reported in these states from 1994 to 2000, gay and bisexual men accounted for 43% of new diagnoses, followed by individuals infected heterosexually at 27%, and injection drug users at 23%. 75% of HIV diagnoses among heterosexuals in these 25 states occurred among African-Americans, a hugely disproportionate toll. We have seen troubling trends in STDs and risk behaviors among men who have sex with men in several areas outside of these 25 states, including Florida, California and New York.
In a press briefing later today, we will be discussing new data from STD clinics in five American cities demonstrating continued high levels of HIV infections among men who have sex with men of all races, but especially among African-American and Latino MSM. In fact, over the past two years, we have seen a number of STD outbreaks among men who have sex with men in several American cities. This map shows cities which have experienced recent outbreaks of Syphilis among men who have sex with men.
In New York City, the rates of Syphilis among men increased 2.8 per 100,000 in 2000, to 6.9 per 100,000 in 2001, and local studies indicate that the majority of these cases are among men who have sex with men. As seen on this slide, the number of Syphilis cases reported among men who have sex with men in San Francisco has increased more than five-fold from 22 cases in 1999, to 116 cases in 2001. Preliminary data for 2002 suggests that this year’s number will be even higher.
Taken together, these data indicate the following: overall, HIV incidents appear to have stabilized in recent years in these 25 states that we’re reporting on. However, this stability is deceptive because it doesn’t show the entire national picture and because it may be masking increases in HIV among heterosexuals and gay and bisexual men in some areas. And finally, we have seen that African-Americans account for the majority of new HIV diagnoses in these 25 states.
Given the continuing toll of the epidemic, how do we move forward? The first step is to recognize and act upon the fact that today’s epidemic is very different from the one we faced a decade ago. The populations at risk, the attitudes about infection, and the science of HIV have all changed and so must our prevention efforts. Today’s epidemic in the U.S. is also characterized by high levels of infection in racial and ethnic communities already plagued by social inequities and other competing health priorities. A wide spectrum of individuals risk from those who have grown tired of hearing HIV prevention messages to those who may not yet fully understand or appreciate their risk, gay men of all races and levels of sexual identification, each with unique prevention needs, and an environment of growing apathy.
Despite or perhaps because of these challenges, Americans overall, and even some persons at high ongoing risk for infection, don’t seem to have the same sense of urgency that characterized the early years of the epidemic. Some are becoming bored with HIV after 20 years. Some are simply tired of the same old messages and many didn’t realize that they were signing on for a lifetime of condom use. But formidable as these challenges are, we must not fail to act, not when there is so much at stake.