By Phillip G. Curtis

In early December, during the National HIV Prevention Conference in Atlanta, the U.S. Centers for Disease Control and Prevention will reportedly announce a new estimate of yearly HIV infections in the United States, a dramatic 50 percent increase from the current 40,000 to 60,000 annual infections.

The new numbers would be the first increase in the CDC estimates in almost a decade. The CDC has not yet said whether the new estimates are absolute increases in new infections, or if the figure is the result of improved testing and reporting.

While alarming, even the rumored increases would still qualify as a long-term prevention success. The CDC estimates that new HIV infections reached a high of over 160,000 per year in the late 1980s.

Still, the number of people living with HIV/AIDS is on the rise. HIV/AIDS mortality rates have dropped precipitously to around 18 percent a year since the advent of successful treatment in 1996. The CDC says more than a million Americans are now living with HIV or AIDS, and around a quarter do not know they are infected.

The resulting calculation—more people living with HIV equals more new infections—underlies the CDC’s current emphasis on routinizing HIV testing.

More than a year ago, the CDC released new testing guidelines intended to streamline the testing and counseling process and to make HIV testing a routine part of medical screening in outpatient settings, including emergency rooms. The thinking is that people who learn they are HIV-positive reduce risky behaviors that lead to transmission of the AIDS virus. Data suggests that people who do not know their HIV status account for well over half of new HIV infections each year. A recent report claimed that even among high-risk populations, such as gay and bisexual men, only a fifth are tested each year.

AIDS Project Los Angeles and other community-based organizations have long advocated for fundamental shifts in CDC prevention efforts to address new realities in the epidemic.

The changes should include:

• Increased prevention funding to adequately address the U. S. epidemic, especially in hard-hit minority communities and among gay men of all colors.

• A more comprehensive reframing of HIV prevention, which includes addressing the health, mental health, social and cultural factors associated with the risk for HIV infection.

• An end to the pre-packaged prevention initiatives now funded by the CDC, and a new emphasis on locally developed and culturally sensitive prevention interventions.

• An emphasis on science, not ideology; specifically an end to funding increases for Bush administration-backed, abstinence-only prevention education (which has never been shown to be effective).

APLA is also concerned that the new numbers could lead to the demonizing of certain populations or that the CDC will push for even more aggressive testing.

“We cannot test our way out of this epidemic, no matter what the CDC would have us believe,” says George Ayala, APLA’s director of education.

The new CDC estimates of annual infections will likely impact discussions of future domestic HIV/AIDS initiatives, including the Ryan White CARE Act, reauthorized in 2006 after a long and politically divisive debate. The latest version of the CARE Act will “sunset” in 2009 and must then be rewritten.

The future of the CARE Act was a major topic at the recent U.S. Conference on AIDS in Palm Springs since Congress is scheduled to begin stakeholder hearings as early as January 2008.

In Los Angeles, the Commission on HIV is developing recommendations for the new CARE Act. A California group is working to craft unified statewide policy recommendations. And at least one community-based organization, Housing Works of New York, is soliciting input on a new CARE Act from consumer groups nationwide.

The $2.1 billion CARE Act remains the largest dedicated source of federal funding for HIV/AIDS care, treatment and services. (The largest sources of funding for care, however, remain Medicaid and Medicare). While CARE Act funding has been cut over the past several years, prevention funding has lagged even further behind. At $719 million in 2006, the CDC’s current prevention funding in inflation-adjusted dollars remains at the same level as the mid-1990s.

Advocacy groups nationwide are now advancing a national strategy to end AIDS in the United States, a plan that would encompass both prevention and care. While the United States has never had a national plan, it requires all countries that receive funding through the President’s Emergency Plan for AIDS Relief to devise such plans. There is now a website (www.nationalaidsstrategy.org) where more than 100 organizations have signed on to the platform. The strategy calls for the United States to develop what it asks of others, a plan that would:

• Improve prevention and treatment outcomes through reliance on evidence-based programming

• Set ambitious and credible prevention and treatment targets and require annual reporting on progress towards goals

• Identify clear priorities for action across federal agencies and assign responsibilities and timelines for follow-through.

• Include, as a primary focus, the prevention and treatment needs of African Americans, other communities of color, gay men of all races, and other groups at elevated risk.

• Address social factors that increase vulnerability to infection.

• Promote a strengthened HIV prevention and treatment research effort.

• Involve many sectors in developing the national strategy: government, business, community, civil rights organizations, faith based groups, researchers and people living with HIV/AIDS.

One question repeatedly asked at the AIDS Conference was whether the CARE Act should morph into a national plan for care, treatment and prevention? Policymakers often warn that including prevention within the CARE Act could dilute the bill’s effectiveness in addressing care, treatment and services for people living with HIV/AIDS. However, now that the CDC has upped the estimates on new HIV infections, the paradigm may shift. Advocates, providers and policymakers will need to address not only the care, treatment and services funded through the Ryan White CARE Act, but also how to ramp up the effectiveness of under-funded U.S. prevention programs.

Philip G. Curtis is director of government affairs at AIDS Project Los Angeles.