Test and Treat HIV/AIDS in Our Nation's Capital Now

The H1N1 influenza epidemic is dominating the news. National resources have been mobilized, the nation's stockpile of anti-influenza drugs is being distributed, and officials from the president and vice president on down are advising the public daily how to avoid, detect, and treat the disease. As of May 4th, the Centers for Disease Control had reported 286 confirmed cases and one death from the H1N1 influenza in the United States. Perhaps concern is justified, as this is a new strain of virus--perhaps not, as its spread appears to be limited. What cannot and should not be ignored is HIV/AIDS, an ongoing epidemic that is as severe in the nation's capital and nearby Baltimore as it is in many countries of sub-Saharan Africa.

The numbers tell the tale. At least 3 percent of all the people living in the DC and Baltimore metropolitan area, 4 percent of adults, are infected with HIV. These rates are on par with infection rates in West Africa, Uganda, Kenya, and several other sub-Saharan African countries. Our nation's capital--together with Miami, New Orleans and New York City--bears the highest HIV/AIDS burden in the country. The details of infection in the population are more sobering still. In both Washington and Baltimore, the epidemic is centered on the poor black population. About 7 percent of African-American men aged 40 to 49 are infected. HIV/AIDS is a zip code epidemic. The 2005 interim report of the Baltimore City Commission on HIV/AIDS Treatment and Prevention shows that the infection rate exceeds 7 percent in the five poorest zip code areas, and is less than 0.3 percent in the wealthiest eight. In both Washington and Baltimore, sexual transmission is the dominant cause. Intravenous drug use accounts for about one third of the infections. Heterosexual sex is the most common mode of transmission of the infection in both black men and women. Sex between men is the most prevalent means of transmission amongst white men. In both cities, infected men outnumber infected women two to one. In this respect, the epidemic in the United States differs from that in Africa, where women account for more than half of the infections. In all, 45,000 to 60,000 people in the Washington/Baltimore area are likely to carry the HIV virus.

Untreated, the infection by HIV is almost uniformly fatal. Death from infection can only be avoided by lifelong treatment with anti-viral drugs. Such treatments require careful and continual monitoring to detect and counter the development of resistance and place a heavy burden on health services. The annual cost per patient, including the costs of diagnostic tests and drugs, is estimated to be about $25,000.

What can be done to stop the spread of the disease? Recent vaccine trials have failed and no one can predict when or if an effective vaccine will be developed. Needle exchange programs, now available in both Washington and Baltimore, do work to reduce but not eliminate transmission by intravenous drug users. Condom use is known to dramatically reduce the risk of infection. Despite persistent efforts by public health officials, only about one third of men regularly use condoms in situations where they risk infection. Although necessary and useful, public awareness and counseling campaigns go only so far. In the words of Washington's mayor, Adrian Fenty, "You have this problem (HIV/AIDS) affecting us, and you tell people how serious it is, and it literally goes in one ear and out the other." A medical solution is needed.

For the first time, there is hope. Consensus is building amongst those who are working to control the HIV/AIDS epidemic in Africa that universal testing followed by early, universal treatment may bring the epidemic to an end. (I described this program in an earlier posting, "An Early End to the HIV/AIDS Pandemic?"). This is the so-called Test and Treat Program. Effective anti-viral treatments are now known to substantially reduce both sexual and maternal transmission of the virus. According to several mathematical models, testing and early treatment of 90 percent of those at risk for infection could stop the spread of the disease and eventually eliminate HIV/AIDS from a population altogether! Several advances make the Test and Treat Program a real option. Inexpensive tests for HIV infection that are greater than 99 percent accurate, take less than a half an hour to read, and draw no blood (a quick mouth swab) are available. These can now be purchased in U.S. pharmacies for home use. Combinations of anti-viral drugs that are effective and can be used for extended periods without serious side effects are being developed. The infrastructure for drug testing and treatment is rapidly expanding in sub-Saharan African countries, thanks to more than $50 billion in assistance provided by the United States through the PEPFAR program and billions more from the Global Fund and other international programs. Test and Treat Programs are beginning begin soon in Botswana and several other African countries.

I propose that we initiate a Test and Treat Program right here in Washington and Baltimore. The rates of infection are similar to those in many African countries. We have detailed knowledge of the epidemic in this region. Moreover, we are home to many of the very intuitions, scientists, and doctors that are leading the fight against the epidemic in Africa. The world's experts on the epidemic are here at the National Institute of Allergy and Infectious Disease of the National Institutes of Health in Bethesda, the Institute of Human Virology at the University of Maryland (I am a trustee), and the School of Public Health at John Hopkins in Baltimore. The local Test and Treat Program would coordinate with the local regional hospitals and clinics. If we can mount Test and Treat Programs in Africa with the hope of eradicating the epidemic, we can do it right here at home where the need is as acute.

Surely there will be obstacles. Although resistance to testing has declined over the years, testing for HIV infection is not universal. Some advocate that it be incorporated as the fifth vital sign, along with temperature, blood pressure, pulse rate and the like. Two years ago the Centers for Disease Control recommended routine HIV testing for all patients ages 13 to 64. Insurance companies must be induced to pay for these necessary tests. How willing will people be to initiate early treatment? We know the chances for long term survival are 30 percent higher for those treated earlier (T cell count less than 350) in the disease rather than later (T cell count less than 200), but data on outcomes of those treated at the earliest stages of infection is not available. How tolerable will be the effects of long term treatment? We will not know until we try.

Test and Treat Programs have controlled two other serious epidemics in the past in the absence of fully effective vaccines: the epidemics of syphilis and tuberculosis. We know such programs can work. It is time to begin them for HIV/AIDS here and now.