Rethinking AIDS Prevention in the U.S.

In 2001, the U.S. Centers for Disease Control and Prevention (CDC) committed to halving the number of new HIV infections in four years. At the time, new cases had been hovering around 40,000 per year for a decade. It soon became clear, however, that reducing new infections was more difficult than they had supposed. The infection rate held steady through 2004, and the CDC is back to the drawing board to craft a new national prevention strategy.

In addition to a call for more federal funding for HIV prevention initiatives, the revised CDC approach, according to AIDS experts, should focus on tailoring interventions to the specific needs of at-risk populations, and addressing the geographic shift of the disease from urban areas on the East and West coasts to the South, where some of the highest numbers of AIDS cases are concentrated.

The new plan's success will depend, in large part, on directing more resources to the African-American community, where the disease has taken a disproportionately large toll. Black women and black gay men have been especially hard hit, partly because many are not aware of their HIV-positive status, says David Holtgrave, PhD, professor and founding chair of the Bloomberg School's Department of Health, Behavior and Society.

"It's a recipe for an explosive epidemic," says Holtgrave, who is among 38 advisers assisting the CDC with drafting a new prevention plan. "If you said, 'Where are some of the worst AIDS epidemics in the world?' you would have to include African-American gay men in the United States. HIV prevention services to this community must be a top national priority."

Community-level interventions, in which respected or trusted members of a group carry HIV prevention messages to other members, have been used effectively in a number of populations, including gay men, African-American women living in housing developments and sexually active adolescents.

Another priority, according to AIDS experts, is the expansion of HIV counseling and testing to prevent the spread of the AIDS virus by those who are unaware of their infection, and the provision of medical care, housing and substance abuse treatment to individuals who are already infected.

The general population is also in need of basic HIV education and programs to address stigma. Holtgrave says about 20 percent of the U.S. population thinks that people with AIDS "got what they deserved."