On September 16, the House Oversight and Government Reform Committee held a hearing, “The Domestic Epidemic is Worse than We Thought: A Wake-Up Call for HIV Prevention.”
In his opening statement, Chair Henry Waxman (D-CA) said, “The Centers for Disease Control and Prevention (CDC) recently announced that the HIV epidemic in the U.S. is growing at a rate far greater than was previously thought…Over the past ten years, CDC’s official estimate for annual new infections has been about 40,000. But last month, CDC announced that in fact there were over 56,000 new HIV infections in 2006. The higher figure was due to improved counting methods, not to an actual jump in infections. But it tells us that the epidemic in the United States is — and has been — growing faster than we had thought.”
Rep. Waxman was highly critical of the current administration’s domestic HIV prevention efforts: “In adjusted dollars, the CDC’s HIV prevention budget has dropped more than 20 percent since 2002…It is indisputable that evidence-based HIV prevention saves money in addition to saving lives by avoiding the high costs of medical care and lost productivity. But on this issue, the administration apparently prefers to be penny-wise and pound-foolish.” He continued, “We will discuss barriers to evidence-based HIV prevention, like the federal needle exchange ban and this administration’s stubborn and irrational focus on abstinence-only programs. And because HIV infections don’t occur in a vacuum, we will hear recommendations from all of our witnesses on how the federal HIV prevention response should address societal factors that contribute to risk, including poverty, homelessness, racial and gender inequality, homophobia, and stigma related to HIV status.”
Ranking Member Tom Davis (R-VA) said, “Using a more sensitive surveillance tool, the Centers for Disease Control found 56,300 new HIV infections in 2006. That’s a 40 percent higher incidence than previous estimates. The upward adjustment does not reflect an acceleration of the epidemic, but a more precise capability to distinguish between recent and longer term infections. So it still appears the epidemic has in fact plateaued in terms of new infections per year over the last decade, but at a markedly higher rate than we thought. With this new knowledge about the path and scope of the epidemic, public heath officials can better target efforts to prevent the spread of the virus that causes AIDS. In fact, we do know how to prevent HIV transmission. Abstinence, safer sex practices, not sharing needles, and proper medical treatment of pregnant women who are HIV-positive can effectively block the most common infection pathways.”
Rep. Davis continued, “But behind the figures lurks one deadly fact: No prevention strategy works on a person who doesn’t know he or she is infected. At any given time, it’s estimated fully 25 percent of Americans carrying HIV have not been diagnosed. They are far more likely to engage in the high-risk behaviors that expose still others to silent infection. Breaking that silence, research has proven the power of information as a barrier against the virus. Once diagnosed and properly counseled, HIV-infected individuals are significantly less likely to engage in behaviors that put others at risk. That leaves public health officials to confront the hard questions: Who should be offered testing? How often? And who pays for any broader HIV screening that might detect latent or unknown infections?”
Julie Gerberding, director of the CDC, highlighted the progress in reducing mother-to-child HIV transmission, calling it “one of the great success stories of HIV prevention. The number of perinatally infected infants with AIDS has declined more than 95 percent since the mid-1990s. This decline is due to multiple interventions, such as routine voluntary HIV testing of pregnant women and the use of antiretroviral therapy by HIV-infected women during pregnancy and infants after birth.”
However, Dr. Gerberding acknowledged there is more work to be done, particularly among racial and ethnic minorities and men who have sex with men (MSM), the populations that have experienced the most dramatic increases in HIV. She told the committee that the CDC is working to develop and implement public service campaigns designed to increase knowledge of HIV and reduce the risk of infection. One of these campaigns, “Take Charge, Take the Test,” is targeted at African American women and “has been shown to increase HIV testing and the identification of new cases of HIV infection.”
Director of the National Institute of Allergy and Infectious Diseases Dr. Anthony Fauci echoed Dr. Gerberding, telling the committee that “[a]mong at-risk groups, MSM comprise the greatest proportion—53 percent—of these new infections.” Dr. Fauci discussed several areas of research to prevent HIV infection, including microbicide development. “One of the most urgent needs in the area of HIV prevention is for microbicides to prevent HIV transmission,” he said. “Microbicides may be especially important for women who are otherwise dependent on male-controlled prevention strategies, such as male condoms.” Dr. Fauci noted that microbicide development poses several challenges: “Last year, two Phase III efficacy trials of a candidate microbicide, cellulose sulfate, were stopped due to safety concerns. Other trials have failed to show product effectiveness or have identified participant lack of adherence to the investigational product as a concern…NIH will continue to pursue research to define markers of protection and safety for microbicide use and will continue to examine carefully all ongoing microbicide trials for safety. Our focus for further development of microbicides will continue to be on candidate products with strong safety profiles and potential for protection.”
At the conclusion of the first panel, Rep. Jackie Speier (D-CA) asked Dr. Gerberding if she was correct in understanding that African American women were experiencing the greatest increase in HIV infection. Kevin Fenton, director of the National Center for HIV/AIDS at the CDC, told Rep. Speier that her understanding was incorrect; the highest rate of increase is among men, and in particular men who have sex with other men. Dr. Fenton said that African American women are disproportionately impacted by the epidemic and account for about half of new infections among women. (Dr. Fenton accompanied Dr. Gerberding, but did not submit testify before the committee.)
Rep. Speier asked Dr. Gerberding about “disappointing results” of microbicide clinical trials. Dr. Gerberding acknowledged that recent clinical trials showed some products under investigation “failed to protect, and in some cases enhanced transmission, because of irritation of mucosal membranes.” Dr. Fauci elaborated on Dr. Gerberding’s answer, saying that the “propensity toward vaginal irritation” of many candidates makes finding an effective microbicide difficult. However, he noted that second and third generation clinical trials were incorporating “potent anti-HIV medication” into the microbicides.
Dr. Adaora Adimora, professor at the University of North Carolina at Chapel Hill, began the second panel of witnesses. She told the committee that the sex ratio (the ratio of men to women) “is likely a key determinant of the structure of sexual networks, marital patterns, and family stability.” Dr. Adimora noted that there are fewer African American men than women in many communities due to higher morbidity and mortality rates and incarceration. “The relative scarcity of men results in low marriage rates and higher divorce rates among those who do marry, and epidemiologic studies demonstrate a strong association between being unmarried and concurrency [of sexual partners]. The shortage of men places women at a disadvantage in negotiating and maintaining mutually monogamous relationships.” Dr. Adimora also touched upon the concomitant effects of poverty, drug use, and incarceration on a community’s HIV rate.
In conclusion, Dr. Adimora recommended that the HIV epidemic among African Americans be “formally declared a national emergency with development and appropriate funding of an effective domestic HIV plan that addresses not only biological and behavioral interventions, but also the epidemic’s social and economic roots.” She also urged the committee to investigate the “markedly disproportionate incarceration of black men” and its effect on HIV rates, and to support comprehensive sex education in schools.
President of the National Association of People with AIDS (NAPWA) Frank Oldham spoke about his organization’s efforts to address and reduce the “structural/systemic/economic barriers that continue to perpetuate HIV vulnerability among the most marginalized groups of Americans.” Mr. Oldham stressed the importance of community-based prevention and treatment services: “NAPWA seeks appropriate resources to provide capacity building assistance (CBA) in the form of technical assistance and skills-building trainings to women-led or women-serving community based organizations (CBOs). The purpose of this CBA is to: (1) increase the effectiveness and sustainability of these CBOs in providing culturally competent, gender-specific HIV prevention services and (2) strengthen partnerships between these CBOs and HIV positive women. Such a partnership is essential to reaching, encouraging, and supporting women’s access to the continuum of HIV services beginning with HIV testing.” He encouraged the committee to adopt policies that further reduce stigma and ensure access to quality, affordable care and support services for HIV-infected persons.
Dr. David Holtgrave, professor and chair of the Department of Health, Behavior, and Society at Johns Hopkins Bloomberg School of Public Health; Dr. George Ayala, director of education at the AIDS Project Los Angeles; and Heather Hauck, director of the Maryland AIDS Administration, also testified.