WASHINGTON - Thirty-one years after doctors saw their first cases of AIDS, scientists say they now have the knowledge to begin to end the epidemic.
The only questions, says AIDS researcher Diane Havlir, are "Do we have the will to do it?" and "Who is going to pay for it?"
Doctors can now prescribe drug cocktails that reduce the amount of AIDS virus in a patients' body to undetectable levels. Landmark research funded by the National Institutes of Health show that these patients are not only healthier, but virtually non-contagious.
Outside the controlled environment of the lab, however, fighting HIV is far more complicated.
Only about one in four Americans with HIV have their virus this well controlled, according to the Centers for Disease Control and Prevention. The rest either aren't getting care, aren't getting consistent care, or don't know they're infected.
"It's very easy to treat HIV, the virus itself," says John Lennox, chief of infectious diseases at Atlanta's Grady Memorial Hospital and a professor at the Emory School of Medicine. "It's very hard to get treatment to people with HIV."
More than 25,000 AIDS researchers, patients and activists will converge on Washington, D.C., next week for AIDS 2012, an international conference being held in the USA for the first time in 22 years. While the meeting's location in the nation's capital will highlight the USA's scientific achievements and generosity in fighting AIDS around the world, the conference will also shine a spotlight on the country's uneven progress in treating the disease at home, activists say.
One in 30 adults in Washington is infected, including one in 16 black men. That's higher than the HIV infection rates in many African countries, including Ethiopia, Nigeria and Rwanda. In some American cities, up to one in three gay men have HIV, according to the CDC.
While infection rates have fallen sharply from their peak in the late 1990s, about 50,000 Americans are newly infected each year, and nearly 1.2 million live with the disease.
"There are big gaps between what we have the potential to do in terms of prevention, and what we're actually accomplishing," says Adaora Adimora, a professor at the University of North Carolina-Chapel Hill. "We need to be able to get treatment to more people who need it, and make sure that care is delivered to them properly."
What sets AIDS apart from other diseases in American history - and even other infectious diseases such as polio or tuberculosis - is that it disproportionately affects people who are on the margins of society, such as gays, minorities and the poor, Lennox says.
Nearly half of all new HIV infections are in blacks, according to the CDC.
Researchers who've examined why HIV has taken hold in minority communities have found no major differences in sexual practices, such as the number of partners or use of condoms. The major difference explaining why blacks and Hispanics have higher rates of HIV infections, Lennox says, is that they are so much more likely to be poor.
Among heterosexuals, those living in poverty are twice as likely to have HIV compared to those with higher incomes, according to the CDC. People living in poverty have a number of barriers to getting tested, says Jonathan Mermin, director of HIV/AIDS prevention at the CDC. Those who don't know their disease status may fail to protect themselves and others, Mermin says. Studies show that those who test positive for HIV reduce their "risk behaviors," such as needle sharing or unprotected sex, by 60%.
"Poverty is a marker for 20 things that are keeping people from getting treatment," Lennox says.
Among those barriers: homelessness; unemployment; lack of insurance; lack of transportation; drug addiction; mental illness; incarceration; domestic violence; other chronic diseases, such as diabetes; lack of paid time off or child care to allow clinic visits; and the continuing social stigma of AIDS, which makes patients fear alerting others to their sexual orientation or disease status.
Undiagnosed, untreated people are far more likely to spread the infection, so the virus circulates more widely in their social circles, Lennox says. And he notes that sexually transmitted infections, which can increase a person's chances of contracting HIV, have always been more common among those living in poverty.
Testing and treating people saves both money and lives, however, Mermin says. A CDC program to expand HIV testing helped diagnose 18,000 people, saving an estimated $2 for every $1 spent, he says, partly by slowing disease spread.
The medical system also makes it tough for patients to get care, Lennox says.
About 30% of HIV patients receive care through Medicaid, the government program for the poor, children and disabled.
"Our health care system is set up at every point to put a barrier in somebody's way, to make them go through a lot of hoops to get care," Lennox says. To get free AIDS drugs, "a homeless person in Atlanta has to prove they are a resident of Fulton County, so they need a letter from a shelter. Then they have to prove they didn't file tax returns."
To prevent HIV-infected patients from deteriorating, and spreading the disease, Lennox says, "Why not say, 'Anyone with HIV, we will use federal money to get you on treatment as soon as possible. Then, if we find out you had insurance, we will take action at that point.' Instead, we make people jump through dozens of hoops, unless they are emergently sick," Lennox says. "So any logical person will say, 'I will stay out of care.' A normal healthy person who is a college graduate has trouble navigating this system, and we are requiring that people do this who have mental illness?"
The Affordable Care Act, which aimed to provide health insurance to an additional 30 million Americans, could help get many HIV-positive patients into care, Adimora says. Some governors across the country, however, have pledged not to expand Medicaid.
Adimora says she hopes these lawmakers change their minds. There is now a consensus among AIDS researchers, she says, that "treatment as prevention" is the strongest new weapon that doctors have in stopping the spread of the virus in the USA.
"Proper implementation of the Affordable Care Act would actually be a huge boon not only for HIV care, but for HIV prevention, because it would allow us to implement some of this extraordinary scientific research," Adimora says. "How we deal with this problem in the next few years is going to help determine the fate of the AIDS epidemic in this country."
Possible to be 'perfect'?
In communities with high infection rates, people can be at risk even without being promiscuous, simply because the virus is found at such high rates within their social network, says Justin Goforth, a registered nurse at Whitman Walker Health in Washington. In these communities, staying HIV-free requires "perfection," Goforth says, or at least 100% condom use.
"Is it really humanly possible?" Goforth asks. "Is it possible to believe someone is going to be perfect?"
Goforth says he contracted HIV 20 years ago while battling serious depression.
"If you really don't give a flip about whether you see tomorrow, why would you take your pills?" Goforth asks.
Young gay men - who don't remember when AIDS was a universal death sentence - are the only group in which the rate of new infections is increasing, largely due to an "alarming" growth in the disease among gay black youths. The HIV infection rate climbed 48% among young gay black men from 2003 to 2009, according to the CDC.
Phill Wilson, founder of the Black AIDS Institute, blames some of that increase on the failure of sex education, which he says has focused too much on abstinence. Wilson says young gay men, who are often rejected by their families, "don't believe their lives are worth protecting."
To help fight that stigma and encourage people to get tested, the CDC this week launched a new campaign, called Let's Stop HIV Together. Ads feature people living with the virus, including singer Jamar Rogers from the TV show The Voice.
Many young people are unaware or in denial of the dangers of unprotected sex, which HIV patient Kevin Swinton compares to "Russian roulette." Other young people are fatalistic, he says. Convinced that they'll eventually contract HIV anyway, they decide to have fun while they can, says Swinton, 36, of Silver Spring, Md. "I knew the risk was out there," Swinton says. "D.C. is small enough that eventually, everybody sleeps with everybody."
By age 25, one in four black gay men has HIV, according to a new report from the Black AIDS Institute, due out Wednesday. About 60% of black gay men have HIV by the age of 40.
Swinton tested positive for HIV in February, at an HIV event sponsored by his church. He had been unemployed and uninsured for more than a year. He delayed getting care for four months.
"When people find out they have the disease, they're in shock, they think, 'I'm going to die,'" says Swinton, who also has type 1 diabetes. "They think, 'If I get treatment, then I'm facing the truth that I have the disease. I'd rather just live my life and see what happens.'"
Swinton agreed to see a doctor only because of Goforth's daily phone calls. Goforth acted like a buddy, accompanying Swinton to his first doctor's visit.
"You can't just leave somebody with devastating news like that all on their own," says Swinton, now working again and insured. "They don't have anything to fight with."
With Goforth at his side, both as a friend and a translator of medical jargon, Swinton says, he felt less alone and confused.
Whitman Walker is participating in a clinical trial, along with other clinics in Washington and New York, to test an unusual way to get patients to attend checkups and take their prescriptions. Patients actually get paid, says Raymond Martins, chief medical officer at Whitman Walker. Patients can receive a Visa gift card for attending their first medical appointment, plus additional gift cards for later visits, but only if they get their disease under control. Researchers will measure whether the strategy increases the number of patients whose disease is under control.
"People say, 'Why would you pay someone to take their medicine?'" Lennox says. "Because they have a transmissible disease. And if they don't take their medicine, they are more likely to transmit it."
In many places, people who learn they have HIV never return to the clinic for follow-up care, Goforth says. Even at Whitman Walker, one of the country's pioneering AIDS clinics, about half of newly diagnosed patients simply disappeared.
To address that problem, Goforth created a "red carpet" program for the newly diagnosed, getting them a doctor's appointment within 24 hours of diagnosis, often on the same day. Now, 90% of patients return for follow-up care.
"This is what my team does," Goforth says. "We have an entire department of 12 people to do this, and it's astounding. It literally takes a village."
By Liz Szabo