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Statement for the Record on HIV Prevention by Helene Gayle, M.D., M.P.H.
Director, National Center for HIV, STD and TB Prevention
Centers for Disease Control and Prevention
U.S. Department of Health and Human Services

Field Hearing
San Francisco, CA
February 14, 2000

Good Morning. Thank you for the opportunity to provide testimony on the current HIV/AIDS epidemic and CDC's current efforts to prevent the further spread of HIV in this country.

The HIV/AIDS epidemic has changed considerably since it was first described in the United States in 1981. After a decade and a half of steady increase, we witnessed our first decrease in AIDS incidence and AIDS deaths in 1996. AIDS- related deaths decreased 42% from 1996 to 1997 and 20% from 1997 to 1998. AIDS incidence decreased 18% from 1996 to 1997 and 11% from 1997 to 1998. These data supports the effectiveness of the new highly active antiretroviral therapy (HAART) that was introduced around the time of these initial declines. The relative greater decline in AIDS deaths compared with AIDS cases has resulted in a 10% increase in the number of persons living with AIDS from the end of 1997 to the end of 1998. More recently there is evidence of a slowing in the decrease in AIDS cases and deaths that may indicate growing treatment failures and lack of access to therapy for a substantial number of people. Change has also occurred in the number of new HIV infections from a high of approximately 150,000 new infections a year in the mid to late 1980s to a plateau of approximately 40,000 new infections a year today. There are an estimated 900,000 persons living with HIV and approximately 250,000 are unaware of their seropositive status.

The demographics of the HIV/AIDS epidemic have changed considerably as well. The proportion of AIDS cases in white men who have sex with men (MSM) declined, whereas the proportion in men and women of color (especially African Americans and Hispanics) has increased. Fifty percent new HIV infections occur in people under 25. Women now account for 30% of new HIV infections; 64% are African American women. African Americans and Hispanics comprise 54% and 19% of new HIV infections respectively. African American and Latino men represent 51% of reported AIDS cases among MSM.

Early prevention activities were targeted to communities initially most affected by the epidemic, primarily gay men and injection drug users (IDUs) as well as the general population that needed information about a new disease threat. As the epidemic has expanded to more diverse communities, CDC's efforts have also expanded accordingly to reach a broader target audience including communities of color (especially African Americans and Latinos), gay men of color, persons living with HIV, youth (especially young gay men), women (including pregnant women), individuals with STDs and communities with high STD prevalence, and incarcerated persons.

The success of HAART is encouraging, but the availability of new, more effective treatments may lead people to believe that HIV prevention is no longer important. HIV prevention efforts have resulted in behavior change, but studies show that high-risk behaviors (especially unprotected sex) are re-emerging. We estimate approximately five million persons are at behavioral risk for HIV infection right now. Consequently, complacency about the need for HIV prevention has now become one of our biggest barriers and challenges.

I would like to highlight three studies that show the significance of complacency in the U.S. and why CDC is so concerned. A study conducted in San Francisco between 1994 and 1997 among a multiracial/ethnic group of MSM showed decreases in consistent condom use, increases in the proportion engaging in unprotected anal sex with multiple partners and increase in the incidence of rectal gonorrhea. MSM reporting having anal sex increased from 57.6% in 1994 to 61.2% in 1997. Those reporting having anal sex and "always" using a condom declined from 69.6% in 1994 to 60.8% in 1997. Men reporting having multiple sex partners and unprotected anal intercourse increased from 23.6% in 1994 to 33.3% in 1997. The largest increase, from 22.0% to 32.1% was seen for men 25 years or less. This study also shows that men who had unprotected anal sex with men and had multiple partners did not know the HIV serostatus of all their partners.

Additionally, rectal gonorrhea incidence increased from 21 to 38 per 100,000 adult men. This increase in incidence was observed in all races and age groups.

The second study was conducted by the Seattle-King County health department from 1997 to 1999 and showed a major increase in infectious syphilis, chlamydia and gonorrhea among MSM in King County from 1997 to June 1999. For example, the annual rate of infectious syphilis per 100,000 MSM increased from zero in 1996 to approximately 10 in 1997 and 90 in 1998, and the projected annual incidence in 1999 was 200 cases per 100,000. There was also an increase in chlamydia and gonorrhea during this period among MSM attending King County ST D clinics. The majority of the men in this study reported likely exposure to STDs through anonymous partners. The high proportion of persons with STDs, is of major concern given the two to fivefold increased risk of HIV infection associated with presence of another STD. Control of STDs is a central component of HIV infection prevention efforts and the resurgence of bacterial STDs threatens national HIV infection prevention efforts.

Recently, we reported on a seven-state study conducted by CDC between July 1998 and February 1999 that found 31% of 1,976 HIV-negative or untested individuals at risk for HIV infection were "less concerned" about becoming infected because of new HIV treatments. The 31% reporting this behavior in the survey included the following by risk group: 40% were injection drug users, 30% were heterosexuals, and 25% were gay and bisexual men. 17% of the 1,976 HIV-negative or untested individuals at risk for HIV infection were "less safe" about sex or drug use because of new HIV treatments. The 17% reporting this behavior by risk group included: 25% injection drug users, 15% heterosexuals, and 13% gay and bisexual men.

At CDC, we continue to strengthen our efforts to decrease HIV transmission through comprehensive strategies including surveillance, research, prevention, policy development, and evaluation. The centerpiece of our collaboration with state and local jurisdictions is the community planning process. The community voice is essential when setting prevention priorities and assuring that funds are following the epidemiolgy and the interventions are relevant to a given community. Progress has been made over time in making the community planning process and the resultant targeting of resources representative of the communities most affected and their prevention needs. However, more progress still needs to be made. The largest single expenditure category for prevention services through community planning is for health education and risk reduction (HERR) services, approximately 39%. In 1998, for HERR, 31% of resources were targeted to African Americans, 3% to Asian American, 20% to Hispanics, 2% to Native Americans and 23% to whites . For the comparable year, 43% of AIDS cases were among African American, <1% Asian Pacific Islanders, 20% Hispanics, <1% Native Americans, and 35% whites. Nationally, the race/ethnic composition for community planning groups (CPGs) in 1998 was 27% African American , 3% Asian/Pacific Islander, 12% Hispanic, 5% Native American and 53% White. Male and female representation is equal. Youth <24 years made up only less 5% of CPG membership.

Given the importance of broad and diverse involvement in HIV prevention, CDC has expanded its alliances beyond its traditional public health partners to include, community based and other non-governmental organizations, faith-based organizations, correctional facilities, health care facilities (including managed care organizations), national minority organizations, business and labor sectors, schools and youth organizations, and substance abuse prevention and treatment programs.

We now know more than ever what works in prevention and are increasing our efforts to translate the best prevention into program implementation using a comprehensive mix of proven prevention strategies such as individual counseling, small group interventions, community-level interventions, social/prevention marketing, prevention case management, structural interventions, HIV counseling and testing and partner counseling and referral services, STD treatment, media campaigns, public information, hotlines and improved linkages to HIV and substance abuse treatment. While continuing efforts to prevent infection in people at greatest risk, we also are focusing more attention to prevention efforts for those already infected with HIV.

To do our job well we need investment in prevention and support for strong policies that reinforce sound science and public health intervention. There are many continuing challenges to face in our efforts to prevent the HIV/AIDS pandemic: HIV stigma, homophobia, unequal access to health services, policies that limit proven public health intervention, gender inequities and lack of female controlled options for prevention, and perhaps most troubling, complacency. This complacency is occurring among individuals, communities and the wider society. We must combat complacency at all levels if we hope to make the impact we all want on reducing the number of new infections in this country and throughout the world.

Thank you for your time and I look forward to working with you and other members of Congress in a bipartisan effort to improve access and treatment to HIV prevention services.