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Risk

Sexual Healing (continued)

By Jim Duffy

HIV infections in the U.S. peaked in the mid-1980s at about 160,000 cases per year and eventually dropped to about 40,000 per year after 1990. So, too, in Baltimore, where an estimated 16,000 people are living with HIV and new cases arise at the rate of about 1,000 per year.

"Some people might look at this and say it's a public health success, because the rate is lower than it was," says David Holtgrave, PhD, chair of Health, Behavior and Society. "But we don't seem to be making progress in getting infections to drop below the new level, so other people might look at this and see a failure."

Actually, it's both. Holtgrave estimates that there would have been between 200,000 and 1.5 million additional cases of HIV nationally between 1985 and 2000 in the absence of public health prevention efforts. But further reductions in the infection rate may well require additional resources to expand proven strategies and develop new techniques. Baltimore especially needs help: A recent federal study found that metropolitan Baltimore has the second-highest rate of new AIDS cases in the nation. (Miami is first.)

But here, too, resources are getting harder to come by. In a recent paper, Holtgrave examined funding patterns in HIV prevention efforts and found that CDC spending has dropped by 19 percent in real dollars since 2002.

"So that means one in five of the prevention dollars we had just a few years ago is gone," he says.

The timing couldn't be worse. There has been a recent upswing in HIV/AIDS cases nationally among men who have sex with men.

"Twenty years ago, people in many communities were going to a funeral a week," Holtgrave says. "This new generation, they haven't seen that to the same extent."

To reach this younger audience of gay men, Holtgrave favors an array of classic public health strategies—outreach, surveillance, testing, counseling, behavioral interventions and treatment—combined with general public education.

But none of these strategies will bear fruit if resources continue to dwindle. A few years back, Holtgrave compared CDC spending on HIV prevention with incidence rates for the infection.

"What we found was that in the early 1980s, the epidemic was driving spending," he says. "But after 1986, once there were substantial resources in the system, it was the other way around. You could predict incidence a few years out pretty much just by looking at resource levels."

He pulls out a graph of HIV incidence rates and prevention spending patterns over the decades and points to the recent downward tick in resources. "It's too early to know for sure if this is going to turn out to represent the start of a jump in infection rates," he says, "but sadly, I wouldn't be at all surprised if that's what it turned out to be."

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