AIDS Action Committee’s Blog

A year later, a response deferred: CDC’s “heightened national response” to HIV/AIDS in African-American community is chaotic, underfunded, and far from its goals.

As CDC quietly releases figures revealing an 80% boost in HIV in Black gay youth, advocates are calling for a national AIDS strategy, adequate funding, and political leadership. Launched with much fanfare in March 2007, the Centers for Disease Control & Prevention’s (CDC) A Heightened National Response to the HIV/AIDS Crisis Among African-Americans called for “expanding the reach of prevention services; increasing opportunities for diagnosing and treating HIV; developing new, effective prevention interventions, and; mobilizing broader community action.”

One year later, the Heightened National Response (HNR) effort has been marked by shifting leadership, lack of communication to local leaders and community organizations, and no new funding for any initiatives that are not restricted to HIV testing. It is now widely believed that Madeline Sutton, MD, MPH, CDC Acting Director of Partnerships in the Department of HIV/AIDS Prevention, the latest in a series of individuals responsible for HNR, will once again restructure the initiative in an attempt to address its significant shortfalls.

Read more at LifeLube. 

In my work in AIDS Action’s Health Library, I’m often asked this question.
Last week, a group of Swiss HIV experts issued a statement basically saying: “No, condom use isn’t necessary – provided that certain other conditions are met.” [Emphasis mine]

Before going into more detail, I think it’s important to note that some other expert groups have disagreed with the Swiss group’s conclusions. The U.S. Centers for Disease Control and Prevention (CDC) issued a brief statement, saying that the CDC “underscores its recommendation that people living with HIV who are sexually active use condoms consistently and correctly with all sex partners.” Likewise, UNAIDS and the World Health Organization stated that, to prevent transmission of HIV, they “strongly recommend a comprehensive package of HIV prevention approaches, including correct and consistent use of condoms.”

So, what exactly did the Swiss experts say? And why is it controversial?

In brief: Based on their review of several medical studies, the Swiss group concluded that an HIV-infected person who is on HIV treatment and has a consistently undetectable viral load “is not sexually infectious, that is, cannot transmit HIV through sexual contact.”

However, according to their statement, the following conditions must also be met:

The Swiss group also acknowledges that “medical and biologic data available today do not permit proof that HIV infection during effective antiretroviral therapy is impossible,” but they believe that the risk is “negligibly small.”

Critics of the Swiss statement have emphasized that research on HIV transmission and viral load has focused on heterosexual couples and vaginal intercourse – and does not necessarily apply to anal intercourse.

A number of people have also pointed out that, even if the Swiss experts are right, their conclusions about unprotected sex would apply to only a small number of HIV-infected persons: people who have excellent adherence to their HIV regimen, a consistently undetectable viral load, and no other STIs.

Practically speaking, the “no STIs” restriction could probably be met only within a monogamous relationship in which both partners were tested for STIs before stopping condom use. STI testing would be essential, because many people with STIs have no symptoms.

The bottom line for me:
Several studies have shown that reducing a person’s HIV viral load tends to reduce their risk of transmitting the virus. This is very heartening, but it does not mean that people with undetectable viral loads have no risk of transmitting the virus.

(Read on …)

With its latest guidelines for HIV testing which do away with pre-test counseling the CDC has moved further away from successful prevention strategies.

Pre-test counseling has always been an opportunity to educate people about HIV risks.  The availability of this information in the course of routine health care has been especially important for certain populations not likely to tap into established HIV/AIDS networks, especially young people of either sexual orientation and closeted gay men. Counseling has also been critical for people who test negative as it might be their only chance to get this information.  The CDC, however, has decided that counseling is a barrier to testing.

It’s unclear when health education became a barrier to health care but it probably started around the same time that the federal government started discouraging frank discussions about sex, particularly gay sex, and drug use.

Sadly, like so much else in the federal government these days, public policy is driven by ideology, not fact (for example, the 2003 controversy over National Park Service’s  sale of A Different View, a creationist book arguing that the Grand Canyon was formed by approximately 5000 years ago by Noah’s flood, as opposed to 5 or 6 million years ago as agreed to by scientists).

Instead of encouraging proven prevention interventions like frank messages targeted to discrete populations, the CDC argues for an unproven strategy of test ‘em,  medicate ‘em and track ‘em.  Although this might be comforting to authoritarian federal bureaucrats, it leaves many of the rest of us deeply troubled.