Why is HIV prevention needed in America?

With an estimated 56,000 new HIV infections in America every year¹, prevention strategies are imperative to the fight against AIDS in America. Some of the most common prevention approaches used in America include the promotion of condoms, the prevention of mother-to-child transmission, HIV testing, and to a lesser extent harm reduction among drug users. Integral to all of these programmes is education, which also features strongly as a prevention method.

However, America’s HIV prevention strategies have not always been successful, and many believe that not enough money is being spent on reducing the spread of HIV. In 2006, just 5 percent of the domestic HIV/AIDS budget was spent on prevention, and this included prevention research.² The 2008 federal AIDS prevention budget was $3.5m lower than the 2007 figure.³

America’s HIV Prevention Strategic Plan

The US Centers for Disease Control and Prevention (CDC) is the main agency coordinating prevention activities in America. However, America does not have a comprehensive plan on AIDS, and prevention efforts, which may be carried out by a wide range of groups and people (such as doctors, counsellors, CDC staff or community organisations), can seem ad-hoc and unlinked.

In October 2007, the CDC published their ‘HIV Prevention Strategic Plan: Extended Through 2010’ - a temporary update of the CDC’s last major strategic plan, which ran from 2001 until 2005. The current plan maintains the CDC’s focus on reducing the number of new infections, increasing knowledge of HIV status and promoting linkages to care, treatment, and prevention services. The four major goals of the plan to be achieved by 2010 are:⁴

• Decrease by at least 10 percent the number of persons in America at high risk of acquiring or transmitting HIV infection.
• Increase the proportion of HIV-infected people in America who know they are infected.
• Increase the proportion of newly diagnosed HIV-infected people in America who are linked to appropriate prevention, care and treatment services.
• Strengthen the capacity nationwide to monitor the epidemic, develop and implement effective HIV prevention interventions and evaluate prevention programmes.

The plan also increases the emphasis on prevention work with African Americans and men who have sex with men (MSM, among whom diagnoses have risen considerably in recent years). It is likely that to achieve the CDC’s goals there will need to be an improved coordination of prevention efforts, and a large increase in funding.

The aim of the plan is to guide the agency’s efforts up until 2010. A more comprehensive prevention strategy to take the country through to 2020 is currently in preparation.

Condom use in America

Condom use in America has increased significantly in recent years. Between 1982 and 2002, the percentage of women who had ever used the male condom with a partner rose from 52 percent to 90 percent.⁵ Similar increases have been seen among young people.^{6 7} Much of this increase can be attributed to the fear caused by AIDS in the 1980s, when Americans were told of the importance of using condoms during sexual intercourse to avoid HIV. Sex education among young people is also thought to have contributed.⁸

Condoms have played a particularly important role in preventing HIV transmission among men who have sex with men. Research looking at nine separate studies of condom promotion work among gay American men found that these interventions collectively resulted in a 26 percent reduction in the incidence of unprotected anal intercourse.⁹ Despite these findings, some studies have found that condom use is becoming less common among gay men (particularly young gay men) than it once was.¹⁰

Although condoms are available through a number of sources in America - including drug stores, supermarkets, family planning clinics and sexual health centres - certain barriers can make it more difficult to obtain them. For example, some stores lock the condoms in glass cabinets to prevent theft.¹¹ Having to call over an assistant to access the condoms may make customers feel embarrassed and reluctant to buy them.

It can also be difficult for people to access reliable information about condoms. Some have been taught untruths in school – for example that HIV is small enough to ‘pass through’ the pores in latex – in an effort to get them to abstain from sex altogether.

Harm reduction in America

HIV transmission among injecting drug users (IDUs) is a serious problem in America because of the risks posed by sharing injecting equipment. Although a high proportion of AIDS cases in America are still attributable to drug use, the rate of new HIV infections among this high-risk group has declined in the past few years. In 2003, an estimated 5,541 IDUs in the 33 states with confidential name-based reporting were diagnosed with HIV/AIDS. In 2006, this figure was estimated at 4,728.¹²

A number of reports have attributed a decline in HIV transmission to the establishment of harm-reduction prevention programmes for drug users.¹³ Syringe (or ‘needle’) exchange programmes (enabling users to exchange their used needles for clean ones) have proved effective in stopping onward transmission of HIV in some areas.^{14 15}

However, needle exchange programmes have been very controversial in America. Because such programmes focus on reducing harm to the user rather than trying to stop illegal drug use altogether, many conservative politicians have strong objections, claiming that such schemes condone and encourage drug dependency.

A ban on states receiving federal funding for needle exchanges was lifted in 2009. However, the 21-year ban undoubtedly led to countless HIV infections. In the past, many organisations had to overcome the ban by securing funding from local or state governments (where legal), or by running covert operations and relying on public donations. With the lifting of the ban, promised by President Barack Obama during his campaign but eventually pushed through by Congress, injecting drug users may have a better chance of protecting themselves from becoming infected.

Preventing mother-to-child transmission of HIV in America

The prevention of mother-to-child transmission (PMTCT) is one area where America’s prevention strategies have worked. Taking antiretroviral drugs and avoiding breastfeeding can reduce the chance of a mother passing HIV to her baby to less than 2 percent. The CDC reported that the number of AIDS cases in children (under 13 years of age) declined dramatically between 1992 (approximately 896 cases) and 2006 (approximately 38 cases).¹⁶

Since 1995, the CDC has recommended an ‘opt out’ approach to HIV testing of pregnant women. This means that an HIV test is offered to a woman as a standard prenatal test, but she has a right to refuse it if she wishes.¹⁷ In some states a baby may also be tested soon after birth if its mother has refused an HIV test or her HIV status is unknown for some other reason. Questions have been raised over this practice, with many arguing that it violates a mother’s right to refuse an HIV test (as her own HIV status is revealed as well as her child’s). However, others have argued that the potential benefits for the baby outweigh the harm to the mother.

PMTCT is comparatively easy to implement as a prevention strategy, as most pregnant women in America access healthcare services at some point during their pregnancy, and almost all have a strong desire to protect their unborn children. This strongly encourages uptake of testing and acceptance of PMTCT drugs and other interventions.

Although America’s success in PMTCT is to be commended, it has not led to a significant decline in all-cause infection rates, as cases of mother-to-child transmission represent only a very small proportion of annual HIV infections.

AIDS education in America

AIDS education is a vital part of HIV prevention. Without knowledge of what HIV is, how it is transmitted, and how transmission can be prevented, people do not know how to protect themselves and others from the virus. Education is also crucial for correcting misconceptions and myths about HIV and for reducing stigma.

Ongoing discrimination against HIV positive people, and a high number of annual infections, suggest that AIDS education in America is failing in its main aims. A 2006 survey for example found that 10 percent of Americans thought that there were drugs that could cure HIV infection, and 29 percent thought that HIV could be transmitted through kissing.¹⁸ A major survey of public awareness about HIV/AIDS showed the percentage of people who had seen, heard or read a lot about HIV/AIDS had declined from 34 percent in 2004 to 14 percent in 2009.¹⁹

In American schools that teach about HIV and AIDS (not all schools do), AIDS education usually forms part of the general sex education programme. Sex education in schools tends to fall into one of three categories – abstinence-only, abstinence-plus or comprehensive. Exactly what is taught within each category can vary considerably, and many have reported that even in schools with comprehensive education, a lot of important information can be missed out or glossed over.²⁰

“The closest thing I got to HIV education [was a] little segment in health class on what they called at the time STDs, that’s about it. We didn’t focus on HIV and AIDS in school, which to me is sad”.Carl, HIV positive teenager, Maryland.²¹

Since the Reagan era, the ideological message of sexual abstinence until marriage has played a key role in sex education across America, particularly during the presidency of George W. Bush. In 1996, Congress made federal funding available for a five-year period to teach abstinence-only education in schools. Federal funding for any other type of sex education was not (and still is not) made available. By 2007, over $1.5 billion had been spent on abstinence-only programmes and the amount allotted to these programmes is increasing each year. The federal government spent approximately $176 million on abstinence-only education programmes in 2007 alone, nearly twenty times the amount spent in 1997.²²

In 2008, the government proposed yet another increase in funding for abstinence-only education,²³ despite results from a number of studies (including one ten-year study funded by the government),²⁴ showing its ineffectiveness. As a result of the evidence, fourteen states have rejected the federal funding for abstinence-only programmes.²⁵

In theory, information learned about AIDS should stay with a person for life. However, adults who may have missed out on AIDS and sex education classes at school, or who have forgotten what they learned, may need further education. Some federal money is spent on providing abstinence-only education to young unmarried adults in their twenties, but as over 90 percent of the American population have had sex by the age of 29, the value of such work is highly questionable.²⁶

More productive education may be provided through intensive CDC-funded prevention programmes that target those at risk of HIV infection (such as sex workers, gay men or drug users)²⁷. Such ‘comprehensive risk counselling’ aims to help people understand the risks of HIV through a series of intensive counselling sessions, and ultimately change their behaviour.

The lack of HIV/AIDS education and risk of HIV infection among older people is also a concern. Around 15 percent of all new reported HIV diagnoses occur amongst people over the age of 50,²⁸ and it is estimated that by 2015 half of the 1 million Americans living with HIV will be older than 50.²⁹ In Florida, there is a higher than average number of HIV infections among older people, as it is the most popular retirement destination in the US. The Senior HIV Intervention Program (SHIP) has been set up to train older people in providing HIV/AIDS information to their peers.³⁰ Educators visit retirement homes and assisted living centres, in order to highlight the risk of HIV infection among older people.

In April 2009, the CDC announced a five-year national communication campaign, Act Against AIDS. The aim of the campaign is to target complacency about HIV/AIDS in America and to raise awareness of the crisis. The budget of $45 million for a five year period will be used to create public service announcements and online communications, as well as messages for specific risk groups such as African-Americans.³¹

"Act Against AIDS seeks to put the HIV crisis back on the national radar screen... Our goal is to remind Americans that HIV/AIDS continues to pose a serious threat in the United States and encourage them to get the facts they need to take action for themselves and their communities". - Melody Barnes, Assistant to the President and Director of the White House Domestic Policy Council³²

HIV testing as a preventative measure in America

America is currently trying to encourage as many people as possible to be tested for HIV, in order to reduce the number of infected people who do not know their status.  Testing allows those who receive positive results to be educated about how to avoid infecting others, thus reducing onward transmission of HIV. For people who test negative, particularly those at high risk of acquiring HIV, information can be given to help reduce their chance of becoming infected in the future.

A survey carried out by the Kaiser Family Foundation in 2006 found that just over half (55%) of all adults aged 18-64 in the US had been tested for HIV at least once in their lifetimes. Of these, 21% reported being tested in the previous 12 months.³³ This compares favourably to figures from a decade earlier - in 1997, just 43% of Americans aged 18-64 said they had been tested. Much of the increase in testing uptake can be attributed to improved levels of routine antenatal testing, but a certain degree is probably due to a greater focus on testing in the country as a whole. Nevertheless, it is thought that approximately 25% of Americans living with HIV are still unaware of their infections.

With the aim of reducing the high numbers of Americans who do not know their HIV status, the CDC published a new set of guidelines in 2006. The guidelines recommend that anyone aged 13-64 who attends a healthcare setting should receive automatic, routine testing. The policy is intended to overcome existing barriers to HIV testing by removing the need for written consent and lengthy pre-test prevention councelling. Instead, patients are notified that the test will take place but are given the opportunity to opt out if they do not wish to take it. ³⁴

It is feared that in busy clinics and hospitals, patients may not be properly informed that they are being tested for HIV, or that they have the right to refuse the test.³⁵ In addition, no new federal funding has been provided to implement the scheme, meaning that few healthcare centres are actually providing universal testing.³⁶ A study measuring the impact of the new guidelines showed a significant increase in the number of people being tested for HIV. However, the increases observed varied drastically between the different healthcare centres participating in the study; confirming the need for additional funding.³⁷

Critics have warned that a concentration on HIV testing programmes might detract from other initiatives, especially community-based health education and risk reduction programmes aimed at those who do not yet have HIV. Results from a study also show that the most cost-effective strategies to prevent HIV transmission include community mobilisation efforts targeting men who have sex with men, syringe exchange programmes, mass media campaigns and free condom distribution.³⁸

America is relatively unique in making routine testing their primary prevention strategy and so time will be the only indicator of its success.

Men who have sex with men

In 2005, men who have sex with men (MSM) made up around 71 percent of all HIV infections among male adults and adolescents.³⁹ Prevention programmes among this group are therefore imperative in America’s HIV prevention strategy.

Across America, many of the prevention programmes for MSM take place within gay communities. One particularly successful project – the Mpowerment Project – promotes safer sex through a number of social, outreach and small group activities.⁴⁰ Through personal empowerment, peer influence and community organising, the project has reduced the incidence of high risk sex in four communities of four states.

Testing for HIV is also encouraged among MSM in America, as a significant proportion of MSM with HIV do not know that they are infected, posing a greater risk of onward transmission. It has therefore been recommended that MSM be tested for HIV at least once a year.⁴¹

Between 2001 and 2006 the number of HIV/AIDS diagnoses amongst MSM rose significantly.⁴² Although this increase has been partially explained by a rise in the number of HIV tests, evidence also suggests that there has been an increase in unprotected sex amongst MSM.⁴³

“Some research suggests that the perceptions of the negative aspects of HIV infection have been minimized since the introduction of HAART, which has led to a false understanding of what living with HIV means and thus to an increase in risky sexual behaviours”.⁴⁴

As a result of the increase in diagnoses, in 2008 the CDC proposed that prevention efforts for MSM be stepped up.

African Americans

African Americans represent almost half of all HIV/AIDS cases in America. Although prevention efforts among this group have increased, in 2007 the CDC highlighted the need for a heightened national response in order to reduce the toll of HIV/AIDS on African Americans.⁴⁵

The reasons for the disproportionate effect of the HIV epidemic among African Americans is complex and as a result, prevention efforts need to take into consideration underlying factors such as poverty, lack of housing and incarceration.⁴⁶

The CDC funds a number of projects that specifically address the epidemic in African Americans. For example, rapid testing programmes have been implemented in traditionally black universities and colleges.⁴⁷ Churches – the focal point of many African American communities – are also at the centre of many prevention programmes. In 2006 President Bush pledged to work more “closely with African American churches and faith-based groups, to deliver rapid HIV tests to millions, end the stigma of AIDS, and come closer to the day when there are no new infections in America.”⁴⁸

Avert.org has more information about prevention efforts among African Americans.

Conclusion

Some have argued that the relatively stable 56,000 new HIV infections each year is evidence that prevention efforts are working. As stable as the incidence may be however, 56,000 annual infections cannot be considered a success. Prevention efforts among pregnant women may have been successful, but the annual infection rates amongst African Americans and the gay community are still extremely high.⁴⁹ Although prevention work is being conducted with these high-risk groups, the programmes do not reach everyone in need and the success rates are often unclear.

General prevention in the form of school-based education is often woefully inadequate. The issues surrounding abstinence-only education may receive the most media attention, but the fact that many students are also receiving inadequate ‘comprehensive’ education, or no education at all is an equally serious problem. As for prevention for adults, only time will tell if the current focus on testing and prevention among HIV positive people will pay off.

America now needs to invest far more in HIV prevention, and it needs to develop a comprehensive strategic plan on AIDS that makes prevention a priority. If it does not, the AIDS epidemic will continue to expand and thousands more will become infected with HIV in America each year.

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