Washington’s New AIDS Battle

The nation's capital is facing a "modern epidemic." That's how Washington, D.C., health officials are referring to the growth in the area's HIV/AIDS population. According to a study released Monday by the city's HIV/AIDS Administration and George Washington University, the city has a higher percentage of residents living with AIDS or HIV (the virus that causes AIDS) than any other city in the country. While the national HIV/AIDS rate is 14 cases per 100,000 people, there are 128.4 per 100,000 Washingtonians. In a city of roughly 500,000 people, that means that 1 in 50 residents with AIDS or HIV. And the epidemic is growing rapidly—the number of people living with AIDS in Washington jumped by 43 percent between 2001 and the end of 2006. Researchers also reported that African-Americans are bearing the brunt of the crisis—57 percent of the city's population is African-American, but black residents make up 86 percent of those with AIDS.

Washington's HIV/AIDS Administration has been criticized for not tracking the data about infections properly prior to this report—which was the first of its kind. But reporting hasn't been the only problem. The district has had at least one unique obstacle in its fight against the disease—it is the only city in the nation subject to a federal ban on financing needle-exchange programs with local tax dollars. This is a significant setback, given that intravenous drug use is the second most common means of spreading HIV/AIDS (after sexual contact).

So how will D.C. turn things around? NEWSWEEK's Sarah Elkins spoke to Dr. Shannon Hader, who has been the HIV/AIDS Administration's director since October, about her plans to combat the epidemic. Excerpts:

NEWSWEEK: Why Washington? What is it about nation's capital that makes it lead the country in HIV/AIDS population?
Shannon Hader:
The data that we are sharing here is sort of a snapshot of what is going on, and not really the why of what is going on. What we are trying to focus on is how to use this data to find solutions, a lot of times when we ask "why" it is because we think there is an easy answer, but there isn't. The reasons that drove the [AIDS] epidemic 10 years ago are clearly not the same as they are today. Today there are multiple risk groups, and it is not isolated to a certain race, a certain person, a certain face, certain behaviors--so we need to look at that.

But when you look at the data in Washington, the infected population is overwhelmingly African-American. How do we explain that?
There is no one who is excluded from this disease. There are some racial disparities—we know that there are other racial disparities when it comes to health in D.C.—so this is consistent with other health disparities. 

The United Nations recently came under fire for overestimating its HIV/AIDS numbers worldwide, and D.C. has also been criticized in the past for not keeping accurate data. Why is it so difficult to get this information?
There are two aspects to talk about here. One, if we compare the information that just came out, interestingly enough, the U.N.'s is very different from what we use. The U.N. has relied on sentinel surveillance, which is periodically testing all the pregnant women who come in, and using that information to project the number of people in the population with AIDS. [The U.N.'s] mathematics had overestimated those numbers, and they didn't know that until they started going door to door. What we do here in D.C. and in the States is somewhat different: our surveillance data is case-report data, so these are individuals who have been diagnosed with HIV/AIDS. If anything, we have underestimated because we are only counting the people who have been diagnosed. If we were to go door to door, we would probably find that more people have HIV/AIDS.

So you're saying that if you were to go door to door in D.C., you'd find that the number of Washingtonians with HIV/AIDS would be higher than previously projected?
Absolutely. But it's impossible to know without a household survey. CDC [Centers for Disease Control] estimates that one out four people don't know their HIV status, so back of the envelope, you could say that 25 percent more people have HIV/AIDS [than we've recorded]. But it's probably much lower than that.

One of the things we're doing with our data is moving forward to get people routinely tested for HIV and, ideally, we will hopefully see the number of reports of HIV cases go up, because that means we will have found more people with HIV/AIDS [and can treat them]. We are hoping for success on multiple fronts—first, we want fewer people to get infected with HIV. Second, people who are already infected with HIV, we want them to survive. We want that number to stay stable, because a decrease in the overall number of people with HIV/AIDS means people are dying.

What plans does the HIV/AIDS administration have for taking care of those who are already infected?
We are building on a lot of programs that we already have and we are looking to move to the next scale. We want further implementation of routine testing, meaning whether or not you ask for an HIV test, you will just be offered it as routinely as any other test. You get your BMI for obesity, you get your blood pressure tested for hypertension, your routine cholesterol test, you [should] get your HIV test, as well. You shouldn't have to ask for that.

Don't you think some Washingtonians might view a routine HIV testadministered in annual doctor's checkupsas controversial?
Why should it be controversial? We're not talking about mandatory HIV testing. Our biggest problem is not that people are refusing to be tested but that they aren't being offered the option. And in fact, when you talk to HIV patients, they are surprised to know that their doctors haven't tested them. They will be in the hospital and be told that they have HIV and they say, "How can that be? I tested negative last year." And we say, "Are you sure you got tested?" It turns out that they assumed they had been tested when in reality they hadn't. There are certain [health] providers that are nervous about treating HIV and there are certain misperceptions about whether [testing is] legal--and, yes, it's legal. 

Intravenous drug use is the second leading cause of HIV/AIDS transmission, and yet because of federal laws governing the District of Columbia, it is the only city in the nation unable to fund needle-swapping programs with local tax money. Is that going to change?
We're hoping with the new approvals and the congressional bill that has been drafted—[District of Columbia House Delegate] Eleanor Holmes Norton and [Mayor] Adrian Fenty have worked hard to have the ban lifted, which would allow us to move forward. … And we are moving forward, even with the ban in place, and are developing a comprehensive substance-abuse program. … There are a lot of other services you need to battle substance abuse: risk-reduction counseling and teaching active users how to be safer … partner support work and encouraging active [drug] users to look to [private] needle-exchange programs can reduce or mitigate risk while injecting. [These programs] also provide ongoing contact with users so that you can provide the services that they need, like providing condoms, encouraging them to follow up with their doctors and discussing reasons for keeping up with their doctors.

Washington recently stepped up its condom distribution program. How has this plan been received?
[This is] the first year of the free condom distribution program. We've given out about 900,000 in the last year. Our target is [to distribute] 3 million condoms annually by 2009. We'd like to reach out to some of the private-sector partners and make sure condoms aren't kept under lock and key. At the drugstore, a lot of condoms are kept under lock and key, and here we want those condoms flying off the shelves—fast.

The Washington, D.C. HIV/AIDS report can be found here.

The Center for the Study of the Presidency has compiled the candidates' HIV/AIDS proposals in the following PDFs:
Democrats: Biden, Dodd, Clinton, Edwards
Democrats: Gravel, Kucinich, Obama, Richardson
Republicans: Paul, Romney, Tancredo, Thompson