The commentary was written by Dr. Thomas Frieden and his colleagues at the New York City Department of Health and Mental Hygiene (DOHMH). When Dr. Frieden spoke at the December 2004 PRN meeting, he outlined the various challenges that exist in terms of stemming the spread of HIV in New York City. With the publication of the NEJM commentary, and a return visit to PRN this past December, Dr. Frieden presented some of the proactive—and admittedly controversial—plans being developed by the DOHMH to limit the HIV/AIDS epidemic in New York, home to one in six of all U.S. patients with AIDS.
|I. The Present
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The number of people living with AIDS in New York City has also continued to climb steadily. “Back in 1995,” Dr. Frieden noted, “we had approximately 30,000 people living with AIDS. With the advent of combination antiretroviral therapy, we’ve seen a doubling over the past ten years. The increasing number of people living with HIV and AIDS is a direct result of the decreased number of people dying of AIDS over the past ten years.”
Since 2001 in New York City, HIV diagnoses are down by one-third, AIDS diagnoses are down by one-quarter, and AIDS deaths are down 18%. What’s more, Dr. Frieden noted, HIV testing has increased 20% over the past two years. “Testing among correctional populations has increased 150%,” he added. “The introduction of rapid testing has also brought a great deal of progress. We’ve long had a problem with people who get tested and don’t return for their results. With rapid testing, this number has fallen dramatically.”
Between 2003 and 2004, the age-adjusted death rate per 1,000 people living with AIDS declined 21.8% for HIV-related causes and 16.3% for non-HIV-related causes (see Figure 1).
The work, however, is far from over. According to epidemiologic data, New York City remains the epicenter of the HIV/AIDS epidemic in the United States. It has the highest AIDS case rate in the United States; while it is home to less than 3% of the U.S. population, the city accounts for one in six of national AIDS cases. The AIDS case rate in New York City is 60 times the national target for 2010, four times the U.S. average, and higher than any other city in the U.S.
Dr. Frieden also pointed out that of the 3,700 New York City residents diagnosed with HIV in 2004, approximately 28% of them learned they were HIV-positive at the time of their AIDS diagnosis. “That’s 1,038 people who had likely been in and out of some place where we could have touched them and offered them testing much earlier in their infection,” he said, “whether it was an emergency department, correctional facility, a social service agency, or a community organization. This really is an indictment of our system. The fact that people didn’t know their status means that they didn’t have a chance to get treatment that could have prevented illness and progression to AIDS for a considerable period of time. They were also much less likely to take steps to protect their partners.”
There are glaring epidemiologic disparities to consider as well. More than 80% of new AIDS diagnoses and deaths in New York City are among African Americans and Latinos. And, as has been documented nationally, an increasing proportion of new AIDS cases are diagnosed in women, most notably women of color. Black male residents of New York City, who are nearly three times more likely to be living with HIV/AIDS than other New Yorkers, have been hit especially hard by the epidemic. Approximately one in 14 black men between the ages of 40 and 54 is living with HIV/AIDS—seven times the rate of other New Yorkers. The only groups with higher infection rates are men who self-identify as gay or bisexual (one in ten are estimated to be living with HIV/AIDS) and injection drug users (one in seven are estimated to be living with HIV/AIDS).
|II. The Future
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Even though routine, voluntary testing is widely recommended and cost-effective, it has not occurred. In New York City in 2002, only one third of adults who had had three or more sex partners in the preceding year — and only half of men who had sex with men who had had three or more partners — had been tested for HIV in the previous 18 months.
To be clear, Dr. Frieden stressed that he is opposed to testing without informed consent. “But I think the laws in New York State that require a separate written consent and explicitly detail what is supposed to be said to a patient before they are tested have outlived their usefulness. These laws were rational when they were first enacted, when there was no treatment for HIV, but this is no longer the case. This will require legislative change in Albany. However, there are some who would oppose that. I have to say that when I go out to minority communities experiencing the brunt of the epidemic, I don’t hear ‘how dare you do this.’ I hear ‘how dare you not have done this ten years ago.’”
Dr. Frieden also stressed that testing needs to be more readily available in non-clinical and community settings. “Plus,” he added, “rapid testing should be further expanded. However, testing for HIV isn’t enough. Linking patients to services and to treatment is also necessary.” A basic comparison of conventional and rapid tests to detect HIV antibodies is provided in Table 2.
Linkage to primary care for those who test positive is a key goal of the DOHMH. This year, the DOHMH will be issuing $4 million in new funding to a variety of HIV testing programs. “We will be requiring that for every person who tests positive, the program is accountable for reporting to us whether that person began receiving HIV primary care within 30 days. That will be the basis for assessing success and continued funding, and we will verify the data that is reported.”
|Early HIV Diagnosis is Crucial
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“Early diagnosis can also help reduce risk of HIV transmission,” Dr. Frieden said. “This reduces spread of infection for two reasons. First, someone who is HIV positive and knows their status will, on average, reduce risky behavior by about half. Granted, we can all point to examples of individuals who do not reduce their risky behavior after learning they’re positive, but if we’re thinking about trying to stop an epidemic on a community basis, a 50% reduction overall is actually a good result.
“We also know from studies that suppression of viral load below 1,500 copies/mL is associated with a drastic reduction in the likelihood of at least heterosexual transmission,” he said, referring to the pivotal prevention study conducted by Dr. Thomas Quinn and his colleagues in Uganda’s rural Rakai district (Quinn, 2000). “Reducing viral load is an important factor to consider.”
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“We’re now distributing a million condoms a month through our website,” Dr. Frieden proudly pointed out. “This program is on our homepage. Any New York City organization can order condoms from us. The right price for a condom, even in this society, is free, at least for those at risk. We would like to see them widely available and, of course, used.”
Syringe exchange programs (SEPs) are another vital program. Most intravenous drug users (IDUs) in the United States continue to use nonsterile needles. According to DOHMH estimates, there are approximately 150,000 active IDUs in New York City. Approximately a third of them are believed to have shared needles within the past six months. SEPs have been documented to decrease disease transmission and to save lives, with no evidence of increases in crime or drug use.
SEPs have been operating in New York City for more than a decade, and the NYC DOHMH is working to expand these programs into neighborhoods with demonstrated need for them. “I really salute the work that Allan Clear and the Harm Reduction Coalition” [see: “Clinical Approaches to Substance Use and Abuse in Primary Care: Treatment and Harm Reduction”], Dr. Frieden said. “SEPs are very effective. The number of New Yorkers who are diagnosed with AIDS from injection drug use has fallen from nearly 6,000 ten years ago to less than 800 last year. It’s a real success story, although of course more remains to be done. It reflects more testing, greater access to SEPs, and real progress in reducing injection drug use-associated HIV.”
Prevention With Positives (PWP) is a relatively new program that mandates specific prevention efforts focusing on those who are already infected. “Every new infection starts with someone who is already infected,” he said. “It is potentially more effective to target 100,000 HIV-positive New Yorkers than 8 million who are uninfected. If all HIV-positive individuals knew their status and participated in PWP, further spread could be stopped.”
HIV Stops with Me is a social marketing campaign funded by the CDC that aims to reduce the stigma associated with HIV and to acknowledge the role that people who are positive have in ending the epidemic. “I think this campaign has the potential to be very effective. I would hope that all clinicians who work with people living with HIV will reassess and readdress risk and risk behaviors with their patients on a regular basis. It is well documented, for a broad variety of problems—whether it’s tobacco use, drug use, alcohol use, or unsafe sex—that brief, personalized, and motivational counseling by the physician drastically improves the likelihood of success, and it doesn’t need to take more than three minutes on a regular basis. Clinicians have a lot of power in this regard.”
|Systematic Treatment and Case Management
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Although HIV infection remains incurable, AIDS is now a chronic disease for those fortunate enough to receive effective treatment. “One of the most startling facts about our city is that, if you’re HIV-positive and you live in Chelsea, you have twice the likelihood of surviving as if you’re HIV-positive and you live in the South Bronx, central Harlem, or central Brooklyn,” Dr. Frieden noted. “This is a direct result of our not ensuring that all patients get the quality care that can be provided and is needed.
“I come to this from the perspective of being an infectious disease physician. There are differences between HIV and TB,” he continued, “but when it comes to tuberculosis, the Health Department monitors treatment, it monitors drug resistance, it monitors whether patients are responding to treatment. If they’re not, the Health Department intervenes with doctors and with patients to try to provide additional services, to ensure that patients are optimally treated.”
Dr. Frieden stressed that he doesn’t think that mandatory testing or mandatory treatment have a role in HIV. “But I do think there are other aspects of a more traditional public health response that could make a huge difference in helping people get better care. We’re currently prevented from doing this by New York State law.”
DOHMH monitoring of patients’ CD4+ cell counts and viral loads is one such planned initiative. “While I recognize that treatment-experienced patients and others may quite rationally decide with their doctors to not try to completely suppress viral load, viral load—on a population basis—has the potential for monitoring how we’re doing with treatment. It will allow us to monitor or identify patients who are not receiving effective care, to monitor trends in drug resistance, potentially to identify clusters of disease, to provide clinicians and patients not receiving care with more intensive services, and to identify indicators of transmission interruption so we know what’s working.”
Beyond monitoring of treatment, the DOHMH is also interested in successfully linking HIV-positive patients to effective counseling and case management. As is reviewed in the NEJM article, the use of effective treatment that incorporates risk-reduction counseling, including distribution of condoms, promotion of the use of condoms and clean needles, and treatment for substance abuse and mental health conditions, would improve individual outcomes and reduce disease transmission. However, this remains uncommon.
As for case management, it is prominent in the HIV service delivery system, yet few if any jurisdictions attempt to ensure that every patient is offered effective treatment and prevention services. Public health interventions to monitor and improve HIV case management can be effective, but are rare.
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With this accountability comes a commitment to provide a full range of high-quality services to all who need them, including high-quality case management; participation in treatment, housing, social services, and substance abuse programs; and no reduction in support for services, but a commitment to use resources more intelligently.
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The DOHMH is aware that its expanded public health initiatives may provoke controversy. “Some religious and political groups oppose effective prevention measures,” Dr. Frieden said. “There are also some advocacy groups that are opposed to expansion of testing. We also have some in the healthcare community that oppose increased monitoring of treatment efficacy. But the world—and the HIV epidemic—has changed over the past 25 years, and I think that our approaches to HIV/AIDS must also change. If we fully apply public health principles, we can improve the health of people living with HIV/AIDS and prevent thousands of New Yorkers from becoming infected with HIV in the next decade.”
A detailed report of the New York City Commission on HIV/AIDS, published in October 2005, specifically outlines recommendations to make New York City a national and global model for HIV/AIDS prevention, treatment, and care. The complete report can be accessed at: http://www.nyc.gov/html/doh/downloads/pdf/ah/ah-nychivreport.pdf.
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