Download Article PDF/SlidesThe 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 | Top of page |
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).
| Expanding Prevention | Top of page |
“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.”
| Conclusion | Top of page |
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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