January #55 : A Modest Proposal - by Sandra Rattley-Lewis

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Work 2000

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A Modest Proposal

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January 2000

A Modest Proposal

by Sandra Rattley-Lewis

A year and a half after promising CPR for the AIDS emergency in the black community, the feds finally deliver—a Band-Aid. SANDRA RATTLEY-LEWIS reports.

The Centers for Disease Control and Prevention (CDC) held its first-ever national HIV prevention conference in August, a full 18 years after the first case of AIDS was diagnosed. Helene Gayle, MD, the head of the CDC’s National Center for HIV, STD and TB Prevention, said her agency put out this call to leading researchers and policy analysts to focus on HIV prevention because the nation has become complacent about AIDS.

CDC Director Jeffrey P. Koplan, MD, promised that HIV in African-American communities would be a special focus of the conference, where the CDC widely distributed its slick new brochure, “On the Front Lines: Fighting HIV/AIDS in African-American Communities.” But the only “breaking news” at the conference was that protease-inhibitor optimism may be resulting in increased sexual risk-taking among gay men. By the end of the four-day confab at Atlanta’s Hyatt Regency, no sound prevention strategy had emerged—especially regarding what some still refer to as the “changing face of AIDS.”

When POZ spoke with Gayle after the conference, she did have a sort of plan to announce: The CDC’s prevention goals for the year 2000 are, she said, the elimination of syphilis and pediatric AIDS. It seems that the CDC—the collector of all U.S. AIDS statistics and author of annual surveillance reports that confirm growing racial disparities in the epidemic—has not read its own data.

The CDC’s 1998 year-end report reminds us that African Americans and Latinos have long overtaken white gay men as the population with the highest incidence of HIV. Black and Latino men and women comprise at least 66 percent of all new infections, even though together they make up only 23 percent of the population. African Americans are seven times more likely to die of AIDS than other Americans, making the disease the leading cause of death for blacks 25 to 44 years old. In particular, while AIDS deaths have fallen dramatically overall since 1996, they have fallen only marginally among African Americans and Latinos. Black men may still be at highest risk, but heterosexual African-American women now get HIV faster than any other Americans. What many in the African-American community still call a “gay man’s disease” is hitting sisters hard, with transmission doubling every year or so. African-American youth are also disproportionately affected—63 percent of all youth diagnosed with AIDS are African American.

Perhaps, as Cornelius Baker, executive director of the National Association of People With AIDS (NAPWA), suggests, the CDC’s 2000 goals “make perfect sense” as responses to the African-American crisis. Baker says that “elimination of syphilis should be a moral imperative of our government,” not only because the STD disproportionately affects African Americans, but because of the legacy of the government’s secret medical research on African-American men with syphilis at Tuskegee, Alabama. Baker speculates that eliminating syphilis could even promote HIV prevention, by helping to undo African Americans’ inherent distrust of public health policies and services. Syphilis also drastically increases HIV transmission risks, more than any other STD. And who can argue against the value of eliminating pediatric AIDS?

But the reality is that the incidence of perinatal HIV has dropped over 70 percent in the last five years, down from its peak of 907 cases in 1992 to 297 cases in 1997, thanks to nearly universal administration of a course of AZT to HIV positive pregnant women. And syphilis is now at the lowest level ever recorded, down 19 percent in 1998 alone. Given these trends, the CDC’s new agenda is modest, to say the least.

“That’s true and not true,” Gayle says. She calls syphilis, “one of the most glaring examples of racial inequity in health care in the country,” and argues that since the tools are available, the elimination of syphilis and pediatric AIDS is “a realistic goal.” “Victory should not be declared too soon,” she argues, or services will be dismantled.

While Baker says delicately that syphilis and perinatal AIDS “should not be the only things on [the CDC’s] radar screen,” many advocates find it harder to be charitable toward the CDC these days, given what they allege is gross mishandling of prevention resources. When a group of fed-up African-American AIDS advocates walked out of a CDC meeting in Atlanta in March 1998, they enlisted political support from the Congressional Black Caucus to push President Clinton to declare AIDS a state of emergency in the black community—and to invest major federal dollars in prevention. The state-of-emergency proposal hit a brick wall, but in October 1998, African-American AIDS activists heralded a major victory when Clinton announced a $156 million budget commitment to, in his words, “end the growing disparities in HIV and AIDS.” Those millions were slated to be disbursed in the 1999 federal fiscal year, which ended September 30. But the deadline came and went, and community organizations were still waiting for grants. Denise Paone, who researches HIV prevention strategies for IV-drug users at New York City’s Beth Israel Hospital, called it unconscionable that “the $156 million just sat there” for 12 months while African Americans were getting sick and dying.

On October 5 the CDC at last announced awards totaling $39 million for HIV prevention. Seventy-six community organizations will receive more than $20 million for services to underserved African Americans at risk; of the remaining money, $7 million will go to prevention programs in prisons and another $7 million to organizations that serve gay men of color. At press time, the Department of Health and Human Services was unable to provide POZ with information on the status of the rest of the money—roughly $117 million—allocated for an emergency response.

While NAPWA’s Baker predicts that the CDC grants will strengthen organizations and raise awareness in communities of color, he says these allocations hardly signify a real commitment to the goal of zero growth in new infections and deaths. In the meantime, many who do HIV prevention in communities of color—and who have long operated with little federal support—say that they will continue to focus on their own priorities, which are not topped by either syphilis or pediatric AIDS.

When POZ spoke with more than 20 HIV prevention staffers and researchers with their ears to the ground in communities of color, they had had no trouble setting some new CDC priorities for 2000.

SEX EDUCATION

Since the highest infection rates are still occurring among African-American men who are gay, bisexual or IV-drug users, destigmatized education about sex and risk behaviors should be mandatory in every high school in the United States. A few cities are proving this possible. For example, Chicago, where STDs are running rampant among youth—18- to 24-year-olds accounted for more than half of gonorrhea cases and three-quarters of chlamydia cases in 1998—will implement a citywide high school curriculum promoting risk-reduction behavior in 2000. But few other cities or states are following suit—meaning a push from the feds couldn’t hurt.

NEEDLE EXCHANGE

Maybe it’s true, as Beth Israel’s Denise Paone cynically observes, that “it’s easier to change the behavior of drug users than our policy makers.” But that’s partially because the CDC has not stepped up to the plate to take on conservative politicians who block federal funding for needle exchange. The CDC’s own stats show that IV drug use accounts—directly or indirectly—for 31 percent of HIV transmission, and multiple studies have shown that needle exchange stops the spread of HIV without leading to increased drug use.

WOMEN'S PREVENTION

There’s no shortage of ideas for women-friendly HIV education and condom distribution. The Washing-ton, DC, Administration for HIV/ AIDS distributes condoms in black-and-gold compacts with a mirror and instructions in beauty parlors, where, according to the program’s director, Ronald Lewis, African-American women spend a lot of time discussing relationships and sex. The CDC should shore up funding for such creative efforts.

Yet Loretta Sweet Jemmott, director of Urban Health Ser-vices at the Univer-sity of Pennsylvania School of Nursing, asks, “Why are we only talking to women about how to negotiate condom use?” She says that the single mothers and other women of color living in public housing who participate in her risk-reduction programs fear that their male partners will “hit them or quit them” if they make condoms an issue. In focus groups conducted in New York City by Syracuse University researchers, most HIV positive women, when asked what should be done to prevent HIV transmission, responded, “Where are the men?” They said that men typically control the politics of heterosexual intimacy—and most resist condom use.

Rebecca Denison, founder of Women Organized to Respond to Life-Threatening Diseases (WORLD) in Oakland, California, says that there is little effective prevention out there for women and even less for heterosexual men. None of the providers POZ talked to has prevention programs in place targeting adult bisexual or heterosexual men, despite the fact that male-to-female sex is the primary way women contract HIV.

One solution is for the CDC to promote accelerated research into the many women-controlled HIV microbicidal gels and creams still in early stages of development. The other is for the CDC to test the effectiveness of programs directed at men or couples—one place resources could really make a difference.

AIDS advocates say it is partly the feds’ responsibility to get the entire nation—not only communities most at risk—to become interested in prevention. Baker argues that the secretary of health and human services, the president and other government leaders must all show up to prevent the escalation of AIDS in people of color communities. AIDS researcher Ednita Wright, formerly of Syracuse University, challenges every church, school and business to consistently hammer home the prevention message. Wright warns that without that level of commitment, at least among African Americans, “AIDS is the only thing since slavery that could decimate us if we’re silent.” But there are some steps only a federal agency such as the CDC can take.

There will be little progress in AIDS eradication in the African-American community without federal planning to ensure that health care and services are in place to overcome longstanding racial disparities. At press time, the Congressional Black Caucus was again pushing for more prevention resources—$349 million for fiscal year 2000. That figure may wind up being much less when Congress has its way, but advocates hope that, whatever the amount, the CDC and other federal agencies that administer the money act quickly this time—to truly respond in an emergency fashion.




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