On August 3, the Centers for Disease Control and Prevention (CDC) announced that the rate of HIV incidence in the United States in 2006 was 40 percent higher than previously estimated. A new methodology allowed the CDC to more accurately reflect when people became infected. The numbers showed other critical insights, namely: African Americans are becoming infected at a disproportionately high rate; infection rates are spiking again among men who have sex with men (MSM); and young people, women and the Latino community are at heightened risk for contracting HIV.

Regan Hofmann: To start, will you explain the revised rate of HIV incidence?

Dr. Fenton:
The new data [reflect the CDC’s use of] breakthrough technology to get the clearest picture of the spread of HIV in the United States today. It confirms that we have a level of new HIV infection that was somewhat higher than we had previously known. The figures suggest that approximately 56,300 new HIV infections occurred in 2006. That’s 40 percent higher than previously estimated. The thing to remember is that this new estimate does not represent an increase in incidence. Since the late ‘90s the level of new HIV infections each year has been relatively stable at about 55,000–56,000.

The numbers were proportionately higher over a series of years, so there is no “spike” in infection rates, but rather a steady rate of infection that was higher overall.
That’s right. Since 1999 we have seen a relative stabilization in new HIV infections occurring each year in the United States. But, the overall incidence really hides what’s happening in various subgroups. There are different trends for different groups. The data suggest that HIV incidence in gay men has actually been increasing yearly since the early 1990s. It’s the only group where we’re seeing consistent and sustained increases. Other groups showed very different patterns. Among African Americans we know that the incidence peaked in the 1980s, it came down in the early 1990s, there was a second peak in the mid- to late 1990s, and since the late 1990s it’s been relatively stable. A similar pattern was true for Hispanics. This does not mean that the total number of African Americans and Hispanics who are living with HIV is not increasing. Every year more African Americans are being added to the pool, but incidence seems to be relatively stable in most groups apart from men who have sex with men.

Do you know how many of those MSM are black?
Not in these analyses. This first cut is giving us a broad picture of some of the main demographic groups. For example, of the 56,300 new infections, we know that approximately 73 percent of those were men and 27 percent were women. We know that about 53 percent of those were MSM and approximately 45 percent were African American.

Do you plan further investigations to get a handle on the nuances of infection rates?
Absolutely. For the first time we’re able to dig deeper to look at various subgroups or subcategories. One of our top priorities is to look at men who have sex with men by race to really begin to understand what’s going on among black, Hispanic and Latino gay men. [We want to know] what’s happening with the different trends among women and HIV. The new data were a wake-up call because we saw that nearly a third of the new HIV in-fections are occurring in young people aged less than 30 years. Most of those infections are occurring in people ages 20 to 29 and very few [infections are in people younger than] 16. But we need to be looking at what to do with a new generation of young people to prevent them from getting infected.

Will these new numbers inform how we can do better prevention going forward? We’re seeing 50,000-plus new infections every year of a disease that is arguably preventable. What should we do differently?

The reality is that we know that prevention works. The key thing we have to ask is: Why are we holding steady in this epidemic and not driving infections rates down further and faster? Is it that we’re not doing the right things or that we’re doing the right things but we’re not doing them at a level to have an impact on the epidemic?

We know there is tremendous unmet need in the United States. Twenty-five percent of Americans who are HIV positive still don’t know their HIV status. So we need to look at how we leverage resources—from the federal government, from the private sector, from communities and from states—to really focus on prevention as we move forward.

There has been discussion about whether prevention needs to relate more closely to people’s behavioral choices. Do we need a better understanding of what drives people to put themselves at risk for HIV?
At the CDC, we are focusing on highly active prevention. Using multiple modalities for our prevention efforts. Not just using condoms, for example, but combining behavior interventions with educational interventions with interventions that tackle some of the social determinants of HIV transmission, whether they be poverty, homelessness, stigma or discrimination. We need to be thinking about better packaging, better targeting and scaling up our prevention efforts.

Can the HIV-positive community help with prevention?
Absolutely. I believe they can help in a number of ways. One is ensuring that everybody’s having authentic conversations about HIV. [We all need] to be talking about HIV to ensure that lack of awareness is not a driving factor for this epidemic. People who are positive also have a role to play in ensuring that people are practicing safer sex regularly and consistently.

Also talking about their HIV status with their partners and having conversations about how HIV is transmitted and what partners and friends can do to reduce risk.

We’ve heard a lot from the CDC on the issue of widespread, routine testing. Can you provide some assurance that if people come forward to get tested for HIV that we might as a country be able to help keep them alive?
I want to reassure everybody that not knowing one’s HIV status is not an option if you are truly committed to ending this epidemic. So even if it means we’re going to be testing more people and we’re going to be identifying new infections, sometimes that is the pressure that the system needs to react.

So you’re saying we should build the need by testing lots of people and the system will respond accordingly?

Exactly. We’ve seen examples of this in the past two years. When there have been [AIDS Drug Assistant Program] waiting lists, there’s been a cry from the community and funds have been identified to take care of those waiting lists. I’m not saying this is an ideal way for moving forward, but it does say the system [is flexible enough to] enable us, when identifying new HIV-positive people, to link them to effective care and treatment services.

Does the U.S. president’s personal involvement in the epidemic play a role in terms of what you do?

One of the things we’ve seen across the world is the importance of leadership on this epidemic. Whether it’s in Botswana [which allowed them to change their HIV testing practices and raise awareness of HIV] or in Thailand [where] we’ve seen these amazing public campaigns on HIV. High-level government leadership is crucial in the fight against HIV/AIDS.

Do you feel it’s important to offer treatment and prevention simultaneously?
I will always say this: We cannot treat our way out of this epidemic. The cost will be staggering, [both in terms of] the lives lost and the quality of life lost. Currently we spend about 4 percent of our national HIV budget on prevention. I think we’ll have a national conversation [about whether] we are investing the right amount in prevention and how we might use those resources most effectively moving forward. It’s really important that we have a balanced portfolio in which prevention, research and treatment are all valued as part of a comprehensive approach to ending this epidemic.

Check out the full video interview online at poz.com.