Challenging Dogma

...Using social sciences to improve the practice of public health

Friday, April 27, 2007

40,000 & Steady: An Economic And Cultural Critique Of HIV/AIDS Prevention In The United States – Jesse Moran Welsh

Unlike many diseases that capture headlines around the world, HIV/AIDS is entirely preventable. When the epidemic made headlines in the early 1980s, the United States responded within the social and political limits of the times – and great strides were made. Over the years we have seen scientific developments and changes to the very social fabric of our nation as a result of the disease. Still, young Americans have never known a world without the AIDS virus. We have been unable to implement adequate prevention programs and now face a resurgence of the epidemic in the black community. Despite increasing global attention to the HIV/AIDS epidemic, the enormous progress once seen in the United States has been replaced by consistent, and disproportionate, infection rates as a result of inadequate funding and meaningful public health initiatives. Our society and technologies may have progress in the past twenty-five years, but our response to the HIV/AIDS has not.
Consistent infection rates over the past 15 years are a direct result of under funding. In his 2001 article, Donald Francis, M.D. recounts the early years of the epidemic and the United States’ response. He describes how the Centers for Disease Control picked up the first signs of the epidemic relatively quickly and began appropriate investigatory and educational activities [1]. The results from the Holtgrave and Kates study also show that the CDC’s HIV prevention budget increased most sharply in the early years of the epidemic [2]. Yet what both articles go on to conclude is a failing on the part of the United States and its public health agencies to sustain adequate prevention and funding. Holtgrave and Kates found that from the mid-1980’s onward…budget anticipates incidence rather than vice versa [2]. Ultimately, as the CDC’s budget began to level off in the early 1990’s so too did the rate of infection. And while there are certainly other factors that can be attributed to these statistics – the development of new medications and the scale of the epidemic in third world countries to name a few – they do not excuse our complacency. When applying meaningful resources, the United States had the ability to reduce the number of new infections by 75% in five years - from 161,000 in 1985 to 40,000 in 1990 [2]. Yet because of a variety of intersecting political and social realities of the time, Francis points out, the CDC was unable to take the next essential step—the delivery of prevention programs equal to the risk posed by HIV [1]. The key phrase being: prevention programs. Immediate action by the United States and the CDC in the early years of the epidemic saw immediate results. From then on, the steady budget has been unable to sufficiently meet the needs of the population. As with so many other diseases that plague our nation, the fact that we value disease treatment far higher than disease prevention set up a vicious cycle: if society doesn’t value prevention, why should politicians spend political capital to support it?[1] The United States has fallen into this pattern of treating what for many has become a chronic illness. Unless we resume our early efforts to attack the spread of infection, we cannot escape the consequences.
Following, and in many ways resulting from, a lack of adequate funding for prevention of HIV/AIDS, specific communities have been hard hit by the epidemic in recent years. For the black community, this disproportionate and increasing rate of infection is largely due to a lack of meaningful public health initiatives that address the specific needs of this cultural group. In 1995 the black community had the greatest number of new infections (18,510), almost 7,000 more than any other group. They also have the highest number of cumulative AIDS cases (399,637) by over 10,000 [3]. This reflects the increasing overrepresentation in recent years of both new HIV cases and prevalence of AIDS cases. In their article on eliminating health disparities in HIV/AIDS, Fitzpatrick et al. stress that because of these increasing imbalances, developing strategies to enhance prevention in the black community is crucial. They suggest the importance of minority investigators as a step toward closing the gap, specifically in their ability to conduct meaningful research and prevention programs and cite Harlan Dalton, professor of law at Yale Law School, who declared that “public health officials cannot enter inner cities with expertise in one hand and goodwill in the other and expect to slay the disease dragon. They must first discern who this public is and how it sees itself in relation to them [4].” Fitzpatrick and colleagues have identified the deep need for understanding that must come before any progress can be made. As with funding, many policies and prevention programs were designed in the early years of the epidemic when politics and fear were large motivators. Going into southern, black communities without newly investigating why they are facing a resurgence of the disease in the first place will only be a waste of efforts. For example, public health officials must understand the knowledge gaps in these highly affected communities about how HIV is spread [5]. Research has already shown that African Americans delay starting anti-HIV treatments by an average of eight months and are less likely to remain on the medication [5]. Another study on collective consciousness pinned much of the failure to act on the shoulders of churches within the black community citing unwillingness on behalf of clergy to separate health and morality [6]. These facts alone exemplify the need to understand and address the specific customs and knowledge of the black community as a first step toward designing meaningful public health initiatives.
Though it failed to reach its original deadline for halving HIV incidence, the United States and the CDC has the ability to obtain its goal. The means is twofold: In order to once again see a decrease in infection rates, the United States must increase funding and attention to programs that will build the “social capital” of our most highly affected communities. Identifying social capital as the cohesion in a society, Holtgrave suggests that improving the foundations of these affected communities will directly increase our ability to reduce the number of new HIV infections [7]. Sociologist would agree. Robert Sampson uses the term “collective efficacy” to describe a communities willingness to act on behalf of the common good [6]. And though both terms suggest a community that recognizes problems and has the ability make unified efforts at improvement, we have yet to fully employ either. Realizing that infection rates dominate specific communities, efforts should be made to stabilize and invigorate those communities to act. This cannot be done without increasing funding and applying that money toward meaningful programs. With the development of effective medical treatments, we have already made enormous strides improving the quality of life for those infected. Many in the healthcare field have also rallied behind the CDC’s 2006 recommendation of HIV testing as part of routine medical care. With one quarter – 250,000 – of all persons with HIV/AIDS are not aware they are infected, this seems to be a great way to increase personal knowledge and awareness of one’s own status. Still, medical treatment and widespread testing are both one step away from the prevention programs that are desperately needed in high-risk areas. Funding must be provided to not only maintain current programs, but to adequately support community-based prevention programs. Our ability to combat the epidemic is a social action that requires the corresponding efforts of many people [6]. Without fostering these programs and building social capital, we will fail to curb the consistent and disproportionate infection rates in the United States.
As of now, we continue to apply band-aids to the epidemic. We have funded research, treatments, and programs in such a way that public health officials have been unable to adapt to the changing face of HIV/AIDS in the Untied States. But this is not to say real prevention is impossible. There must be a reinvestment at every level. Funding has already been shown to have a direct relationship to the number of infections, and we are beginning to recognize the deep impact of community-based interventions. For real progress to once again be made, financial reinvestment in the social capital of HIV/AIDS impacted communities must take precedence.
Francis DP. Have We Learned Anything After 20 Years of AIDS? Call for a National Health Board. Public Health Reports 2001; 116:390-395.
Holtgrave DR, Kates J. HIV Incidence and CDC’s HIV Prevention Budget. American Journal of Preventative Medicine 2007; 32(1):63-67.
Centers for Disease Control. Basic Statistics and Surveillance for HIV/AIDS. Atlanta, GA: CDC.
Fitzpatrick LK, Sutton M, Greenberg AE. Toward Eliminating Health Disparities in HIV/AIDS: The Importance of the Minority Investigator in Addressing Scientific Gaps in Black and Latino Communities. Journal of the National Medical Association 2006; 98(12):1906-1911.
Garnet C. HIV and AIDS Still Gaining Strength Among Minorities, Women. The NIH Word on Health. Bethesda, MD. November 2002.
Wallace RM, Fullilove MT et al. Collective consciousness and its pathologies: Understanding the failure of AIDS control and treatment in the United States. Theoretical Biology and Medical Modeling 2007; 4(10).
Johns Hopkins School of Public Health. Q & A with David Holtgrave. Baltimore, MD: Johns Hopkins School of Public Health News Center.

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