Re-Centering Science in the Fight Against AIDS

Despite many significant biomedical advances, we now enter the fourth decade of AIDS with a largely unabated crisis still on our hands.
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June 5th marks the 30th anniversary of AIDS. In June 1981, the Centers for Disease Control and Prevention published the first accounts of rare illnesses reported in young gay men in New York and Los Angeles in its Morbidity and Mortality Weekly Report. Within a few years, the disease that we first came to know as GRID (gay related immune deficiency or "the gay plague") and now know as AIDS permeated all segments of our population, and many parts of the world.

Since 1981, medical science has helped us understand the mechanisms of this infectious disease and how to treat it. We have also developed a large body of social science to inform HIV prevention. However, our knowledge about prevention largely has been ignored. New medical treatments have saved or improved millions of lives. But we could save many more if we developed scientifically-directed prevention policies as well.

Much has changed in the last 30 years, due primarily to biomedical advances to treat AIDS. In the mid 1990s, after quarter million deaths in the United States, the maintenance of HIV disease was achieved through the development of effective antiretroviral therapies. These treatments, while certainly not a cure, have led to a rapid decline in AIDS-related mortality and have transformed HIV disease into a manageable, chronic condition. In 1981, a 20 year-old diagnosed with AIDS could expect to die from AIDS-related complications by age 22; today a newly diagnosed 20-year-old who adheres to treatment can expect to live well into his 50's and likely longer.

More recently, biomedical innovations have also advanced our prevention efforts. In 2009 an HIV vaccine trial in Thailand found that a combination of two vaccines lowered the rate of HIV infection by 31% in heterosexuals. Last year a scientific trial showed that HIV-negative gay men, taking a daily dose HIV medication tenofovir, were 44% less likely to acquire HIV. We've also seen advances in vaginal microbicides, with a South African trial reporting 39% fewer HIV infections among women using tenofovir gel.

But despite these significant biomedical advances, we enter the fourth decade of AIDS with a largely unabated crisis.

About 1.2 million Americans live with HIV/AIDS. Every year, 56,000 more Americans are newly infected. Roughly 50% of new infections are among gay men, and half are among African Americans, whereas by most estimates gay men represent only 2 % of the population, and African Americans constitute 13%.

Globally, 2.7 million people were newly infected in 2008, but for every two HIV-positive people who access treatment globally, another five are newly infected. Most of the 33 million people living with HIV around the world do not have access to treatment.

However, 2011 is also a time of great hope. This is because, after decades of HIV policies informed by fear and ideology, in recent years our national leaders have replaced these policies with ones informed by science. Bans denying HIV-positive people entry to the U.S. and on the use of federal funds for syringe exchange, have been repealed. Abstinence-only-until-marriage education--which numerous government studies found ineffective--has largely been defunded.

Under President Obama we have witnessed a renewed focus on HIV here at home. Last July, President Obama launched a first-ever national HIV/AIDS strategy to reduce new infections, improve treatment outcomes, and reduce disparities affecting black and gay Americans.

Scientific knowledge in the biomedical sphere has empowered us to make great strides in our war on AIDS. But the power of science has not fully been harnessed to reshape HIV prevention. Despite clear evidence that marginalization along lines of economic status, race, sexual orientation, and gender heighten vulnerability to HIV, prevention over the last 30 years has failed to address these systemic issues.

Condom availability and syringe exchange have been shown to reduce HIV risk. So too, interventions targeting the discrimination faced by gay men and African Americans will likely have similar beneficial effects. In fact, the CDC recently stated that our efforts to curtail HIV disparities should not focus solely on changing individual behavior, and must address the social determinants, which exacerbate the epidemic.

Science shows us the way. Research indicates that gay youth who are accepted by their parents are 3.5 times less likely to have unprotected sex than their peers who are not accepted, and that homophobia and victimization within families and in society contribute to heightened vulnerability. Structural interventions within families and communities to combat anti-gay discrimination and enhance the acceptance of gay people would help prevent HIV in this population.

Research also indicates that HIV-related stigma and fear of discrimination deter people from testing and seeking medical care, and that untested HIV-positive individuals compromise their own well-being and the overall public health. We must enact public education programs that destigmatize HIV testing and embed it into the fabric of people's lives. One model program can be found in our nation's capital, where anyone applying for or renewing a driver's license is offered an HIV test.

Social policies shaping HIV prevention largely have ignored the findings of social science. If we are to make advances in the prevention of HIV, our efforts must be directed by science in a manner similar to how biomedical advances have informed HIV health polices. At this pivotal moment and in the hands of an enlightened executive branch, it is critical that science direct the course of HIV prevention, and polices be developed to enact change within our social structures.

Sean Cahill, PhD is Managing Director of Public Policy, Research and Community Health at Gay Men's Health Crisis (GMHC) and a published author. Perry N. Halkitis is Professor of Applied Psychology and Public Health at the Steinhardt School, New York University.

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