Zero percent. That is how much progress the U.S. has made in meeting its HIV prevention goal.
"We have not made tremendous progress," David Holtgrave, PhD, tells WebMD. "HIV is still a major issue in the U.S., but it is not getting the attention it deserves.
A former CDC scientist, Holtgrave is now professor of behavioral science and health education at Rollins School of Public Health and director of behavioral and social science at Emory University's Center for AIDS Research in Atlanta.
The numbers are a bit deceptive, Holtgrave is quick to point out. They don't mean current AIDS prevention programs aren't working. There's strong evidence that they're keeping the U.S. HIV epidemic from getting worse than it is. But there's clearly a lot more work to be done.
AIDS Fear Down, HIV Fatigue Up
There's no cure for AIDS. There's no vaccine to prevent HIV infection. Unfortunately, many Americans don't know this, and many more may not care.
"There is some HIV fatigue. People have been hearing about the story since the early to middle 80s," Holtgrave says. "We are beginning the third decade of AIDS. And there is some misperception that there is already a cure for HIV. I think that some people may believe there is a vaccine already. They believe the consequences of HIV are not as substantial as they once were."
Truth be told, for most Americans the consequences of getting HIV infection really aren't what they used to be. And even if they were, there's just no way we could maintain the level of alarm we felt 20 years ago, says David Huebner, PhD, at the Center for AIDS Prevention Studies, University of California in San Francisco.
"You just can't live in that state of fear -- the state of mind that, for many gay men, came from going to several funerals a week," Huebner tells WebMD. "That psychological energy is not sustainable. Even without treatments, people would have developed fatigue around prevention efforts."
And fear-based prevention messages are counterproductive.
"There is a lot of research showing serious psychological consequences from living daily with the fear of getting a deadly disease," Huebner says. "I don't know that the safety engendered by that terror was healthy. Thankfully, HIV is now a different disease. As prevention people, we have to start thinking about it differently. We can't expect gay men to act the same way they did before."
Why haven't HIV prevention programs worked better in the U.S.? One reason is that there have been missed opportunities.
These opportunities still exist. But as might be expected in a disease spread by sex and drug use, they are highly controversial.
One of these opportunities is the idea of allowing injection drug users to exchange dirty, possibly HIV-contaminated needles and syringes for new ones -- no questions asked.
"We found that in the U.S., that one thing alone -- needle and syringe exchange -- could probably prevent more than 12,000 of the 40,000 new HIV infections each year," Holtgrave says. "That is a good example of having a tool you know is quite useful and leaving it on the shelf rather than using it."
Huebner, too, expresses frustration over this issue.
"Needle and syringe exchange is an empirically proven effective intervention," he says. "We know it works -- and in the U.S., it is illegal to do with federal funds."
Another issue is teaching effective condom use.
"Everywhere but California, it is illegal to teach condoms in public schools," Huebner says. "That is ridiculous. How do we expect people to protect themselves if they do not get the information they need?"
More Effective HIV Prevention
Condoms, Huebner is quick to point out, certainly are effective in preventing HIV transmission. But they can never be the total solution to safe sex.
"Condoms change sex dramatically," Huebner notes. "If we tell people they have to do something that makes sex less pleasurable forever, that is a hard message to get across. Condoms are not a viable solution over the human lifespan."
Abstinence -- refraining from sex until marriage -- is another highly effective means of preventing HIV. But abstinence, like condom use, is not a lifelong solution. And at least one part of the U.S. population has little to gain by waiting until marriage.
"We live in a society where gay men cannot enjoy the benefits of marriage," Huebner says. "At my sister's wedding last week, 250 people came to support them. And that does not occur for gay men. This kind of social support is a very powerful incentive for heterosexuals to be faithful and to stay together. Without that incentive, it is harder for gay men. They don't get that kind of support."
Needle exchange, effective sex education, and gay marriage make for a pretty controversial prevention agenda.
"The next frontier in AIDS prevention is to make changes to society that support people to be healthy and make healthy choices," Huebner says. "Currently, that is difficult."
Holtgrave, too, calls for changes in our approach to HIV prevention. He takes a pragmatic approach. Current HIV prevention programs succeed by targeting prevention messages to specific populations. It's effective, Holtgrave says -- but a different targeting strategy could work even better.
"For years we have been custom-tailoring prevention messages on the basis of sexual orientation, socio-demographic status, substance abuse history, race and ethnicity, and geography," he says. "We want to include in that list a person's HIV status. Whether they are aware of status, whether they are negative at low or high risk, or whether they are positive determines the messages to which they respond. For each of those four populations, a different set of services may be necessary."
AIDS fatigue may be setting in. But that's only one more obstacle to overcome.
"It is as important as it ever was for people to learn how to protect themselves, how to protect their families, and how to protect their partners against HIV," Holtgrave says. "Even though people are getting tired of that message, they need to hear it."
Published July 9, 2004.