The Changing Face of an Epidemic by Patrick Georgoff

Referred to by some as a “modern” epidemic, the explosion of HIV/AIDS in Washington, D.C. highlights the ever-evolving nature of the virus.  No longer an acute disease, HIV can be treated with antiretroviral therapy.  However, a lifetime of medication has serious effects on people’s health and on how they (and others) view the disease.  The spread of HIV outside of “classic” high-risk populations has led to a resurgence of the disease among poor, heterosexual minorities in Washington D.C.  HIV positive D.C. residents of the “old guard” and researchers from the National Institutes of Health discuss what this means for a nation that seems to have all but forgotten about the ravages of HIV.


William is what you might call a dinosaur of HIV.  At 60, he has been living with the disease for nearly 25 years.  As a gay, white man diagnosed at the onset of a tumultuous and at times ugly epidemic, he has seen it all.  In one two-week period, eight of William’s friends passed away from complications related to HIV/AIDS.  A difficult past has hardened William, a longtime resident of Washington D.C., but has done little to temper his indignation for the contemporary epidemic that is ravaging our nation’s capital today.

According to the District of Columbia’s Bureau of Surveillance and Epidemiology, over 3 percent of the district’s residents had HIV in 2008.  This translates to an infection rate of almost 1 in 10 people between the ages of 40 and 49, a number similar to African nations like Uganda and Kenya.1  In one report examining heterosexual behavior, almost half of residents from parts of the city with the highest prevalence said they had overlapping sexual partners within the past year and only 3 in 10 said they had used a condom the last time they had sex.2  Not surprisingly, HIV rates have increased by 22 percent since 2007.

Adrian Fenty, the mayor of Washington D.C., has described the epidemic in the capital as “very complex and modern.”  But what makes this epidemic modern? And for that matter, why is HIV/AIDS so prevalent in our nation’s capital?

To be sure, HIV today turns previous stereotypes on their head.  It’s not homosexuals, drug users, and sex workers who dominate the epidemic and it’s not a tortuous death that defines it.  Significant advances in drug therapy have transformed HIV from an acutely devastating disease to a chronic condition where the drugs intended to treat the disease are instead raising a host of new medical issues.

“The new face of HIV is not pneumocystis and toxo and CMV,” said Dr. Henry Masur, Chief of the Critical Care Medicine Department at the National Institutes of Health.  “It’s now diabetes, hypertension, and lipid disorders.”

While an ever-evolving armentarium of antiretroviral drugs may allow healthcare providers to suppress a patient’s viral load, these drugs are not without their side effects.  In fact, survivors like William (whose last name has been excluded to protect anonymity) tend to worry more about metabolic complications related to drug toxicities than AIDS itself.

“The complexity with which these medications are used, the multiplicity of exposure, and the pace at which medications change make it hard to tease out specific toxicities,” said Dr. Colleen Hadigan, a research scientist at the National Institutes of Allergy and Infectious Disease who focuses on the metabolic complications of HIV.

“Not everyone suffers from the toxicities of antiretroviral therapy,” she explained in her Bethesda, MD office. “But as those infected begin to reach their 50’s and 60’s, you start to see things like cardiovascular disease and diabetes develop that, while not necessarily linked to medications, are nonetheless very difficult to treat in the context of continued therapy.”

This important shift – from acute to chronic – has a significant impact on the trajectory of the epidemic.  “It’s not as much as an emergency,” said Dr. Masur, “people aren’t as scared.”  By taking fear out of the equation, the perception of what it means to have HIV has changed drastically.

“To see what people lived through back in the 80’s and early 90’s and to see the horrific things people suffered through – the fear, the isolation, the pain, the condemnation – and now, to see people being infected, that just really blows my mind,” said William.  “They just don’t think of it as a big deal.  They sort of look at it like people look at gonorrhea or syphilis, it’s something that just happens and you go to the doctor and you move on,” he says.

William, whose emaciated face insinuates years of lipodystrophic drug therapy, used to lead a support group in the capital for young men with HIV/AIDS.  He recently quit the group out of frustration, however, after seeing so many members shirk the responsibilities that come with living with the virus.

“I’m very surprised at the number of people who ignore the past and who don’t seem to remember or appreciate the devastation so many people suffered through to get us here today,” he said. “I’m really shocked and angry, especially with people who know their HIV status and continue to have unprotected sex or don’t disclose their status.  They justify their behavior by saying that it’s not a big deal; you can just take a pill.  There are so many people who just don’t think it’s their responsibility.”

Stephen Bailous, the Vice President of Community Affairs at the National Association of People Living with AIDS, is aware of the grave misconception that the epidemic is no longer a major issue in D.C.  “There’s a perception in the community that because we don’t see young men in wheel chairs, we don’t see our friends wasting away, and we don’t see people who are walking around looking healthy one day, sick the next, and dead the following week, that HIV is no longer a serious problem and the problem has been resolved,” said Bailous, who is also HIV positive.

But it hasn’t been resolved.  HIV/AIDS has simply spread to a new, more vulnerable population.  In the District, most newly reported cases of HIV are transmitted through heterosexual contact, women are a growing proportion of the epidemic.  Further, while making up just over half of the population, over three quarters of D.C. residents with HIV or AIDS are African-American1.  This shift is an important part of what defines a modern epidemic.  “HIV has turned into a minority disease that is definitely affecting people who are black and brown,” said Bailous, “and it’s not just sexual orientation that’s driving this either…this is a disease of poverty.”

The virus is situated particularly well in the D.C., where a grim economic situation – D.C.’s poverty rates are among the highest in the country3 – mixes with social and political triggers to exacerbate the spread of the virus.  There is simply no other disease whose basic functionality is so closely associated with the kinds of stigmatized behavior frequently found in vulnerable populations. In Washington and elsewhere around the country, this has a very real impact.

In the late 1980’s and early 1990’s white, gay males fought hard to garner political support for the battle against HIV/AIDS.  As a unified and relatively well-educated group, they were able to make great strides in capturing the attention of prior administrations and the nation as a whole.  Today, however, the District’s long marginalized African-American population suffers from a paucity of political leverage.

“Minorities in the district are less cohesive and less well-represented,” noted Dr. Masur.  He points out that providing appropriate treatment for minorities today is “different and more difficult in many ways.”

With well-funded treatment programs available to residents, the real barriers to care in D.C. mirror the ills of poverty.  For the unemployed individual without a stable home or access to primary care, treating their HIV/AIDS can often take the backseat to more immediate concerns. As each year passes, the number of people living with HIV/AIDS in the District increases while the number of new infections annually remains the same.

This is due in large part to the number of late testers, or those who have their first positive HIV test less than one year before the development of AIDS.  This trend – 70 percent of those infected in D.C. in 2007 were late testers compared to only 39 percent nationally4 – is particularly detrimental to curbing the spread of the virus.  A lack of treatment leads to a higher viral load, which, in turn, increases infectiousness.  Without being able to acknowledge their infection, late testers can unknowingly put others at risk.

So in a modern epidemic, where the poor get walloped, blacks bear the real burden, and women continue to make up a much higher proportion of those contracting HIV each year, what’s stopping us from implementing policies to fight these trends?

“It’s political will,” argues Bailous.  “How can we ask countries around the world to have a plan to address AIDS and we cannot put one in place for ourselves?  I don’t think it’s an accident that when we talk about AIDS in this country, from our leadership, we talk about AIDS like it only happens in Africa.”

While treatment options may have improved dramatically, HIV/AIDS remains a costly drain on the financial, social, and physical wellbeing of urban centers throughout the US.  If a serious conviction to look beyond the epidemic’s outwardly benign transformation continues to elude residents in places like our nation’s capital, apathy towards HIV/AIDS will remain.

“In the end,” Bailous notes, “there is no other disease where you might lose your job or your house or be disowned by your family and friends because of your diagnosis. No other disease has that kind of stigma associated with it.   People that say HIV is just like any other chronic disease, well, they obviously don’t have it.”

 References

  1. Government of the District of Columbia Department of Health HIV/AIDS Administration.  HIV/AIDS epidemiology update 2008.  Retrieved from http://dchealth.dc.gov/doh/cwp/view,a,1371,q,598650,dohNav_GID,1839,dohNav,|33815|,.asp January 5, 2010.
  2. Government of the District of Columbia Department of Health HIV/AIDS Administration and George Washington University School of Public Health and Health Services, Department of Epidemiology and Biostatistics (GWU).  Heterosexual Relationships and HIV in Washington, D.C. Retrieved from http://dchealth.dc.gov/doh/cwp/view,a,1371,q,598650,dohNav_GID,1839,dohNav,|33815|,.asp January 5, 2010.
  3. U.S. Census Bureau.  Small Income and Poverty Estimates for the United States, 2008. Retrieved from http://www.census.gov/cgibin/saipe/national.cgi?year=2008&ascii= January 5, 2010.
  4. Government of the District of Columbia Department of Health HIV/AIDS Administration.  District of Columbia HIV/AIDS Epidemiology Annual Report 2007. Retrieved from http://dchealth.dc.gov/doh/cwp/view,a,1371,q,598650,dohNav_GID,1839,dohNav,|33815|,.asp January 5, 2010.

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