Prevention Effort on HIV Transfers Focus to Carriers

Half a dozen HIV-positive people meet weekly for group therapy in a Long Beach conference room decorated with an American flag at one end and an “HIV Stops With Me” banner on the other.

At a recent gathering, Quincy Edmonds, a muscular 33-year-old diagnosed with HIV nine years ago, ticked off some of the things he thinks can lead people like him to risky behavior that could spread the virus: depression, loneliness, drug abuse.

“Thank you. Thank you for sharing that,” a counselor said cheerily. “We need to learn to talk about these things.”

Such discussions represent a new tactic in HIV prevention that is set for substantially expanded use in California and the rest of the country in the next several months.

Since the HIV epidemic began two decades ago, health officials have focused most of their prevention efforts on a single, difficult goal: keeping such high-risk groups as gay men and intravenous drug users from being infected. But now that strategy is being revamped in favor of a new approach: training those with the disease not to spread it.

Last year, California’s Office of AIDS took the surprising step of redirecting as much as 25% of the state’s annual prevention budget toward campaigns aimed at “prevention for positives” programs.

In April, the federal Centers for Disease Control and Prevention, which controls almost $800 million in annual domestic prevention funds, announced it would begin heavily favoring programs aimed at preventing HIV-positive people from spreading the virus.

Programs expected to benefit under the new state and federal mandates include: one-on-one counseling with HIV-positive patients and their sex partners; routine testing both inside and outside medical settings (aided by the recently approved rapid HIV test); therapy directed toward mental health, drug abuse and self-esteem, such as Edmonds’ group meetings; and stronger efforts to reduce mother-to-child transmissions.

“I know it sounds trite to say, but the reality is that every newly diagnosed HIV case is the result of someone who is positive that’s spreading the disease,” said Drew Johnson, chief of HIV education and prevention for California’s Office of AIDS. “We need those with the disease to help us stop or at least slow its spread.”

However, though the CDC won’t make funding decisions until later this year, many activists expect a significant loss of funding for some traditional programs that rely on prevention methods, such as condom distribution and community workshops for HIV-negative people.

Though some health experts and AIDS activists praise the plan, more of them worry that it might backfire. Critics say the shift in policy could lead to higher HIV rates, especially if it comes with cuts in traditional high-risk outreach programs.

Dr. Tom Coates, a professor of infectious diseases at UCLA Medical School and a national expert on HIV prevention, said that trying to keep infected people from spreading the disease is common sense, but that research in the area is limited. “We have a far way to go before we know this works,” he said.

Moreover, Coates pointed out, the new focus on broader testing comes at a time when governments have little extra money to help newly diagnosed HIV patients pay for the treatment and medications they will need. California’s $52-million annual prevention budget has been cut nearly 10% since 2001.

“These policies are being promulgated at a bad time,” Coates said.

“I wish we could have waited until there was more evidence” or enough money to pay for the program, he said.

Some experts also fear that, even if these newer policies work for some, they could be dangerous for others -- especially minority groups like African Americans and Latinos, who often don’t get tested because of social stigmas and other barriers.

“This one-size-fits-all policy assumes everyone is knowledgeable about the disease and wants to get tested regularly. That’s not the case,” said Dr. Octavio Vallejo, a faculty member at UCLA’s AIDS Institute.

At the Vista Community Clinic in Vista, near San Diego, Fernando Sanudo, the clinic’s outreach director, said the state’s recent shift had forced him to redirect $125,000 of his half-million-dollar annual HIV prevention budget to new HIV-positive focused programs.

In theory, Sanudo said, the new HIV-positive prevention programs are a good idea and may show some results. Nevertheless, he said, he thinks traditional outreach programs probably work better for his mostly minority clientele.

“We’re still at the point of needing to educate most of these people about even the most basic aspect of this disease,” Sanudo said.

For their part, state and federal health officials insisted that they have not walked away from programs for HIV-negative people but that something new had to be done.

After years of reductions in the number of new HIV cases -- which declined from 160,000 a year nationally in the mid-1980s to roughly 40,000 cases now -- the most recent federal data indicate that rates are starting to rise in several groups. New HIV infection rates among gay and bisexual men, for instance, rose an alarming 7.1% last year.