Commentary: Losing The Trail Of The Hiv Epidemic

There are very encouraging reports from the AIDS front. Powerful drug combinations are helping tens of thousands of patients live longer, healthier lives. Researchers said on Feb. 2 at the 5th Conference on Retroviruses that AIDS deaths plunged 44% in the first half of 1997 compared with the same period in 1996. And new data show that HIV, the virus that causes AIDS, isn't developing resistance to the drugs given in combination.

The heartening news, however, masks other urgent problems, which public health officials will only be able to solve by taking steps to better track the epidemic and tackle persistent social ills such as drug abuse. The new drugs only reduce AIDS deaths, and do not prevent most infections. And the rate of new infection seems to be unchanged. Dr. Kevin DeCock, head of the division of HIV prevention, surveillance, and epidemiology at the Centers for Disease Control, estimates that a staggering 400,000 to 650,000 Americans are now HIV-positive.

INVISIBLE. Worse, this vast infected population is getting harder and harder to track. HIV infection is only reported to health agencies when patients develop symptoms--often years after infection. And the new drug therapies often prevent AIDS symptoms from ever appearing. The result: huge numbers of people with HIV who are invisible to the public-health agencies--and who may be spreading the virus. "We are rapidly losing our ability to track the epidemic," says Dr. Mary Ann Chiasson of the New York City Health Dept.

That would be a disaster. Without proper surveillance, "we might as well pack up and go home," says DeCock. Knowing who is getting infected where and how is crucial to preventing infection in the first place.

The increasing difficulty in tracking HIV's spread couldn't come at a worse time. The epidemic is in the midst of a dramatic demographic shift, moving from mostly white homosexual males to blacks, Hispanics, and women, especially those who are poor, intravenous drug users, or the sex partners of drug users. Without some form of surveillance, this will be impossible to track.

The U.S., in the grip of the worst AIDS epidemic in the industrialized world, needs to take two controversial steps. The first is to track people as soon as they learn they are infected. AIDS activists have long resisted the idea, worried that fear of discrimination against those who are HIV-positive could discourage others from getting tested and treated.

That resistance is softening. In January, the Gay Men's Health Crisis dropped its opposition to the idea of tracking--if infected people aren't identified by name. But no one has yet developed a workable system of anonymous I.D. tags. Unless one can be devised fast, the CDC needs to bite the bullet and require clinics, doctors, and hospitals to report the names of those infected.

The U.S. also must get far more serious about breaking the chain of transmission. That means redoubling efforts to provide clean needles, rehabilitate drug users, and tackle the myriad social problems that lead to high-risk behavior. It also means spending more to develop new prevention ideas. Expensive? Yes. But preventing infection by HIV is vastly preferable to having to provide expensive drugs to hundreds of thousands of Americans for the rest of their lives.

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