WASHINGTON — Angela Byrde, 27, is getting the second HIV test of her life — at the Department of Motor Vehicles.
Her situation exemplifies issues with Washington’s and America’s AIDS epidemic, and what the nation’s capital is doing to address it. As a diabetic with Medicaid coverage, Byrde has seen doctors several times a year since she was 12, but they never suggested that she be tested for HIV, even though she lives in a city with one of the country’s highest HIV-infection rates.
Now the city, trying to find the estimated 5,000 Washingtonians who are infected but do not know it, is offering tests in grocery stores and high schools, on corners where addicts gather and even in motor-vehicle offices. And it is paying people to take them.
“Seven dollars to take a mouth swab?” Byrde said. “It just works. And they make sure you don’t lose your place in line.”
Starting today, Washington will host 20,000 scientists, public-health officials, activists and journalists at the biannual conference of the International AIDS Society, the world’s biggest gathering devoted to the disease. It is the first time in 22 years that it has been held in this country, where the epidemic was first spotted 31 years ago. And it has come here because the Obama administration lifted the Reagan-era prohibition on people who are HIV-positive from entering the country.
Despite decades of alarm over the AIDS epidemic and advances in treatment, testing is so inadequate in the United States that about 240,000 Americans do not know they are infected, and many spend years spreading it.
The District of Columbia is a microcosm of both the best and worst trends in modern AIDS prevention and treatment. Infection rates there were so bad that they were compared with those in Africa. But the city’s new programs, like testing people at motor-vehicle offices, have been paying off.
New cases have fallen to 835 from 1,103 in 2006. And the number of mothers who infected their babies shrank to zero in 2010 from nine in 2005.
“It’s a tale of two cities,” said Phill Wilson, executive director of the Black AIDS Institute. “You can see the epidemic as bad as it is anywhere around the globe, and you can see some of the best practices.” As such, he said, Washington is “the perfect city to have this conference in.”
A new political will is driving the city’s turnaround.
“D.C. used to be a bureaucratic nightmare,” said Dr. Anthony S. Fauci, director of the National Institute of Allergy and Infectious Diseases, which is just three subway stops outside the city, in Bethesda, Md. When Adrian M. Fenty took office as the mayor of Washington in 2007, Fauci said, “it was a whole new morning in America.”
The change is evident on many fronts. The number of HIV tests given has nearly tripled to 122,000 a year, from 43,000 in 2007. The city gave away 5 million male and female condoms last year, 10 times as many as it did in 2007. More than 300,000 clean needles a year are given away — to heroin users and to transsexual prostitutes who inject hormones.
Patients are being found in earlier stages of their illnesses, when the disease is more treatable. And 89 percent of those who test positive see doctors within three days. Under the city’s Red Carpet program, nonprofit organizations are paid to drive new patients to the doctor.
Washington has some advantages over rival cities. Almost 94 percent of its residents have health insurance, second only to Massachusetts. And there are no waiting lists for AIDS drugs or addiction treatments.
Also, Washington has switched from anonymous to name-based testing, so it can better track infection trends. And in 2007, Congress, which oversees the city’s administration, dropped its ban on cleanneedle distribution; since then, infections attributed to dirty needles have plunged by 72 percent.
Black men there are the hardest hit: 6.3 percent in Washington are infected, a rate that rises to more than 30 percent for middle-aged black homosexual and bisexual men. Even so, the Black AIDS Institute just named Washington one of “the three best cities to be a black gay man in,” based largely on available medical care. (The others were New York and Los Angeles.)
Still, the city has tremendous weaknesses.
Washington finances 70 nonprofit groups, and their effectiveness varies greatly. Each has its own executive salaries, ingrained habits and political patrons. Some are excellent, some have sunk in financing scandals, and some are “left over from the days when all they did was hold people’s hands and watch them die,” said Dr. Gregory Pappas, chief of AIDS for the city’s health department. “The game has changed — but some, God bless them, are the same old people doing the same old things.”
Another weak point is the inefficiency of random testing. Each test consumes about 20 minutes alone in a room with a counselor — and only about one of every 100 people tested at the Department of Motor Vehicles, for example, is infected. (Byrde was not.) Even at AIDS clinics there, only 2 percent of tests are positive. Many family doctors resist testing at all.
“I spoke to one older practitioner, and he felt he’d be liable if he tested his patients and they didn’t want to know the diagnosis,” said Dr. Lisa Fitzpatrick, an AIDS specialist at United Medical Center in southeast Washington. “He said: ‘I see three generations of one family. I’d offend them if I asked.’”
Experts say “contact tracing” — asking a newly diagnosed patient to name everyone he has slept with and then testing them — is far more efficient. Aggressive contact tracing has been central to Cuba’s largely successful battle against AIDS.
Many patients decline to cooperate. For example, Justin Goforth, chief of adherence for Whitman-Walker Health, a health center that specializes in treating homosexual patients, said asking for names at the first visit, as required by law, was bound to fail. “At that first visit,” he said, “everyone is freaked out and scared, and remembers maybe 5 percent of what the doctor says.”
Even with cooperation, the city has only enough money to trace the contacts of a third of those who test positive for syphilis, gonorrhea, HIV or other sexual diseases, Pappas said. But it is efficient: About 10 percent of contacts have HIV.
Front Section, Pages 5 on 07/22/2012