The Unending Plague

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America likes to consider itself exceptional, a nation blessed with unshakeable good fortune and driven by unyielding ambition. I think that sentiment explains why we so often get caught with our pants down. Our self-absorbed exceptionalism breeds a lazy arrogance that consistently confuses just getting started with finishing the job: Iraq. Al Qaeda. Katrina. It's a long list to which we can now officially add AIDS.

The U.S. Centers for Disease Control and Prevention announced this weekend that the American AIDS epidemic is at least 40 percent larger than we have believed for more than a decade. The announcement drew front-page stories, shocked many everyday Americans and prompted those of us working on AIDS in black communities to sigh a collective, "I-told-you-so."


Since the mid-1990s discovery of "combination therapy"—popularly known as the "AIDS drug cocktail," a tellingly cavalier moniker—America has embraced the notion that it beat AIDS. We've certainly made strides. Combination therapy drastically slowed the funeral march we once thought inevitable, prompting national news media to offer a string of breathless stories examining "when plagues end," as an infamous 1996 New York Times Magazine cover blared.

But that success was tenuous and uneven from the start. The treatments were then and still are expensive and challenging. And African Americans never bounced back as robustly as the rest of the nation. Indeed, 1996 was significant for two reasons: It was the first year America saw a decrease in AIDS death rates and the first year in which more blacks died than whites. By 2004, blacks represented 38 percent of all AIDS deaths. So much for plagues ending.

Meanwhile, declarations of victory notwithstanding, the epidemic has continued to grow every year, driven largely by new infections among blacks. Since the mid-1990s, the CDC has estimated that America logs about 40,000 new infections a year, roughly half of them black. Many of us warned for years that, as bad as that estimate was, it was more likely the tip of the iceberg than its base. And on Saturday—at the same biennial meeting at which Dr. David Ho introduced the world to combination therapy 12 years ago—CDC released its long-awaited study, finally proving those stark predictions correct.

The study is the result of new testing technology that allows researchers to, in effect, time-stamp an HIV infection. Previously, they could determine only whether HIV was in a person's blood, not how long it had been there. Without being able to differentiate a new infection—say, six months old—from an old infection—say, six years old—researchers couldn't detect with precision how fast or slow the epidemic was spreading. They could say only how fast or slow we were diagnosing its spread. "It's like shifting from standard-view to wide-screen HD TV," quipped CDC's prevention director Kevin Fenton in explaining the technology to reporters Saturday.


Using their new tool, CDC researchers went back and created new estimates for the annual growth of America's epidemic. The results were arresting. The CDC now says America has never logged fewer than 50,000 new infections a year. That low mark came in the early 1990s and leveled off there until the late 1990s, when infections began ticking upward.. From that point forward, there have been between 55,000 and 58,500 infections a year; in 2006, the most recent data available, the CDC found 56,300 new infections.

That finding also implies that the current estimate for the total number of Americans living with HIV/AIDS—as many as 1.2 million—is inaccurate and that the real number is likely 40 percent higher as well. The CDC has said it will release a new estimate by year's end.


One thing the study doesn't change is our understanding of who's getting hit the hardest by all of this—black people and gay and bisexual men. African Americans accounted for 45 percent of 2006 infections, though we're about 13 percent of the population. Gay men were 53 percent of all new infections that year.

Frustratingly, the CDC's new technology has yet to give us adequate breakdowns on other disproportionately affected groups. The new report told us nothing, for instance, specifically about black women. And nothing about how many of those gay infections are among blacks. But it doesn't take a behavioral scientist to draw pertinent conclusions. Several previous studies have shown black women far disproportionately impacted—accounting for as much as a third of female infections—and black gay and bisexual men in the United States having among the highest infection rates worldwide.


It's high time the CDC makes explaining these racial disparities an urgent priority. No more reveling in wild, unsubstantiated theories about "down low" bisexual men infecting black women. (CDC research has belatedly proved, by the way, that closeted bisexual men are more likely to use condoms with both female and male partners.) We need public health monitors to use their new, more precise measuring stick to help sort out fact from fantasy so we can start working to end this mess.

It's also time for the nation to stop lying to itself about controlling the epidemic.


Last week the world gushed as Congress passed a beefed-up version of President Bush's foreign aid package for HIV. America should certainly be proud that it is finally making an historic commitment to help fight the epidemic in places like sub-Saharan Africa. But as a Black AIDS Institute report noted last week, if black America were its own country, it would have a larger epidemic than seven of the 15 countries to which Washington is targeting assistance. Only four countries outside of sub-Saharan Africa would have equivalent percentages of their population who are HIV positive.

As a New York Times op-ed last week succinctly put it, "Surely we should be doing as much to prevent the spread of the AIDS virus in our own communities as we are trying to do abroad."


Yet, since 2001, funding for domestic AIDS programs has not gone up, and in some programs—including prevention—it has actually gone down. That was a shocking fact even before we found out the epidemic is 40 percent larger than believed. It's also terribly short-sighted because we're going to deal with these infections sooner or later—and each year we delay makes the ultimate price higher. "The epidemic in the United States will have tremendous short-term impact and long-term impact," Fenton, the CDC's prevention director, offered in describing what the just-released study should say to budget makers. "This is indeed a wake-up call to the entire society."

Kai Wright is a regular contributor to The Root.

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