Viral rebound?

National | Rising HIV infection rates in some of America's biggest cities worry AIDS researchers

Issue: "Midwest's middle men," Oct. 21, 2000

Mourners, activists, and ordinary citizens on Oct. 7 draped the Capitol Mall with a gigantic red ribbon-a ribbon made of human beings wearing red ponchos and marching in Washington, D.C.'s annual AIDS Walk. Other events across the country also marked National AIDS Awareness month and raised lots of money. In San Diego, AIDS Walk participants raised a record $701,000.

It appears that those fighting AIDS/HIV are going to need the money. Reports by the Centers for Disease Control, the Institutes of Medicine, and at least one metropolitan public health department show that HIV infection rates are once again on the rise. Researchers blame the viral resurgence on waning adherence to the "safer-sex" ethic, the failure of condom-centric HIV prevention efforts, and the breakdown of previously effective drug regimens. They also are worried: With a fresh wave of the virus percolating through major urban areas, a second wave of AIDS may not be far behind.

A spike in HIV infection rates in San Francisco was among the first red flags. This summer researchers there discovered that the rate of new infections among male homosexuals had nearly tripled since 1997. This finding accompanied other disturbing trends among homosexual men, including a falling rate of consistent condom use (from 70 percent to 54 percent), a higher incidence of rectal gonorrhea, and a return to high-risk, multi-partner sexual behavior.

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"I think there's a sense that the drugs have taken care of the problem," said Tom Coates, director of the AIDS Research Institute at the University of California at San Francisco. "Second, I think people believe the disease is slowing." San Francisco has generally been "ground zero" for AIDS/HIV trends, so experts worry that the city's rising infection rate is a blood-borne bellwether for the entire country.

"We think there needs to be a wake-up call for the rest of the nation," said Dr. Ronald Valdiserri, deputy director of the National Center for HIV, STD and TB Prevention at the CDC. "Obviously, we want to be careful about extrapolating what's happening in one city. But the CDC considers this a very important finding."

Since the virus was first identified, America's cities have acted as its primary incubators. In the mid-1980s the disease struck like an urban cobra, killing first in San Francisco, Miami, and New York-all homosexual meccas. Then it slithered out across the rest of the country, cutting an epic trail of death. As of 1999, AIDS has killed 430,411 people in the United States-nearly as many as live in the entire state of Wyoming. The cities still are hotbeds: Last year, 10 cities (New York, Los Angeles, San Francisco, Miami, Washington, D.C., Chicago, Houston, Philadelphia, Newark, and Atlanta) accounted for nearly half of cumulative reported AIDS cases.

Several cities may be seeing the leading edge of a new viral wave. CDC researchers administered HIV tests to 3,492 homosexual men between the ages of 15 and 22 in Baltimore, Dallas, Los Angeles, Miami, New York, San Francisco, and Seattle. The results, released this summer, were grim: On average, 7 percent of those tested were HIV-positive. In New York, 12.1 percent-or more than one in 10 homosexual men-were infected, a level some researchers compare with the infection rates currently raging through Africa.

In the mid-1990s AIDS fighters were optimistic. Though the number of new AIDS cases rocketed upward during the first decade of the epidemic, rising by between 65 and 90 percent annually, by 1996 the graph line was diving. Aided by HIV prevention efforts and medical breakthroughs such as the complex, multi-drug regimens called "cocktail therapies," both new AIDS cases and AIDS-related deaths fell through 1997.

Since then, the statistical nose dive has leveled out. CDC analysts now believe earlier HIV prevention efforts may only have had a stopgap effect: Those most predisposed to treatment-such as older, homosexual males caught in the first AIDS epidemic-have already been reached. But many of today's

at-risk populations, like the urban poor, are hard to reach with either educational efforts or early testing and treatment. In addition, some patients have difficulty adhering to expensive and often laborious drug therapies. And therapies that once seemed to be working are now fizzling in the face of a virus that Margaret Chesney calls "cunning."

"At first it appeared that these (drug therapies) could block the virus's replication process," said Ms. Chesney, co-director of the Center for AIDS Prevention Studies at the University of California, San Francisco. "Eventually the level of the live virus in the system would decline. The hope was that the decline would lead to eradication. That hasn't happened." Instead, she explained, the drugs work temporarily, but even after a patient's blood tests show no trace of HIV, the virus "breaks out" and begins to replicate anew. The new incarnation is stronger than before, sometimes even invincible from the standpoint of current treatment technologies.


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