AIDS in the U.S.: the patient profile has changed, so should testing practices

[Cross-posted from the UNC Health Care weblog]

There is growing sentiment, and evidence, that attention to HIV and AIDS has shifted so far abroad, to Africa and in developing countries elsewhere, that Americans have overlooked a growing epidemic in our own collective backyard.

But even in the U.S. we’re looking through bleary eyes. This isn’t the 1980s. We need to give our eyes a good rubbing and let them focus afresh. When we do, we’ll realize the “high risk” population – IV drug users, men who pay for sex and men who have sex with other men – has changed.

The question has been who to target for testing. When a diagnosis of HIV is made early people can start receiving care sooner, probably use fewer health care dollars, have a better prognosis and, hopefully, remove themselves from the sex pool.*

But it’s the wrong question. Everyone needs to be tested, says Yvonne Carter, MD, an ID fellow at UNC. Carter reviewed data for more than 200 black men and women in the rural South, where the epidemic is most rampant. They were 18-61 and denied IV drug use and male-male sex. After some fancy statistics she found that socioeconomic status, health insurance status and history of incarceration were not associated with having more advanced disease.

But there was a group whose rates of advanced HIV was twice as high as others’ – the men. Women, Carter says, usually have more interaction with a health care provider. Men, especially black men, she says, tend not to go to the doctor until they’re very sick.

“This stresses that HIV testing is important, and implies that we can’t hang our hats on this person or that person,” Carter says. She presented her study Oct. 30 at the IDSA meeting.

Carter, a black woman, was drawn to disparities research after a trip to Africa as a medical student at Maryland. She came to UNC to be mentored by Ada Adimora, one of our many top HIV/AIDS doctors. Adimora leads the Rural Health Project, which continues to provide important data, including that for Carter’s work.

In 2008 Adimora told Congress that AIDS in black men represents a national emergency. Black men account for more than half of all AIDS deaths, and about 45 percent of new diagnoses. But the question about “who” to test needs to change to “how” and “when,” as in, how soon and how can we test everyone, often.

- Clinton Colmenares

* Lisa’s note: The notion that people who are HIV+ must resign themselves to a life of celibacy is controversial, mostly because it’s so unrealistic.  Partner notification, 100% condom use, and other prevention methods, such as pre- and post-exposure prophylaxis with antiretroviral medications make it possible for people with HIV to have relatively normal sex lives.

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