The African Epidemics
The AIDS pandemic has killed at least 25 million people worldwide since 1981. Although worldwide in its effects, the AIDS pandemic's most concentrated and severe effects are felt in Sub-Saharan Africa. This disparity has been attributed to a lack of antiretroviral treatment, where less than 1-in-10 infected have access to treatment.
The UNAIDS 2006 Report on the global AIDS epidemic gave the adult HIV prevalence for Sub-Saharan Africa as 6.15%, compared to 0.11% for North America, and 0.3% for Western Europe.
Broken down by region, East-Central Africa has infection rates (>5%) that are substantially higher than West Africa (<2%), but that do not reach the levels of Southern Africa (>15%). Principal modes of transmission include: unsafe sex between heterosexual partners (married and unmarried), prostitution, needle drug use, and anal sex between men (homosexual and 'men who have sex with men').
The District Epidemic
Hader stresses that every mode of transmission is up: heterosexual sex, homosexual sex, and use of needles for injected drugs. Jose Vargas, a Washington Post reporter working on a documentary about AIDS in Washington says, "D.C. is unique in that all of those three transmission rates is high, and they're all in double digits." Likewise, the epidemic is reported by the Washington Post to touch "every race and sex across population and neighborhoods, with an epidemic level in all but one of the eight wards."
However, the report also states that black men have an infection rate of nearly 7%, and that 'men having sex with men' has remained the disease's leading mode of transmission. The WaPo writes,
More than 4 percent of blacks in the city are known to have HIV, along with almost 2 percent of Latinos and 1.4 percent of whites. More than three-quarters – 76 percent – of the HIV infected are black, 70 percent are men and 70 percent are age 40 and older.
Ron Simmons, who is black, gay and HIV positive, said he's not shocked by the study's findings. "You have a high incidence of HIV among African Americans, and a lot of African Americans live in the city," said Simmons, who is a member of a black gay support group. "D.C. also has a high number of gay men, and HIV is high among gay black men."
Heterosexual sex was the principal mode of transmission for blacks with the disease, 33 percent. Men having sex with men was the chief mode of transmission for white residents, 78 percent; and Latinos, 49 percent. Black women represent more than a quarter of HIV cases in the District, and most, about 58 percent, were infected through heterosexual sex. About a quarter of black women were infected through drug use.
Because the city's numbers are based only on those people who have been tested, the actual numbers of infected D.C. residents is presumed to be higher than reported.
Just as Dr. John Snow, one of the fathers of epidemiology, recognized that a cholera outbreak in London, given its geographic extent, was traceable to certain pumps tainted by exposure to human waste, the geography of the HIV/AIDS epidemic in Washington D.C. is likewise of varying concentration. The geography of the epidemic is heavily weighted toward certain wards of Washington, D.C. Wards 1, 2, 5, 6, 7 and 8 feature both high rates of AIDS and poverty. According to the recent study, almost half of those who had connections to these wards said they had overlapping sexual partners within the past 12 months, three in five said they were aware of their own HIV status, and three in 10 said they had used a condom the last time they had sex.
Less affected and more affluent, Wards 3 & 4 are part of northwest Washington D.C., the historically white area of the capital. This racial distribution was created by the practice of 'redlining.' Areas west of 14th St. NW were not to be sold to non-whites, a racial division lingers today despite the abandonment of the illegal practice.
What is to be done?
The city formed an HIV/AIDS Administration in 2005, only recently fully staffed its surveillance unit, and lifted a ban last year on a needle exchange program (a 10-year-ban that had been imposed by Congress over home rule objections). Publicly supported HIV testing has also been expanded by 70 percent. And starting in 2007, the District became the second jurisdiction in the country to support a public-sector condom distribution program. This program supplied 1.5 million condoms in 2008.
Washington D.C. already has the nation's highest per capita spending on HIV/AIDS, at approximately $145/person compared to the national average of ~$10/person.
While there are likely applicable lessons from the San Francisco epidemic (which reached its peak in 1992 with a 4% infection rate), are city officials missing out on valuable lessons from Western Africa, which has managed to keep infection rates below 2% despite neighboring regions with far higher epidemic rates? And, what can be learned about the AIDS epidemic in Washington D.C from a comparative approach focused on Eastern Africa, where infection rates are similar but treatment and awareness programs are far worse than in the capital of the United States?
Full text of the reports [PDF format]