In the 30 years since the first diagnosis of HIV/AIDS, the disease has killed 25 million people worldwide. It is a staggering number -- and there is still no vaccine available to wipe out the virus.
AIDS in the United States is responsible for more than a million deaths. It ravaged the bisexual and gay community, killed countless intravenous drug users, and is increasingly prevalent among black men in poor urban areas, according to Avert, an international AIDS charity.
And yet World AIDS Day 2011 finds millions of people living with the disease, enjoying longer and healthier lives than once thought possible.
"We have seen a graying of the epidemic," said Dr. Sindy Paul, medical director of the division of HIV, STD and TB services at the state Department of Health, noting that 79 percent of New Jerseyans with HIV are over 40.
HIV patients are living long enough to die from diseases associated from aging -- instead of dying from AIDS, according to Connie Calisti-Meyers, assistant state health commissioner, division of HIV, STD and TB services.
Indeed, the public health community can point to impressive strides. In addition to drugs that offer HIV patients a near-normal lifespan, prenatal treatment has reduced the rate of transmission from mother to child to one or two per hundred, compared to one in four in the 1990s.
But it's not enough. The theme of this year's World AIDS Day is "getting to zero." And experts say far more progress is needed on education, prevention, testing, and treatment to achieve the ambitious goal of completely halting the spread of this disease.
One of the greatest struggles is against ignorance. "People now tend to think of [HIV/AIDS] as a disease that has been wiped out, which is not true," said state Sen. Loretta Weinberg (D-Bergen). "We need to be continually educating people. This is a disease that has been elevated to a chronic illness. It is being controlled but not cured by any stretch of the imagination."
Most infections are transmitted through sexual contact or the sharing of needles by users of intravenous drugs like heroin. Promoting safe sex, dispensing clean needles to drug addicts, and getting more people tested and into life-long antiviral treatment programs if they test positive, are the chief strategies for battling the disease.
Paul said it's recommended that everyone aged 13 to 64 be tested, with a special urgency for pregnant women. Obstetric interventions have given the war on HIV "one of our prevention success stories," Paul said. "We have gone from having 77 infected children born in New Jersey back in 1993, to between one and five (per year) today."
As many as 20 percent of Americans with HIV in the U.S. don't know they are HIV-positive, according to the U.S. Department of Health and Human Services. "And this is not a once in a lifetime test," said Paul. "The same individuals may need to be tested multiple times" if they are at risk for HIV. New Jersey has 170 sites around the state that perform the HIV test, a saliva swab that takes a few minutes. Paul said 105,000 people were tested at those 170 sites last year. "To make sure there are no barriers for the patients, financial or otherwise, we do the test at no cost."
The state reported 865 new cases last year, compared with nearly 3,000 new cases in 2000. The mortality rate has declined from 81 percent in 1990, to 7 percent in 2009. "The decrease in the number of newly reported cases is a combination of preventive efforts and the improved treatments we have," Paul said.
A 2006 state law authorized a pilot program to test the distribution of clean needles in Atlantic City, Camden, Paterson, Newark and Jersey to reduce blood-borne diseases like HIV and hepatitis. Calisti-Meyers said to date 700,000 syringes have been distributed. The department is now evaluating the syringe-distribution pilot and will soon report on the results to the legislature and the governor, she said.
Legislation to allow adults over age 18 to purchase syringes without a prescription has passed the state Senate and is likely to be voted on by the Assembly in the lame duck session that ends in January, said Weinberg, chair of the Senate health committee. "One of the main things we can do is to allow the purchase of clean needles" to prevent the spread of AIDS among drug users.
Weinberg said people who decide to engage in sex should first be tested, and ask their partners to be tested: "The bottom line is people should be practicing appropriate sexual activities." She said it's good that the number of new cases seems to be declining, "but that doesn't mean that we have solved this problem, and believing we have solved it sets up an atmosphere for the problem to increase."
Carol Wolff is executive director of the Camden Area Health Education Centers, which is distributing clean syringes to 2,000 Camden drug users as part of the state's pilot program. She said nurses are testing the patients for HIV and hepatitis, and helping them get into drug treatment programs. "This saves lives and reduces cost, when you consider the cost of getting hepatitis or HIV. That fact that we have had 2000 people come forward [for syringes] tells me there is a knowledge level and people care enough about their lives to use clean needle instead of dirty needles. The other thing is that people are asking for [drug] treatment as well. There is an assumption that people who are drug users are not interested in another lifestyle, but when they come to exchange syringes they are also asking for treatment."
Nurse Peter Oates, manager of health care services at the François-Xavier Bagnoud Center, a clinic at the School of Nursing at University of Medicine and Dentistry of New Jersey in Newark, said "We need to get people tested, get them in care and keep them in care." He said the Centers for Disease Control and Prevention estimates only about 40 percent of HIV patients stick with their medication. He said he has about 250 patients who were infected with HIV prenatally, prior to the medical advances that have nearly wiped out the transmission of HIV in the womb.
"The treatment of HIV has really exploded over the past 10 years," Oates said. "We have some fabulous medications now, and provided the patients stay on their medications and take them every day, every dose, their life expectancy is almost a normal life expectancy."
But if patients skip doses, the virus becomes resistant to the medication. "The virus is so clever it actually notices when you are not keeping topped up with the medication to keep the viral load suppressed. What happens is it mutates itself to become resistant to medication and once resistance starts you are very limited in what you can put them on." Instead of taking an oral medication, a patient who develops resistance may need an injected drug.
A recent public health strategy is to get as many HIV-positive people as possible into treatment, to reduce the amount of virus in the blood, and thus reduce the risk of transmitting the disease. "People are talking about using treatment as a form of prevention," he said. "We have done a fabulous job on care and treatment, but we've not done such a good job on prevention."
One of the most challenging populations is young African American men who have unprotected sex with other men, he said. "Behavior change is the most difficult thing in the world, it really is. You can educate people but to make them change their behavior even when they have knowledge is very difficult, especially when it comes to sex."
Educating young people will be the goal Thursday morning in Tenafly, where 400 high school students from throughout Bergen County will gather for an annual World AIDS Day symposium. Among the speakers will be Dr. Steven Sperber, chief of infectious diseases at Hackensack University Medical Center. The event "is dedicated to educating young people about HIV and the importance of protecting yourself and getting tested," Sperber said. Among the speakers will be an individual with HIV who will speak to the students and answer their questions. The program will address "how to prevent HIV and what to do when you are in a situation regarding sex. This is a challenge for young people when faced with a situation where they might not be thinking as rationally as they might the next day."