A woman is given an instant HIV/AIDS test.
 A woman is given an instant HIV/AIDS test. - 
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Fifteen years ago, the Millennium Development Goals challenged the world to stop and begin to reverse the spread of HIV by 2015. The world missed that goal, and today, 35 million people are still living with HIV and millions are suffering from AIDS. It can be hard to see how to bend the curve on the spread of this virus.

However, several places have managed to start to make inroads against the virus. Vancouver, British Columbia, and San Francisco have both made strides in reducing the spread of the virus. Last year, New York Gov. Andrew Cuomo announced his plan to end the HIV epidemic in the state. Another city that’s had some success is Washington, D.C.

“We had about 1,300 cases at a peak in 2007, and we are just under 500 as our preliminary numbers for 2013,” says Michael Kharfen, head of the Department of Health’s HIV/AIDS, Hepatitis, STD and TB Administration

The district’s three-pronged strategy of outreach, treatment and prevention is the secret to its success, according to Kharfen.

Outreach means finding and testing as many people as possible – in schools, hospitals and on street corners. Sometimes Washington residents have to opt out of a test.

Treatment means getting people who are HIV positive into medical care and onto HIV medications as soon as possible, so they can stay healthy. Recent studies have shown that this method, known as “Treatment as Prevention” or “TasP” makes HIV positive people more than 95 percent less likely to transmit the virus to someone else, Kharfen says.

Prevention means needle exchanges, safer sex ad campaigns and giving out millions of free condoms. All this was achieved, Kharfen said, with an annual budget of around $85 million.

Another factor, he says, is the close relationship between Washington's government and its medical providers, like Whitman-Walker Health. It has many LGBT and low-income clients, two groups that bear a disproportionate burden of HIV infection.

“You can show that over a four-year period you can reduce the incidence of HIV by 70 percent and really get a marked improvement,” says Dr. Richard Elion, Whitman-Walker Health's clinical research director. “But that last 30 percent, over time, is not showing a decline. And that now is really where the illness is.”

So how do public health officials hit a shrinking target?

Washington has to get creative, Elion says. Whitman-Walker runs public health studies and surveys that look at at the next generation of HIV/AIDS treatments, approaches that include new medications and cold hard cash. One study looks at the impact of paying HIV-positive people a couple hundred dollars a year if they remain HIV undetectable, and therefore not infectious. Compare that to the roughly $20,000 it can cost for medicine for each newly infected patient.

Providers face challenges in getting patients to adhere to treatment for most chronic conditions, like diabetes and heart disease, Elion says. “The difference is that HIV because it’s an infectious disease has ramifications as a result of that lack of control," he says.

Whitman-Walker’s surveys helped show that a new prevention strategy known as "pre-exposure prophylaxis," or "PrEP," which involves taking HIV medicine to prevent infection, works in the real world. 

Methods like these, known as biomedical interventions, should chip away at that shrinking target, says Dr. Anthony Fauci, head of the National Institute of Allergy and Infectious Diseases. And as for those lofty Millennium Development Goals? It's OK to miss a target, he says.

“When you set a goal and strive for it – although you may not reach precisely the goal that you set – it increases the energy, it increases the effort and it increases the fate that you’re going to get there,” Fauci says.

The ultimate goal is a world of “HIV zero,” no more AIDS deaths and no more HIV transmissions, Fauci says. He and other scientists say that day probably won’t come until there is a safe and effective vaccine, and that’s at least a decade away.

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Follow Tim Fitzsimons at @@tfitzsimons