Could the AIDS virus be stopped with gift cards?
Desperate for a way to stop the escalating spread of HIV among young gay men, public health officials are looking to novel strategies, such as enlisting local gay opinion leaders to urge their peers to practice safe sex.
Promising signs from such a project in North Carolina led the Centers for Disease Control and Prevention to begin rolling it out on a broader scale, to more than 200 community groups. The budget is $1.5 million over a two-year period.
The idea is to give gift coupons to popular, influential men in the gay community and encourage them to talk up condom use, regular HIV testing and other responsible actions.
It may sound frivolous, but little else has proven effective for the men most affected by the epidemic.
Last week, new figures showed still-rising HIV infections in gay and bisexual men, with about 53 percent of new cases in that group. Meanwhile, HIV rates among injection-drug users and heterosexuals is declining.
The CDC says it's also committed $5 million to a five-year social marketing campaign to promote HIV testing to young black gay and bisexual men, who have been diagnosed with HIV at especially high rates.
"The CDC is committed to ensuring that its resources are going to the populations hardest hit by the epidemic," said Richard Wolitski, acting director of the CDC's Division of HIV/AIDS Prevention.
The new approaches are an encouraging sign of help, but the funding behind them doesn't come close to raising prevention spending to the level most experts say it should be, said Julie Scofield, executive director of the National Alliance of State and Territorial AIDS Directors.
"It's a drop in the bucket," she said.
Dramatic rise in new infections
Scrutiny of U.S. prevention efforts increased after the CDC's release last weekend of new estimates of annual HIV infections. The CDC said the nation had roughly 56,300 new infections of the AIDS virus in 2006 — a dramatic increase from the 40,000 annual estimate used for the last dozen years.
The agency acknowledged it had been undercounting but said new testing technology offered a more accurate picture of trends in the U.S. epidemic. For example, the new report found infections are falling among heterosexuals and injection drug users, even as they continue to rise in men who have sex with men, especially among blacks.
Advocates have complained that prevention spending in general has been too low, and that what is spent is not targeted properly.
The CDC's HIV prevention budget has remained at roughly $700 million since 2001, while costs have risen. (That's about 3 percent of what the federal government spends on AIDS; much of the rest is on medicines, health care and research.)
Meanwhile, prevention programs that target gays and bisexuals are scattershot. Even in progressive cities, these efforts sometimes amount to little more than offers of testing and free condoms, some experts said.
Great attention was focused on the gay community when AIDS first hit the United States in the 1980s. But the epidemic gradually became perceived as a threat to the general population, and some political leaders have kept the focus away from gay men, said Leroy Blea, a Berkeley, Calif., health official who is past president of the National Association of County and City Health Officials.
"It's not a very easy population to fund," Blea said. "It's often more politically viable to fund programs for women and children and youth.
The CDC's Division of HIV/AIDS Prevention estimates that about 42 percent of its fiscal 2007 funding was targeted at gay and bisexual men. That translates to about $280 million.
But with 53 percent of new HIV infections occurring in men who have sex with men, that's not enough, some experts said.
"At a minimum, we need to be matching percentages to where the epidemic is," said David Holtgrave of Johns Hopkins University.
Prevention programs are largely funded at the state and local level, and funding has not quite kept up on those levels either.
In California, about 70 percent of HIV infections occur in men who have sex with men, but about 64 percent of the state health budget targeting HIV is focused on gay and bisexual males.
Some experts say it's been hard to find prevention efforts proven to work, and that's especially true for black and Hispanic gays.
Weaknesses in prevention became clear about five years ago in North Carolina, with an outbreak of HIV among male students at some historically black colleges.
The North Carolina Department of Health and Human Services tried a program that had been tested in white gay men in London.
With $1 million in funding from the CDC, North Carolina health officials went to gay nightclubs in Charlotte, Raleigh and Greensboro and recruited men who were well-liked and socially influential.
$25 gift cards
These opinion leaders were given four $25 gift cards, along with marketing materials, to talk up safe sex. A study of the effort, published in June in the American Journal of Public Health, indicated more men were practicing safe sex.
The research was based on repeated surveys over time of about 300 men. It found a 32 percent reduction in unprotected anal intercourse during 2005, and a 40 percent reduction in the average number of sexual partners.
The funding ran out and the program ended. And the surveys weren't backed up by HIV testing.
But CDC officials are impressed enough to package it, and are identifying other cities where it can be tried. The training of community activists in the strategy should start in a few months, Wolitski said.