February 11, 2004
Using a one-of-a-kind HIV screening program, North Carolina researchers have documented for the first time an outbreak of HIV infection as it is in the process of spreading. With its funding set to expire this fall, however, the outbreak may also be the last the program has the opportunity to discover.
The program, Screening and Tracing Active Transmission (STAT), is a collaborative effort launched in November 2002 by the University of North Carolina-Chapel Hill and the North Carolina Department of Health. It goes beyond more traditional HIV surveillance programs in its ability to not only quantify recent HIV infections in a particular area, but to specifically focus on discovering cases of acute HIV infection and then mapping a "sexual network" of these infections.
Within months of its implementation, STAT made headlines when it discovered an ongoing outbreak of HIV infection among mostly black, college men who have sex with men in North Carolina. While justifiable attention has been paid to these findings -- the first-ever confirmed outbreak of HIV on U.S. college campuses -- the more intriguing story focuses on the program that made the findings possible. If the program were adopted on a much larger scale, it no doubt would discover many more such outbreaks as well.
Study Details: An Outbreak Discovered
In the first three months after its launch in November 2002, the STAT program spotted five cases of acute HIV infection that had been missed by typical antibody testing. (For more information on STAT, read Keith Henry's conference coverage.) This small family of acute infections included what appeared to be an unlikely coincidence: a pair of acute HIV infections among two young, black males attending two different colleges in the same North Carolina city.
"Acute infection is a period of high infectivity and it's a rare diagnosis to make," said Lisa Hightow, M.D., a clinical instructor at UNC-Chapel Hill, one of the researchers involved in the STAT program and the lead author of an analysis of its findings among college students. "So to find two cases of acute infection in two college students of the same demographic in the same town but in two different colleges, that to us signals a problem," she said. "This is an area where transmission of HIV is actively occurring."
Concerned researchers attempted to determine if the findings were indicative of a larger web of infections. Headed by Lisa Hightow, M.D., the team of researchers from UNC-Chapel Hill and the North Carolina Department of Health and Human Services conducted a retrospective review of state HIV surveillance records among 18- to 30-year-old males diagnosed with HIV between Jan. 1, 2001 and Dec. 31, 2003.
The review of this four-year period turned up 998 HIV infections among young adult men. Of the 735 infections researchers were able to analyze by the time of this conference, 84 (a surprising 11.4%) were among current college students. The students attended one of 27 of North Carolina's 116 undergraduate institutions, as well as another four colleges in the states surrounding North Carolina. The researchers noted that, while the number of infections remained relatively stable for non-college students over the three-year scope of the study, they increased markedly among college students beginning in the second half of 2001. In 2000, only six HIV cases were found; in 2001, that number increased to 19; in 2002, 29; and in 2003, 30 HIV infections were discovered. College males were three times more likely than non-college males to be diagnosed with acute or recent HIV infection.
Using North Carolina's existing partner notification and interview system, researchers were able to create a "map" connecting 61 of the 84 infected students to a network of sexually transmitted HIV infections. No single college acted as a hub for the network, the researchers found; colleges in the University of North Carolina system, other public colleges, private colleges and historically black colleges were all impacted similarly by the outbreak, suggesting that this was a socioeconomically diverse group of individuals. The racial makeup and risk factors of these infected men were not as diverse, however: 88% were African American, and nearly all reported having sex with men within the past year.
To better determine the risk behaviors of the infected individuals, researchers from the U.S. Centers for Disease Control were invited to conduct patient surveys and more extensively review the available data. They found that only 4% of those infected reported having sex exclusively with women, but 33% reported having sex with both men and women, indicating that this cluster of HIV cases has probably spread beyond the men identified in this study. (Women were not included in the researchers' examination due to the small number of infections found among them in this particular investigation, but Dr. Hightow noted that there is still concern that college women are also becoming infected.) HIV infection among these college men was strongly associated with seeking out partners at gay bars/clubs or on the Internet, as well as the use of Ecstasy. Only one of the 84 infected men reported using injection drugs.
A Broader Phenomenon: Men on the "Down Low"
This study's findings dovetail with the growing profile of an HIV risk group that generally receives far less attention than it deserves: men, particularly black men, who are on what has been dubbed the "down-low" (DL). The DL, a relatively little-known and unacknowledged sexual culture that is particularly prevalent among African Americans, was described by Greg Millett, M.D., of the U.S. Centers for Disease Control and Prevention in an oral presentation at this conference. Men on the DL have high-risk sexual contact with men but don't identify as being gay or bisexual, he explained. As a result, these men may comprise a "bridge" over which HIV is transmitted from the gay male population into the heterosexual female population. (An unrelated poster presentation at this conference from Judith Sackoff, M.D., also pointed to indirect evidence that men who have sex with both men and women do indeed act as an HIV "bridge" between homosexuals and heterosexuals.)
HIV is far more prevalent among young, black men who have sex with men than their white counterparts, Dr. Millett noted, and black women are infected with HIV through heterosexual sex at a far higher rate than white women. Is the DL phenomenon to blame for the difference? The few studies that exist on this issue fail to answer that question, Dr. Millett said, if for no other reason than that the very nature of being on the DL -- sexual encounters between men who don't consider themselves gay or bisexual, and do not acknowledge their homosexuality with close friends, family or spouses -- makes it extremely difficult to accumulate any authoritative data.
So why do African-American men seem to be the main progenitors of the DL trend; why not whites or other minorities? Again, research is scant in this area, so theories are all that most experts have to rely on. Most revolve around African Americans' socioeconomic roles and status in U.S. society, Dr. Millett said. Black men, particularly in the U.S. South, are less likely to trust information handed down to them from health officials, advocates or physicians, are more likely than whites to go to prison (another key area for the spread of HIV and other sexually transmitted diseases) and are more likely than whites to use injection drugs. All of these factors, Dr. Millett says, may drive an already-stigmatized group of individuals even further underground, thus reducing the chance that they will acknowledge homosexual tendencies, even to themselves -- and making them far harder to reach with HIV prevention, testing and counseling efforts. It is that sort of scenario that may have helped spur the HIV outbreak that STAT discovered on North Carolina college campuses.
The Bottom Line: Alarming Findings and a Program at Risk
For the first time, the STAT program has documented an outbreak of HIV infection while it is still in progress, which raises hopes that prompt and thorough interventions can nip the outbreak before it grows even further. Although much has been made about the surprising discovery of HIV in colleges, however, this should not in itself be such a shock. Most of these recent infections, after all, are occurring in young, black men who have sex with men, a trio of characteristics that are associated with higher rates of HIV infection -- and characteristics that are prevalent throughout much of the southern U.S. "I think if other states in the Southeast look for this, they would find it," said Peter Leone, M.D., the medical director of North Carolina's HIV prevention and care program. "I don't think it's unique to North Carolina."
At a press conference following the North Carolina presentation, mainstream reporters asked researchers why it took so long for HIV to find its way into college campuses. There may be more pertinent questions to ask, however: How do we know it has taken this long? How do we know it hasn't happened before? How do we know it isn't happening right now on other college campuses, or in other communities, in other states throughout the country? This is, after all, the first time, and in the first location, that a program like STAT has ever been used.
What's truly alarming is that none of these questions may be answered anytime soon. STAT, the program that brought about the headline-grabbing North Carolina findings, is due to exhaust its funding this November, and no significant progress has yet been made toward either the program's renewal in North Carolina or its reproduction in other parts of the U.S.
"I'm still sort of appalled that we don't have people saying, 'We can't tolerate this,'" Dr. Leone said of the inaction. "It really just floors me. The CDC [U.S. Centers for Disease Control and Prevention] should be jumping up and saying that we've got to do something about it."
STAT researchers requested more than $1 million in additional funding from the CDC last year, both to continue STAT and to implement more comprehensive testing and prevention programs in North Carolina colleges, according to Dr. Hightow. Although the CDC was intimately involved in the mapping of the sexual network among North Carolina college students, Dr. Hightow noted, months have now passed without a response to the funding request. "This project is no good if we don't do anything about it, but, unfortunately, we can't do any more than we've done without more money," Dr. Hightow said.
At the moment, the prospects for the implementation of STAT in other states also do not appear particularly strong either. Though Dr. Hightow said that several states with large high-risk populations, including Florida and New York, have expressed an interest in the program, STAT is not necessarily easy to reproduce on a large scale: It requires a high level of collaboration between well-established existing services, such as acute HIV testing and HIV partner notification, which many states do not yet possess. "We're pretty unique in how we do it," Dr. Hightow said. "This is a great example of how collaborations can work."
Lastly, of course, is the reality that even after ongoing outbreaks of HIV can be spotted using a system like STAT, prevention efforts must be implemented or strengthened in order to curtail new infections, and bridges may need to be established to get the newly infected into counseling and treatment. Many of the colleges impacted by this outbreak have taken steps to implement HIV education, prevention and screening programs, Dr. Hightow said. For instance, a program called Project Commit to Prevent, which works with historically black colleges, has been ramped up since officials first warned them of the outbreak last year. Some colleges have also included HIV education materials in their freshman orientation packages. "All would want to do more, but they're limited by funding as well," Dr. Hightow said. Without further data from STAT and new funding, it will be difficult to design and tailor these programs to the outbreak as it evolves.
What we are left with, then, is an alarming finding, discovered by a unique method of detecting and tracing recent infections, with relatively dim prospects at present for an improvement of the situation. It can be hoped that additional funding will be secured for the STAT program, as well as for organized prevention, counseling and care efforts directed at the people impacted not only by this particular outbreak, but by any other ongoing outbreaks that STAT is able to discover in the time it has left. Given the current political climate and the deteriorating condition of HIV-related services throughout the country, however, there is a possibility that hope is about all there will be.
Abstract: Men on the "Down Low": More Questions Than Answers (Oral 83)
Authored by: Greg Millett
Affiliations: CDC, Atlanta, GA
Abstract: Transmission on Campus: Insights From Tracking HIV Incidence in North Carolina (Oral 84)
Authored by: L. B. Hightow, P. MacDonald, C. D. Pilcher, A. H. Kaplan, E. Foust, T. Q. Nguyen, P. A. Leone
Affiliations: Univ. of North Carolina at Chapel Hill, NC; North Carolina Dept. of Hlth. and Human Svcs., Raleigh, NC
Abstract: Investigation of HIV Transmission in Black MSM College Students and Non-Students in North Carolina (Oral 85LB)
Authored by: L. Fitzpatrick, L. Grant, C. Eure, S. Phillip, G. Millett, K. Jones, L. Hightow, R. Stall, P. Leone, S. Holmberg, E. Foust, A. Greenberg
Affiliations: CDC, Atlanta, GA; North Carolina Dept. of Hlth., Raleigh, NC; Univ. of North Carolina, Chapel Hill, NC
Abstract: Are Bisexual Men a Bridge Population for Transmission of HIV to Female Sex Partners? (Poster 846)
Authored by: J. Sackoff, L. Coffee
Affiliations: New York City Dept. of Hlth. and Mental Hygiene, NY
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