Despite major medical advances and more than 30 years of effort, the United States is still in danger of losing the war on AIDS, according to the country’s top disease-control official.
In an essay in The New England Journal of Medicine published on Tuesday, World AIDS Day, Dr. Thomas R. Frieden, the director of the Centers for Disease Control and Prevention, and Dr. Jonathan Mermin, the agency’s chief of AIDS prevention, paint a bleak picture of the fight.
“Hundreds of thousands of people with diagnosed H.I.V. infection are not receiving care or antiretroviral treatment,” they wrote. “These people account for most new H.I.V. transmission.”
There are 45,000 new H.I.V. infections each year, the article noted.
In an interview, Dr. Frieden said he “still views the glass as half full.” While medicines are improving, legal barriers have been lifted and Americans are getting tested, more people with H.I.V. need to be put on treatment and kept on it.
While the article’s language was dry and academic, some AIDS experts said it amounted to a call for radical changes in how the disease is fought. But those changes can be made only by state and local health departments, over which the C.D.C. has little control.
“Tom is giving the view from 30,000 feet,” said Dr. William Schaffner, the chairman of preventive medicine at Vanderbilt University. “He’s trying to be the conductor of a disparate orchestra in which the drums and trombones have different bosses and are paid by different people.”
Other experts complained that Dr. Frieden should have gone further, calling for much more funding, a heavier reliance on preventive drugs and the decriminalization of H.I.V. transmission. “It’s a pretty weak piece,” said Mark Harrington, the executive director of the Treatment Action Group, an AIDS activist organization.
Dr. Frieden was effectively calling for H.I.V. to be fought the same way that syphilis and gonorrhea are, “and we’re doing terribly on those,” Mr. Harrington sai
He and other advocates urged wider adoption of a multipronged approach to treatment and prevention like that used in San Francisco, which offers services to the most difficult patients, including addiction and mental health treatment, help with housing and even escorts to the hospital.
Among the most notable failures cited by Dr. Frieden and Dr. Mermin:
Nearly 65 percent of the estimated 1.2 million Americans with H.I.V. are not on treatment; many disappear right after being tested. Those patients, whose H.I.V. is undiagnosed or newly diagnosed but who are untreated, account for 90 percent of all new infections.
Infected people are rarely asked to name their sexual partners so that health providers can reach out to them. When health providers do have names, little is done with the information.
Risky behaviors — including unprotected anal sex and needle-sharing — appear to be increasing.
Infection rates are rising among young gay men, especially blacks and Hispanics.
The essay is a follow-up to one Dr. Frieden wrote for the journal for World AIDS Day 10 years ago, when he was New York City’s health commissioner.
That one was equally pessimistic and dryly radical. In it, Dr. Frieden expressed frustration with “AIDS exceptionalism” — laws that made it difficult for public health authorities to treat AIDS as they might tuberculosis, syphilis or meningitis.
A decade ago, it was almost impossible to even test for H.I.V. because intensive counseling was often required first, which took time and money and scared people off. Lab results were reported to health officials with no names attached, leaving them unable to find infected people or to tell if treatment was working.
Dr. Frieden argued then for a public health approach to outweigh a strictly medical one. The difference is that a medical doctor’s first duty is to the patient, while health officials like him are charged with protecting the population at large.
The two come into conflict, for example, when an infectious patient willfully refuses treatment and keeps passing on a disease. In the 1990s, during an outbreak of drug-resistant tuberculosis in New York City, Dr. Frieden famously detained patients who refused to take their pills, locking them in hospitals for months until they were cured.
In 2005, he advocated H.I.V.-control measures that he said would “offend both sides of the political establishment.” Condoms and clean syringes were needed even if conservatives disliked them, he said, and the tracing of sexual partners needed to be done even if H.I.V. activists opposed it.
Some of those goals have become law.
Although H.I.V. testing is not mandatory except in the military and under a few other circumstances, the counseling requirement has been dropped. Many hospitals test all patients unless they specifically refuse, and some cities even pay people applying for driver’s licenses to take H.I.V. tests.
Lab results are now reported by name almost everywhere. That makes it possible for local health workers to contact patients to make sure they receive help and to ask for the names of their sex partners so they, too, can be treated.But that is failing, Dr. Frieden said in the interview. Only about half of those testing positive for H.I.V. are ever asked for names, and those who choose to answer “named relatively few.”
Local health departments lack the staff to trace contacts. “To be fair, it’s legitimately hard,” Dr. Frieden added. Some people find sex partners through apps like Grindr without ever learning their names.
New tests can detect the virus within 10 days of infection, but they are not being used enough, he said. An estimated 155,000 Americans with H.I.V. do not know it. And of those who are tested, 20 percent already have AIDS or are close to it — meaning they may have been spreading the virus for years.
The C.D.C. recommends that sexually active gay men be tested four times a year, but that rarely happens.
Treatment is also inadequate. Multiple studies have shown that patients who are immediately put on drugs remain healthy longer and stop infecting others. Yet only about 36 percent of those infected have prescriptions, Dr. Frieden said. (Others have put the figure higher. In San Francisco, 82 percent of H.I.V. patients get prescriptions.)
The national averages are dragged down by states, mostly in the South, that have high H.I.V. rates but rejected the Affordable Care Act’s expansion of Medicaid, which would have covered testing and treatment.
There have been important scientific advances, like new milder drugs and the rollout of Truvada, a pill that prevents infections.
But “the fact that the dial hasn’t moved on 45,000 new infections a year is a tragedy,” said Mitchell J. Warren, the executive director of AVAC, an organization lobbying for AIDS prevention.