Jul 212012
Natrussa Williams of the Family and Medical Counseling Service with a Washington resident after he agreed to take an H.I.V. test last week while waiting at the Department of Motor Vehicles

Angela Byrde, 27, is getting only the secondH.I.V. test of her life — at the Department of Motor Vehicles.

Her situation exemplifies what is wrong with Washington’s AIDS epidemic, and America’s — and what the nation’s capital is finally doing to fix that. As a diabetic with Medicaid coverage, Ms. Byrde has seen doctors several times a year since she was 12, but they never suggested that she be tested, even though she lives in a city with one of the country’s highest H.I.V. infection rates.

Now the city, trying to find the estimated 5,000 Washingtonians who are infected but do not know it, is offering tests in grocery stores and high schools, on corners where addicts gather and even in motor vehicle offices. And it is paying people to take them.

“Seven dollars to take a mouth swab?” Ms. Byrde said. “It just works. And they make sure you don’t lose your place in line.”

Starting on Sunday, Washington will host 20,000 scientists, public health officials, activists and journalists at the biannual conference of the International AIDS Society, the world’s biggest gathering devoted to the disease. It is the first time in 22 years it has been held in this country, where the epidemic was first spotted 31 years ago. And it has come here because the Obama administration lifted the Reagan-era prohibition on people who are H.I.V. positive entering the country.

Despite decades of alarm over the AIDS epidemic and many advances in treatment, testing is so inadequate in the United States that about 240,000 Americans do not know they are infected, and many spend years spreading it.

The District of Columbia is a microcosm of both the best and worst trends in modern AIDS prevention and treatment. Infection rates here were so bad that they were compared to those in Africa. But the city’s innovative new programs, like testing people at motor vehicle offices, have been paying off.

New cases have fallen to 835 from 1,103 in 2006. And the number of mothers who infected their babies shrank to zero in 2010 from nine in 2005.

“It’s a tale of two cities,” said Phill Wilson, executive director of the Black AIDS Institute. “You can see the epidemic as bad as it is anywhere around the globe, and you can see some of the best practices.” As such, he said, Washington is “the perfect city to have this conference in.”

A new political will is driving the city’s turnaround.

“D.C. used to be a bureaucratic nightmare,” said Dr. Anthony S. Fauci, director of theNational Institute of Allergy and Infectious Diseases, which is just three subway stops outside the city, in Bethesda, Md. When Adrian M. Fenty took office as the mayor of Washington in 2007, Dr. Fauci said, “it was a whole new morning in America.”

The change is evident on many fronts. The number of H.I.V. tests given has tripled to 122,000 a year, from 43,000 in 2007. The city gave away five million male and femalecondoms last year, 10 times as many as it did in 2007. More than 300,000 clean needles a year are given away, both to heroin users and to an even higher risk group: transgender prostitutes who inject hormones.

Patients are being found in earlier stages of their illness, when it is more treatable. And 89 percent of those who test positive see a doctor within three days. Under the city’s Red Carpet program, nonprofit organizations are paid to drive new patients to the doctor.

Washington has some major advantages over rival cities. Almost 94 percent of its residents have health insurance, second only to Massachusetts. And there are no waiting lists for AIDS drugs or addiction treatment.

Also, Washington has switched from anonymous to name-based testing, so it can better track infection trends. And in 2007, Congress, which oversees the city’s administration, dropped its ban on clean-needle distribution; since then, infections attributed to dirty needles have plunged by 72 percent.

Black men here are the hardest hit: 6.3 percent in Washington are infected, a rate that rises to more than 30 percent for middle-aged black gay and bisexual men. Even so, the Black AIDS Institute just named Washington one of “the three best cities to be a black gay man in,” based largely on available medical care. (The others were New York and Los Angeles.)

Still, the city has tremendous weaknesses.

Washington finances 70 nonprofit groups, and their effectiveness varies greatly. Each has its own executive salaries, ingrained habits and political patrons. Some are excellent, some have sunk in financing scandals, and some are “left over from the days when all they did was hold people’s hands and watch them die,” said Dr. Gregory Pappas, chief of AIDS for the city’s health department. “The game has changed — but some, God bless them, are the same old people doing the same old things.”

Another weak point is the inefficiency of random testing. Each test consumes about 20 minutes alone in a room with a counselor — and only about one of every 100 people tested at the Department of Motor Vehicles, for example, is infected. (Ms. Byrde was not.) Even at AIDS clinics here, only 2 percent of tests are positive. Many family doctors resist testing at all.

“I spoke to one older practitioner, and he felt he’d be liable if he tested his patients and they didn’t want to know the diagnosis,” said Dr. Lisa Fitzpatrick, an AIDS specialist at United Medical Center in Southeast Washington. “He said: ‘I see three generations of one family. I’d offend them if I asked.’ ”

Experts say that “contact tracing,” asking a newly diagnosed patient to name everyone he or she has slept with and then testing them, is far more efficient. Aggressive contact tracing has been central to Cuba’s largely successful battle against AIDS.

But many patients decline to cooperate. For example, Justin Goforth, chief of adherence for Whitman-Walker Health, a health center that specializes in treating gay patients, said asking for names at the first visit, as required by law, was bound to fail. “At that first visit,” he said, “everyone is freaked out and scared, and remembers maybe 5 percent of what the doctor says.”

Even with cooperation, the city has only enough money to trace the contacts of a third of those who test positive for syphilis, gonorrhea, H.I.V. or other sexual diseases, Dr. Pappas said. But it is efficient: about 10 percent of contacts have H.I.V.

His department, he added, has just begun experimenting with “social network tracing,” which was pioneered in Harlem and San Francisco and produces 25 percent positive infection rates. It involves having groups like HIPS, a social service agency for prostitutes, offer their members incentives to bring in friends they suspect are infected for testing. In Harlem, the incentive is a movie ticket. Washington offers up to $10.

The city also too often fails to track patients once drugs are prescribed. Studies have shown that patients who take their drugs consistently lower by 96 percent their chances of infecting others. But only 29 percent of those diagnosed in Washington take their drugs every day, which is about average for an American city, according to the Centers for Disease Control and Prevention.

Cuba is the rare international success story at this too. Every Cuban is assigned a government doctor, who is expected to ensure that patients take their medicines. Every patient is required to take a two-week course in living with H.I.V., and all medical records are in a national computer network.

Mr. Goforth uses a miniature version of that model, and says his clinic has an 80 percent success rate: every patient is assigned a case manager who gives a course in “what’s going on in your body and why you need to take the drugs,” he said.

Homeless or troubled patients get to use a day room with meals, showers, laundry services, support groups and psychiatric care available.

More important, the clinic has its own pharmacy, and the computer notifies the manager if a prescription goes unfilled.

“If you don’t show up, we stalk you,” Mr. Goforth said.