Applying Public Health Principles to the HIV Epidemic

Abstract

Although human immunodeficiency virus (HIV) infection has killed more than half a million people in the United States, a comprehensive public health approach that has stopped other epidemics has not been used to address this one. When HIV infection first emerged among stigmatized populations (homosexual men, injection-drug users, and immigrants from developing countries), the discriminatory responses ranged from descriptions of AIDS as "retribution" to violence and proposals for quarantine, universal mandatory testing, and even tattooing of infected persons. This response led to HIV exceptionalism, an approach that advocated both for special resources and increased funding and against the application of standard methods of disease control. The need for extra resources remains essential, but the failure to apply standard disease-control methods undermines society's ability and responsibility to control the epidemic. Now, given the availability of drugs that can effectively treat HIV infection and progress on antidiscrimination initiatives, perhaps society is ready to adopt traditional disease-control principles and proven interventions that can identify infected persons, interrupt transmission, ensure treatment and case management, and monitor infection and control efforts throughout the population (Table 1). Doing so will have political and economic costs. The political costs include offending both sides of the political establishment: conservatives who oppose the implementation of effective prevention programs, including syringe exchange and the widespread availability of condoms, and some HIV activists who oppose expansion of testing, notification of the partners of infected persons (also known as partner counseling and referral services), and what some see as inappropriate "medicalization" of the response to the epidemic. The economic costs, particularly to improve population-wide case management and notification of partners, would be substantial. But the human and economic costs of failing to adopt a comprehensive public health approach are much higher.