Larry Kramer told the NY Times today that there is no AIDS policy in the U.S. To which Kevin Fenton, the aimless director of CDC’s AIDS efforts, replied, non-sequitur-ly, “CDC is not resting.”
The occasion was CDC’s publication in PLOS One of new figures claiming that the annual number of new HIV infections in the U.S. is only around 50,000.
And if you read the CDC’s new Fact Sheet on HIV infection, just posted, you find out that
The current level of HIV incidence in the United States is likely not sustainable. Prevention efforts in recent years have successfully averted significant increases in new HIV infections, despite the growing number of people living with HIV and AIDS who are able to transmit the virus.
CDC English is a little difficult for native speakers to interpret, but I think that the translation of “likely not sustainable” is: “we need more money or else the incidence is going to go up.”
Now, 50,000 new HIV infections each year is bad news for 50,000 Americans. But on a population basis, it’s not a very high number. The HIV prevention industry will wring its hands, and perhaps Mr. Kramer will, too. They can all grumble that after 30 years of AIDS there should be no new infections at all. But that’s ridiculous. A pipe dream. HIV is a sexually transmissible infection. And STIs can’t be eradicated — because, well, people have sex. No matter what. And sometimes the kind of sex that isn’t recommended by the experts. With the wrong people. And so forth.
Really, that there are only 50,000 new infections each year is a sign of (a) the low inherent infectiousness of HIV and (b) Americans’ sharp awareness of how to protect themselves from HIV infection. It’s not really clear that any new prevention is needed.
What is needed: get effective treatment into more HIV-infected people. Obviously, to slow the progression of HIV-based impairment in the individual — but also as a public health measure, to reduce the HIV carrier’s infectivity and thereby reduce the probability of transmission. It would have medical value and public health value. But there’s not much policy on that.
CDC officials are bean counters, not policy makers. That’s why, Mr. Kramer, your expectations are too high. The CDC’s job is not to do anything about AIDS. CDC’s job was never to do anything about AIDS. CDC’s job was, and is, and presumably will always be: to keep CDC in business.
They’re terrific bean counters, obsessive, scrupulous, punctilious, completely absorbed in their own assumption that their data are a source of truth, committed to deciphering the supposedly unequivocal message the data send.
The message, always, is “CDC needs to do more of what it’s been doing.”
I gave the CDC a hard time in August 2008, when the agency published its estimate that there are 56,000 new HIV infections in the U.S. each year. That seemed too high, I told the NY Times at the time. Of course, it was useful for the CDC’s rudderless AIDS division to claim that HIV incidence was higher than everyone thought: suddenly, lots of people were urging that HIV prevention programs be beefed up.
Now, the agency has backpedaled. The 2006 incidence wasn’t 56,000 after all, the CDC now figures, it was only 48,000. And anyway 56,000 is the same as 48,000, the agency now says.
Let me summarize: Back in 2008, the CDC’s estimate supposedly showed that prevention wasn’t working, so the agency needed to do more of it. The new estimate, which is almost the same as the old estimate, shows that prevention does work, so the agency needs to do more of it. All CDC calculations point to the same conclusion: keep CDC in business.
If CDC were interested in the nation’s health, more so than maintaining its meager status quo, it would be advocating for more treatment (to Donald McNeil’s credit, he makes that point in today’s NYT article).
And if CDC were interested in HIV as a public health problem, and not just in bean counting for the purposes of keeping itself in business, it would stop putting its beans into 30-year-old jars. What’s the point of the tired “race/ethnicity” breakdown? Does anybody know anymore how to categorize people into the ancient non-Hispanic-black/Hispanic-including-black/non-Hispanic-white codification? Does anybody know what it means?
And the famous transmission categories, the MSM-IDU-heterosexual-other breakdown: that was useful early on, when we weren’t sure that the modes of communication of HIV were fully known. But that era ended in 1985.
Dear CDC: Could you please put your beans into some useful jars?
No, it’s asking too much. Because CDC’s aim isn’t to be useful. It’s to keep counting beans exactly the way it knows how to count them, and put them into the same jars as always, and keep on concluding that the data — the beans — show that CDC must keep on doing exactly what it has been doing.