Viral rebound?

Mourners, activists, and ordinary citizens on Oct. 7 draped the Capitol Mall with a gigantic red ribbon-a ribbon made of human beings wearing red ponchos and marching in Washington, D.C.'s annual AIDS Walk. Other events across the country also marked National AIDS Awareness month and raised lots of money. In San Diego, AIDS Walk participants raised a record $701,000.

It appears that those fighting AIDS/HIV are going to need the money. Reports by the Centers for Disease Control, the Institutes of Medicine, and at least one metropolitan public health department show that HIV infection rates are once again on the rise. Researchers blame the viral resurgence on waning adherence to the "safer-sex" ethic, the failure of condom-centric HIV prevention efforts, and the breakdown of previously effective drug regimens. They also are worried: With a fresh wave of the virus percolating through major urban areas, a second wave of AIDS may not be far behind.

A spike in HIV infection rates in San Francisco was among the first red flags. This summer researchers there discovered that the rate of new infections among male homosexuals had nearly tripled since 1997. This finding accompanied other disturbing trends among homosexual men, including a falling rate of consistent condom use (from 70 percent to 54 percent), a higher incidence of rectal gonorrhea, and a return to high-risk, multi-partner sexual behavior.

"I think there's a sense that the drugs have taken care of the problem," said Tom Coates, director of the AIDS Research Institute at the University of California at San Francisco. "Second, I think people believe the disease is slowing." San Francisco has generally been "ground zero" for AIDS/HIV trends, so experts worry that the city's rising infection rate is a blood-borne bellwether for the entire country.

"We think there needs to be a wake-up call for the rest of the nation," said Dr. Ronald Valdiserri, deputy director of the National Center for HIV, STD and TB Prevention at the CDC. "Obviously, we want to be careful about extrapolating what's happening in one city. But the CDC considers this a very important finding."

Since the virus was first identified, America's cities have acted as its primary incubators. In the mid-1980s the disease struck like an urban cobra, killing first in San Francisco, Miami, and New York-all homosexual meccas. Then it slithered out across the rest of the country, cutting an epic trail of death. As of 1999, AIDS has killed 430,411 people in the United States-nearly as many as live in the entire state of Wyoming. The cities still are hotbeds: Last year, 10 cities (New York, Los Angeles, San Francisco, Miami, Washington, D.C., Chicago, Houston, Philadelphia, Newark, and Atlanta) accounted for nearly half of cumulative reported AIDS cases.

Several cities may be seeing the leading edge of a new viral wave. CDC researchers administered HIV tests to 3,492 homosexual men between the ages of 15 and 22 in Baltimore, Dallas, Los Angeles, Miami, New York, San Francisco, and Seattle. The results, released this summer, were grim: On average, 7 percent of those tested were HIV-positive. In New York, 12.1 percent-or more than one in 10 homosexual men-were infected, a level some researchers compare with the infection rates currently raging through Africa.

In the mid-1990s AIDS fighters were optimistic. Though the number of new AIDS cases rocketed upward during the first decade of the epidemic, rising by between 65 and 90 percent annually, by 1996 the graph line was diving. Aided by HIV prevention efforts and medical breakthroughs such as the complex, multi-drug regimens called "cocktail therapies," both new AIDS cases and AIDS-related deaths fell through 1997.

Since then, the statistical nose dive has leveled out. CDC analysts now believe earlier HIV prevention efforts may only have had a stopgap effect: Those most predisposed to treatment-such as older, homosexual males caught in the first AIDS epidemic-have already been reached. But many of today's

at-risk populations, like the urban poor, are hard to reach with either educational efforts or early testing and treatment. In addition, some patients have difficulty adhering to expensive and often laborious drug therapies. And therapies that once seemed to be working are now fizzling in the face of a virus that Margaret Chesney calls "cunning."

"At first it appeared that these (drug therapies) could block the virus's replication process," said Ms. Chesney, co-director of the Center for AIDS Prevention Studies at the University of California, San Francisco. "Eventually the level of the live virus in the system would decline. The hope was that the decline would lead to eradication. That hasn't happened." Instead, she explained, the drugs work temporarily, but even after a patient's blood tests show no trace of HIV, the virus "breaks out" and begins to replicate anew. The new incarnation is stronger than before, sometimes even invincible from the standpoint of current treatment technologies.

The virus is taking a disproportionate toll on minority communities, due in part to higher use of intravenous drugs. Together, blacks and Hispanics accounted for 66 percent of all new AIDS cases in 1999. Three times as many Hispanics as whites contracted the disease last year, as did eight times as many blacks. AIDS remains the leading cause of death among blacks between the ages of 25 and 44. Last December in Houston, city officials declared a state of emergency and issued a call to action to slow the rising rate of infection by injection among blacks.

According to a report issued by the Baltimore City Health Department, approximately 18,000 residents of that city are believed to be living with HIV. According to researchers at Baltimore's Institute for Human Virology (IHV), HIV and AIDS are ravaging three zip codes in the city. IHV behavioral psychologist Lydia Temoshok says one older African-American man she counsels at a city AIDS clinic characterized the impact of AIDS on his neighborhood this way: "All my friends are dead."

That was a phrase commonly spoken by homosexual men in the mid-1980s and early 1990s as the virus bloomed into full-blown AIDS and struck down thousands of people, most of them in their 20s and 30s. But Ms. Temoshok, who has studied the epidemic since 1981, fears that more urban African-Americans could soon be repeating the mantra. She reports counseling many in Baltimore who are newly infected with a strain of the virus that is immune to current medication. "We're still 10 years away from developing new medications," she said. "That's plenty of time to develop full-blown AIDS. These are people who don't have access to preventive medical care." Many are injection drug-users and live in poverty.

Some researchers and activists fear that it is the sputtering HIV prevention message, already one-dimensional in its advocacy of condoms as a cure-all, that may give rise to a new wave of death. AIDS activist Cleve Jones said "public education campaigns have slackened because we're not seeing people dying like we did in the '80s and early '90s. We forget that every year there's a whole new class of high-school kids going out into the world. We need to maintain these messages."

In the seven-city CDC study, 41 percent of homosexual males reported that they did not wear a condom during sex. "We're talking of men who are just becoming ... acculturated into the gay social scene," John Hylton of the Johns Hopkins University School of Hygiene and Public Health told The Washington Times. The CDC researchers concluded: "Considering their youth, the high prevalence of unsafe sex and the high HIV prevalence in those tested, many of the HIV-negative men are likely to become HIV-infected in the near future."