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HIV/AIDS: It's Not Just What You Do, It's Where You Live

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July 23 marked the opening of the International AIDS Conference in Washington, D.C. For the first time in 22 years, the conference is returning to U.S. soil. Advocates, scholars and policymakers alike are calling for universal treatment programs that both save lives and enhance HIV prevention. However, too few conversations about the domestic epidemic are focused on how we achieve those goals; scaling treatment must start with dramatically scaling routine HIV screening in the most highly impacted communities of the U.S.

Historically, many HIV testing and prevention efforts have been risked-based, meaning that they focus on reducing behaviors that increase your chances on contracting HIV, such as unprotected sex and drug use. These prevention efforts have been successful in increasing knowledge and changing attitudes. Sadly, these efforts have fallen short in addressing our nation's alarming racial disparities in HIV infection. Despite the fact that African Americans do not engage in any riskier behaviors, they have seven times the rate of HIV infection as whites; these disparities are even wider for African American women, who have nearly 15 times the rate of infection as white women.

The testing and prevention efforts have also done little to reduce the number of new infections each year in the U.S. Americans have steadily been contracting HIV at the rate of 50,000 individuals each year for some time. Twenty percent of individuals who are HIV-positive don't know it, and they account for about 50 percent of new HIV infections. To effectively diagnose those individuals who do not know their status, we have to change our testing and prevention strategies.

A mounting body of scientific evidence shows that where you live, your race and your socioeconomic status -- not just behaviors -- strongly correlate with HIV infection. A 2011 study found that individuals who adhere to drugs for AIDS treatment have a 96 percent lower risk of transmitting HIV to others than people who don't take antiretroviral medications. The study culminated in calls for widespread HIV testing and redoubling public health efforts to retain HIV-positive individuals in treatment and care. The acclaimed journal Science heralded this finding as the scientific breakthrough of 2011.

This important discovery may explain geographic clustering of HIV infection and should inform our testing and prevention efforts. Communities with high poverty rates may have limited access to medical services or low rates of insurance coverage. Many individuals in these communities may not have recently undergone testing, and there may be large numbers of individuals who are HIV positive but do not know it that unknowingly transmit the virus to others. This may contribute to high levels of "community viral load," or the level of HIV virus in a community. High community viral load increases the chances that individuals come into contact with HIV. Essentially, where you live may be nearly as important as what as what you do.

Both the CDC's new High-Impact HIV prevention strategy and President Obama's National HIV/AIDS Strategy call for resources to be allocated to the most heavily impacted communities. This should include promoting widespread, routine HIV testing and treatment in neighborhoods with high infection rates.

History and science tell us what works in HIV prevention: Routine HIV testing, treatment, social marketing, community mobilization, and political leadership have all been critical components of effective HIV prevention policies, but have rarely been combined in the most highly affected neighborhoods. To address this social justice and public health crisis, we must redouble our efforts by combining these effective approaches in the nation's most highly affected neighborhoods. This geographic approach to HIV prevention is gaining traction across the country: Harlem United, non-profit agency in New York City, found high rates of HIV infection in their BLOCKS campaign, which offered HIV testing block-by-block; Bronx Knows promotes HIV testing and treatment across the entire borough. Lead the Way in San Diego also promotes HIV testing in a door-to-door campaign.

Just last month, we launched an HIV testing and treatment campaign in partnership with dozens of community leaders, churches and a federally-qualified health center in Southwest Philadelphia. Our campaign, entitled Do One Thing, encourages an entire community to do one thing: Get tested. Do One Thing combines a social marketing campaign with massive scale-up of HIV testing at a federally qualified health center; door-to-door testing; community testing events; and engagement from business, faith and political leaders in one of the most highly impacted neighborhoods of Philadelphia. We will then provide testing and link anyone who tests positive to medical care. We aim to develop a model that can be shared and replicated in urban communities across the United States.

We now have the tools to eradicate the AIDS epidemic; in 2012, where you live and the color of your skin should not impact your risk for contracting HIV.

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