Baltimore continues to lead major American cities in the percentage of gay men infected with HIV, according to a recently released report from the U.S. Centers for Disease Control and Prevention.
About 38 percent of men who have sex with men in Baltimore were infected — twice the overall percentage in the 21 cities studied by the CDC in 2008.
More troubling, researchers said, was the number of those who were unaware of their infection. That was nearly three-quarters in Baltimore and rising, compared with about 44 percent nationwide.
While officials locally and federally say the study was somewhat limited, with about 8,000 men surveyed at bars, clubs and other gathering places for gay men, they say the message is clear: Not enough is being done to test and treat the most at-risk group of Americans. They add that it will take effort to overcome barriers such as the stigma of being gay.
"The impact among cities varied greatly, but at least one in four were infected in many cities," Jennifer Horvath, a CDC spokeswoman, said about the report. "It's alarming, and it does point to the importance of ensuring access to HIV testing."
More than half of those testing positive for HIV each year and about half of those living with HIV in the U.S. are gay men, according to the national figures.
The reasons gay men — or according to the CDC category any "men who have sex with men" — don't get tested aren't entirely clear, officials said.
The stigma associated with being gay is still strong, particularly in urban black communities, said Richard Matens, Baltimore's assistant commissioner for chronic diseases. A lot of their activity is hidden from friends and family, not to mention public health officials.
Some people would rather admit to being an intravenous drug user, another high-risk group for HIV, he said. And programs in the city have been more effective in lowering the number of drug users infected through needle exchange programs — to fewer than 200 new cases in 2008 from 700 new cases in 1994.
That's helped bring down the overall HIV infection rate in the city to an estimated 3 percent, but not specifically among gay men. (Exact infection rates among gay men are hard to come by; the CDC sample of about 500 men in Baltimore was among those who go out to bars and clubs.)
The city has held focus groups in the gay community and tapped the Maryland Institute College of Art to help create new public messages that resonate. Officials are doing outreach in after-hours clubs for gay men.
"In Baltimore, HIV is a very complex disease to prevent and address," Matens said. "In other areas of the country, they may have one of the high-risk groups driving the disease — heterosexuals, IV drug users and men who have sex with men — but in Baltimore, we have all three."
Dr. Ryan Westergaard, who works in an HIV clinic in Baltimore and sees all three groups, said most patients acknowledge the drug use and not the unprotected sex with men, so they get more attention.
And at one point, drug users needed the attention. When the HIV epidemic hit in the 1980s, gay communities were hit hard. By 2001, however, gay men were trailing drug users in the number of new cases, state officials said. But the tide turned again in Maryland about six years ago, when gay men again took the lead in new cases.
Westergaard, a fellow in the division of infectious diseases at Johns Hopkins University's School of Medicine, suspects one problem is that young people today don't have friends dying of AIDS and have gotten complacent. Couple that with a sense of invincibility, and they don't feel a need to be tested or treated.
In poor urban neighborhoods, there isn't always an easy opportunity to get tested and treated, he said. Most people don't have insurance or see a doctor regularly. So, recent efforts to include HIV testing in routine medical care won't reach everyone in Baltimore.
When patients come to the clinic, often because they've become sick, some admit they don't want to know their HIV status so they won't have to deal with it.
The problem is that when they don't know they are infected, they continue to spread the disease through unprotected sex, Westergaard said. Medications around for the last 15 years would not only make them less likely to pass the disease, but also more likely to live a normal life span.
"I get pleasure telling patients that they have the same life expectancy as those without HIV," he said. "The problem is if it goes untreated for 20 some years, AIDS-related complications are not uncommon. But telling people they're not going to die is pretty powerful."
All those issues — the stigma, sense of invincibility, lack of health care, fears — are barriers to testing and treatment, said Colin Flynn, chief of the Center for HIV Surveillance in Maryland's Infectious Disease and Environmental Health Administration. He helped conduct the CDC study in Baltimore.
He said that's how the number of infected got so high in Baltimore — 38 percent, according to the CDC report, which was about the same as in the last CDC study in 2004-2005. And perhaps that's why more are unaware of their HIV status — 73 percent in this report, up from 62 percent.
Flynn believes the number has become "self sustaining" as infected black men in poor neighborhoods, where there are higher rates of most diseases, continue to engage in unprotected sex with other members of the community.
And the rate of infection isn't likely to drop without more resources, said Heather Hauck, director of the Infectious Disease and Environmental Health Administration
The state receives about $10 million for HIV prevention from the CDC and $40 million under the federal Ryan White Care Act to pay for treatment of low-income people. Much of the money goes to Baltimore, counties around the city and the Washington suburbs, she said.
Baltimore City gets another $20 million in Ryan White money for care, and six clinics get $5 million. Around $1 million in federal dollars that had been going to the city for prevention was cut last month.
"The alarming numbers show us, and epidemiological data show us that over the years, we really need to add resources," she said. "We certainly believe a national investment in prevention would allow us to bring a successful program to scale and allow more people to be tested and linked to care and treatment."
New York (29)
Top HIV cities:
The CDC surveyed 21 cities for HIV infection among gay men
Source: Sept 24 CDC Morbidity and Mortality Weekly Report