With Baltimore facing a growing AIDS caseload and an epidemic that increasingly strikes women, a city commission is urging officials to make good on a "state of emergency" declared three years ago.
Describing the city's response as splintered and lacking in direction, the group called yesterday for renewed attention to risk groups that also include African-American men and residents of hard-hit neighborhoods in West Baltimore.
"It's not an issue that's at the forefront as it used to be," Dr. William Blattner, the commission's chairman, said at a news conference. "But it's at the heart of the city and it's eating away at the heart."
Blattner and others lauded the city Health Department for its efforts to stem the epidemic but said there wasn't enough coordination among other city agencies - including housing, schools and social services.
"There really wasn't much of a response by the city agencies to this declaration of a state of emergency," Blattner, an AIDS epidemiologist at the University of Maryland Institute of Human Virology, said in an interview.
Although the number of new infections has fallen somewhat in recent years, the city has an ever-growing number of people living with the virus and needing services. This is due, in part, to the fact that new drugs and novel ways of combining them have made it possible for people to live much longer.
Certain neighorhoods beset by drug addiction, violence and poverty bear a disproportionate burden, especially those running along Park Heights Avenue, Liberty Heights Avenue and Reisterstown Road on the west side. One neighborhood, defined by the ZIP code 21217, has 6 percent of the city's population but 13 percent of people living with AIDS, according to the report.
Baltimore ranked fifth in the per-capita number of new AIDS diagnoses in 2003, trailing only New York, Miami, San Francisco and Fort Lauderdale, Fla. That year, almost 40 of every 100,000 people received the diagnosis.
The character of the AIDS epidemic has shifted in recent years, with unprotected sex among heterosexuals overtaking needle-sharing as the leading mode of transmission. Also, women now account for about 40 percent of people diagnosed with AIDS - almost double the percentage diagnosed a decade earlier.
As it has for many years, the epidemic disproportionately strikes African-Americans, with 88 percent of new infections occurring within that group last year. Black men, according to the commission's report, are infected at 10 times the rate of whites.
Mayor Martin O'Malley declared a state of emergency on Dec. 2, 2002, after being lobbied intensely by black ministers and an AIDS commission organized by City Council President Sheila Dixon, who has lost family members to the disease.
A group called the Baltimore City Commission on HIV/AIDS was formed to monitor progress. There are 20 members, including doctors, clergy, business leaders and community activists. In the past year, the commission held monthly meetings to gather public input, leading to the drafting of a report and the news conference to discuss its key findings and recommendations.
O'Malley was not present yesterday, but spokeswoman Raquel Guillory later said the mayor was confident the city Health Department will implement better strategies to fight the disease.
"The report shows that we still have a lot of work left to do to fight the epidemic," she said.
Dr. Joshua Sharfstein, the city's new health commissioner, said the AIDS problem warrants a more focused response.
"Overall, the strain on the system is definitely increasing," he said. In 2004, there were about 14,000 people living with HIV infection or AIDS, compared with 4,100 a decade earlier.
Sharfstein said he is concerned about the future of federal funding through the Ryan White Act, which supplies $19 million of the $28 million being spent this year on AIDS prevention and treatment in Baltimore. Under a formula proposed by the Bush administration and pending before Congress, Baltimore could lose some Ryan White money that is allocated to the state and passed along to the city, he said.
Sharfstein said he plans to make available a new test at city health clinics that can detect genetic evidence of the virus immediately after a person is infected. The test now in use detects antibodies to the AIDS virus, which sometimes don't appear for a few months after infection.
Dr. Peter L. Beilenson, the former health commissioner, said the city made significant inroads into the drug-related epidemic by drastically increasing the availability of drug treatment - including methadone - and starting the nation's largest city-run needle-exchange program.
But reducing sexual transmission is much harder, in part because much of it is driven by men who have unprotected sex with other men but don't identify themselves as gay. Some are married or involved in relationships with women, putting their female partners at risk.
One of the commission members, Dr. Rena Boss-Victoria of the Morgan State University School of Public Health, said many young men don't get tested, treated or educated about AIDS because they feel there is no hope for the future.
Terry Brown, a commission member who works with a group that provides mental health services in West Baltimore, said HIV infection in the prisons spills into the streets as inmates are released. In addition, children left unattended when their parents are incarcerated sometimes turn to prostitution to support themselves.
"Kids on the streets are having sex for survival," said Brown, a vice president of Baltimore Behavioral Health.
Shelton Jackson, a 28-year-old student at Morgan State, said he was surprised to find that people in Baltimore are reluctant to talk openly about being infected. Jackson said he has been HIV-positive for eight years.
"These last few years, I have been very open about my status - who I am," said Jackson, of Newark, N.J. " I got a lot of resistance after moving to Baltimore - people so shocked about my being open about being gay and about my status. We can't all be in the closet."