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Beyond condoms

Although the number of new AIDS cases in Maryland has been declining in recent years, transmission rates among young gay men and transgender people remain alarmingly high and continue to rise. Public health officials warn if the trend isn't reversed, years of progress against the illness could be undermined as the virus infects a new generation of victims. That's why the $20 million grant to Baltimore City from the federal Centers for Disease Control announced today is urgently needed to target young gay and transgender individuals with new preventive and treatment strategies that reduce their risk of contracting the disease.

Gay teens, young adults and transgender people are notoriously hard for health workers to reach because they so often feel marginalized and estranged from their families and communities. In Baltimore City, those most likely to contract HIV are also disproportionately black and poor; although African-Americans comprise about 64 percent of the city's overall population, they make up more than 85 percent of its HIV infections. As a result, health workers not only need to find new ways to meet their medical needs but also to address the stark social and economic disparities that put them at risk.

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Compounding the problem, the social isolation experienced by gay teens and transgender people means they have relatively little contact with the health care system in the form of regular medical checkups and doctor's visits — and as a result they often don't know they're carrying the HIV virus that causes AIDS. Moreover, even if they get tested they are less likely to go into treatment, and those who do go into treatment are less likely to stay there.

City health officials say that as many as one in five young gay males who is infected with the virus does not know it and continues to have unprotected sex. A similar situation exists among transgender women, many of whom cannot find work in the mainstream economy because of discrimination and are forced to engage in commercial sex in order to support themselves. They are at particularly high risk of infection because they are likely to be involved with multiple partners of various sexual orientations, and they have little control over the activities they engage in.

From experience, health workers know such behaviors are extremely difficult to change. That's why the strategies the city is preparing to roll out focus on prevention among people who are not currently infected but who are at risk of becoming so. Modern drugs can reduce HIV levels in the body to the point where the virus is nearly undetectable, greatly reducing the infectiousness of individuals and their ability to spread the disease as long as they are taking the medication. Health workers plan to devote much of their effort to ensuring at-risk individuals take their daily medication and stick with the regimen over time.

The program will also rely on another preventive medication called PREP (for pre-exposure prophylaxis), a relatively new drug that can prevent the HIV virus from permanently infecting someone if they are exposed. Given to people who engage in risky behavior, the drug can reduce their chances of contracting the virus by up to 92 percent. City health officials, who plan to incorporate the daily pill as a key element of their strategy, say PREP has the potential to greatly reduce the number of new HIV infections if consistently used under medical supervision.

This is a broad collaborative effort that will see Baltimore partner with nearly a dozen local community organizations and nonprofit groups in a sustained effort to address the health crisis threatening one of the city's most vulnerable populations. The CDC grant adds important new tools to the city's capacity to reduce HIV infection rates among the estimated 20,000 gay men of all races in Baltimore, and it will begin to address the needs of a transgender community that until recently remained largely hidden from view. Health officials have realized they need to move beyond urging people to use condoms to focus on more effective forms of prevention, and that's why this initiative is so important.

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