News this Week

Science  13 Jul 2012:
Vol. 337, Issue 6091, pp. 138
  1. Around the World

    1 - Cambodia
    Mysterious Disease Kills Dozens in Cambodia
    2 - Rome
    Drastic Cuts Infuriate Researchers
    3 - Washington, D.C.
    NSF Finds Icebreaker To Reach McMurdo
    4 - Republic of Congo, Cameroon, and the Central African Republic
    New World Heritage Site Spans Three Countries
    5 - Panama City
    South Korea Considers ‘Scientific’ Whaling
    6 - Raleigh, North Carolina
    Revised Sea Level Rise Bill Goes to Governor

    Cambodia

    Mysterious Disease Kills Dozens in Cambodia

    CREDIT: SAMRANG PRING/REUTERS

    Scientists have identified a possible culprit in the syndrome that has killed dozens of children in Cambodia since April, the Cambodian Ministry of Health and the World Health Organization announced on 8 July.

    Between April and 5 July, 59 children in Cambodia fell ill with symptoms that include respiratory illnesses, fever, and convulsions, according to the health ministry. Of those patients, 52 died.

    As of Monday, a conclusive diagnosis was not yet in. But laboratory work at Institut Pasteur du Cambodge in Phnom Penh pointed to hand, foot, and mouth disease, a contagious and sometimes fatal illness. Samples from 15 of 24 patients tested positive for Enterovirus 71, one of the pathogens that causes the disease.

    Vietnam has been badly hit by hand, foot, and mouth disease, so “we were expecting an outbreak sooner or later,” Institut Pasteur head virologist Philippe Buchy wrote in an e-mail. http://scim.ag/Cambdisease

    Rome

    Drastic Cuts Infuriate Researchers

    Italian scientists are up in arms over budget cuts at a dozen national research institutes, part of a spending review announced on 6 July that will strike €26 billion from the national government's budget. “News about these cuts came out of the blue, and it's outrageous,” says Fernando Ferroni, the president of the Italian National Institute of Nuclear Physics (INFN), which will be hardest hit.

    INFN, which contributed to last week's discovery of the Higgs boson, will see its €278 million budget cut by 3.8% this year and by another 10% both in 2013 and in 2014. Italy's National Research Council (CNR), a €1 billion funding agency, faces cuts of 1.2% this year and 3.3% each of the next 2 years. The cuts have to be approved by the Italian parliament within 60 days.

    Heads of the institutes received no warning but hope to change the mind of Italian research minister Francesco Profumo at a meeting scheduled for this week. “We shall do our best to convince our politicians that research is a key element for the economical growth of our country,” says CNR President Luigi Nicolais. http://scim.ag/Italycuts

    Washington, D.C.

    NSF Finds Icebreaker To Reach McMurdo

    Vladimir Ignatyuk

    CREDIT: STEVE ROYCE

    The U.S. National Science Foundation (NSF) announced 3 July that it has struck a deal with a Russian shipping company to charter a heavy-duty icebreaker to clear a path this winter to the largest U.S. scientific base in the Antarctic.

    Two months ago, the Murmansk Shipping Company, which operates the icebreaker Vladimir Ignatyuk, informed NSF that the Ignatyuk would not be available for the 2012–13 season. The Ignatyuk had led the break-in and resupply of McMurdo Station during the 2011–12 season, but was concerned about the ship's ability to continue to operate safely in the Antarctic pack ice. To allay those concerns, NSF hopes to locate additional vessels in the region who would be in a position to assist, should the need arise, says Kelly Falkner, acting director of NSF's Office of Polar Programs.

    NSF has also been stockpiling fuel at McMurdo; had there been no icebreaker available for the coming season, Falkner says, the station would have had enough fuel to continue operations at a reduced level through February 2014. http://scim.ag/NSFice

    Republic of Congo, Cameroon, and the Central African Republic

    New World Heritage Site Spans Three Countries

    The United Nations Education, Science, and Cultural Organization (UNESCO) designated the first tri-country World Heritage Site on 2 July. Conservationists hope the designation will help protect wildlife in the Republic of Congo, Cameroon, and the Central African Republic.

    Known as the Sangha River Tri-National Protected Area (TNS), the site spans 25,000 square kilometers and is one of the few pristine wildernesses left in Central Africa; it is home to some of the region's last populations of gorillas, chimpanzees, and elephants. But increasing human activity such as elephant poaching, logging, and clear-cutting for oil palm plantations threaten the site's biodiversity.

    Although TNS already receives funding from several other conservation organizations and foreign countries, the World Heritage Site designation cements a commitment that the three countries' governments made in 2000 to protect the area from destruction, says James Deutsch, director of Africa programs for the Wildlife Conservation Society.

    There are many protected wildlife parks that run along country boundaries. Declaring TNS as the first trinational World Heritage Site represents “a strong step forward for conservation across Africa,” Deutsch says.

    Panama City

    South Korea Considers ‘Scientific’ Whaling

    CREDIT: LEE JIN-MAN/AP PHOTO

    South Korea announced it is considering hunting whales for scientific purposes at the annual meeting of the International Whaling Commission (IWC) last week. In a statement to IWC, South Korean delegation head Joon-Suk Kang said the country's non-lethal sighting surveys have not been able to sufficiently assess whale stocks or identify their feeding habits and impact on fisheries. So the government is considering taking whales to “analyze and accumulate biological and ecological data on the minke whales migrating off the Korean peninsula,” he said. The announcement was condemned by a host of governments and conservation groups.

    A clause in the International Convention for the Regulation of Whaling (ICRW) allows any country to unilaterally decide to hunt whales for scientific research. Japan has used that clause to capture more than 16,000 minke and smaller numbers of other whales since a moratorium on commercial whaling took effect in 1986. The South Korean delegation said it will submit a research plan to IWC's Scientific Committee before taking any whales.

    Raleigh, North Carolina

    Revised Sea Level Rise Bill Goes to Governor

    The North Carolina House of Representatives voted on 3 July to revise controversial legislation passed by the state senate that would have barred planning officials from considering acceleration in sea level rise due to climate change. The changes take out the requirement that planners use only linear estimates of future sea level rise, but also bar state agencies from considering accelerated sea level rise in decision-making until 1 July 2016.

    Climate scientists gave a lukewarm reception to the changes. “This version is better than the original Senate version,” says climate researcher Robert Jackson of Duke University in Durham, North Carolina. “It's still bad policy though because it requires the state to bury its head in the sand for 4 more years.”

    North Carolina's Senate already voted on 2 July (40 to 1) to adopt the revisions. Now, the bill will move on to the governor, who must sign off on it before it can become law. http://scim.ag/NCSLbill

  2. Random Samples

    Putting Zoonotic Diseases on the Map

    CREDIT: MAP BY ILRI, ORIGINALLY PUBLISHED IN ILRI REPORT TO DFID: MAPPING OF POVERTY AND LIKELY ZOONOSES HOTSPOTS, 2012

    New diseases emerge all the time, jumping the species barrier from animals to humans. A new study, led by the International Livestock Research Institute in Nairobi, maps the location of such zoonotic events over the last 72 years. While Western Europe and the United States (where the density of livestock is highest) are still hotspots, developing countries are catching up. More than half of the events that were newly identified in 2012 (the previous survey was done in 2004) occurred in poorer countries, with areas such as Southeast Asia and Brazil in the lead.

    The world's increasing demand for meat and milk products presents an opportunity for people in developing parts of the world to lift themselves out of poverty, the authors write. But as more pigs and poultry are raised in concentrated spaces in these countries, the risk of zoonotic diseases rises: 56 zoonotic diseases together cause 2.5 billion cases of human illness and 2.7 million human deaths per year. Ethiopia, Nigeria, Tanzania, Togo, and India are bearing the brunt of the disease burden.

    Higgs, Found

    CREDIT: REX FEATURES VIA AP IMAGES

    Back in 2009, British theoretical physicist Peter Higgs posed in front of his likeness in an oil painting by Scottish artist Ken Currie that had been commissioned by the University of Edinburgh in the United Kingdom. In the painting, one Higgs, holding his glasses, stares out, seemingly toward the viewer, while his mirror image is seen studying the remnants of a particle collision. It was more than 4 decades ago that Higgs, now professor emeritus at the University of Edinburgh, first suggested the existence of an elusive subatomic particle that would convey mass to all other fundamental particles in the universe.

    When the painting was unveiled, Higgs expressed surprise, saying, “It is a great surprise to me that the university wanted to paint my portrait. I would not have predicted it 30 years ago.” He got a considerably bigger surprise last week. On 4 July, scientists at CERN jubilantly announced that they had (most probably) found the particle that now bears his name (no, not God) (see story, p. 141).

    By the Numbers

    172 — Number of papers fabricated by Japanese anesthesiologist Yoshitaka Fujii over the past 19 years, an investigating panel reported 2 July. Should each paper be retracted, Fujii would hold the record for paper retractions for a single author.

    40:1 — Ratio of stories about the reality television-famed Kardashian family to those about ocean acidification in major U.S. media outlets in 2011 and early 2012, according to a Media Matters for America study.

    ScienceLIVE

    Join us Thursday, 19 July, at 3 p.m. EDT for a live chat on sports-related head injuries. http://scim.ag/science-live

  3. Newsmakers

    Staring Down the Horns Of Budget Cuts

    Ramaswamy

    CREDIT: USDA PHOTO BY BOB NICHOLS

    Sonny Ramaswamy, the new director of the $1.2 billion National Institute of Food and Agriculture (NIFA), the U.S. Department of Agriculture's center for extramural research funding, says he hopes to raise the profile—and the budget—of agricultural research. But Ramaswamy, a charismatic entomologist who started in May, faces a tough fiscal environment. “Everybody's ox is going to be gored,” he says, but adds that: “I'm cautiously optimistic that we're going to come out well.”

    Ramaswamy, 60, was dean of agricultural research at Oregon State University since 2009. He reduced a proposed $20 million cut from the OSU College of Agricultural Sciences' budget to $8 million by canvassing the state to build support. “You present the vision of what research can do,” he says. Ramaswamy replaces NIFA's first director, molecular biologist Roger Beachy, who resigned in May 2011. Ramaswamy is undertaking a review of NIFA, which has received criticism for focusing on large, multi-institution grants at the expense of smaller projects.

    “He's excited, he's working hard, and he's passionate speaker,” says Karl Glasener, director of science policy for the American Society of Agronomy, Crop Science Society of America, and Soil Science Society of America.

  4. Marine Ecology

    Rising Acidity Brings an Ocean of Trouble

    1. Robert F. Service

    Carbon dioxide emissions have changed the chemistry of the world's oceans in ways that are already harming shell-building organisms and could lead to broad impacts on marine ecosystems.

    Tip of the spear.

    Acidity levels in Netarts Bay, Oregon, hit levels the rest of the ocean won't see for decades.

    CREDIT: TNNR/WIKIMEDIA COMMONS

    NETARTS BAY, OREGON—Alan Barton hates beautiful summer days. Not the warm sunshine—here on the central Oregon coast, where it is cold and rainy for much of the year, sunshine is welcome. Rather, for Barton, an oceanographer who helps run an oyster larvae hatchery here, it's the breezes he can't stand.

    When the wind blows from the north as it normally does in the summer, it pushes the surface waters out to sea, drawing up cold water from the deeper ocean. That water is enriched with carbon dioxide (CO2), given off by microbes as they metabolize organic matter that sinks to the ocean bottom. When the CO2-rich water washes into Netarts Bay and the intake pumps and oyster larvae tanks at the Whiskey Creek Shellfish Hatchery, the excess CO2 causes the seawater's acidity to spike and reduces the amount of carbonate ions that oyster larvae use to build their shells.

    The change can kill oyster larvae instantly or stunt their growth. In 2007 and 2008, Whiskey Creek lost 80% of its annual larvae production and nearly had to close up shop before Barton, working with regional scientists, fingered rising ocean acidity as the source of the problem. Now, the hatchery copes with fluctuations in pH by making sure to draw water into its tanks only after acidity declines. But even that success has left Barton frustrated. “This is what I like to do,” he says, shucking an oyster. “I hate thinking about carbonate chemistry.”

    The reprieve for Whiskey Creek and other shellfish hatcheries and farms along the West Coast of the United States could be short-lived. The burning of fossil fuels emits some 35 billion metric tons of CO2 into the atmosphere every year. That has already begun to change the fundamental chemistry of the world's oceans, steadily increasing their level of acidity. On page 220, scientists in Switzerland and the United States report projections from a new high-resolution computer model showing that over the next 4 decades, the combination of deep-water upwelling and rising atmospheric CO2 is likely to have profound impacts on waters off the West Coast of the United States, home to one of the world's most diverse marine ecosystems and most important commercial fisheries.

    The new computer model is only one of several recent warning signs. Numerous laboratory and field studies over the past few years underscore rising concerns that ocean acidification could devastate marine ecosystems on which millions of people depend for food and jobs. The new results “are a major concern,” says Richard Feely, a chemical oceanographer at the National Oceanic and Atmospheric Administration's Pacific Marine Environmental Laboratory in Seattle, Washington. “It's dramatic how fast these changes will take place.” George Waldbusser, an ocean ecologist and biogeochemist at Oregon State University, Corvallis, says it's not clear precisely how rising acidity will affect different organisms, but the changes will likely be broad-based. “It shows us that the windows of opportunity for organisms to succeed get smaller and smaller,” he says. “It will probably have important effects on fisheries, food supply, and general ocean ecology.”

    Nailing a killer

    Concerns about ocean acidification have been ramping up for several years (Science, 18 June 2010, p. 1500). Although it hasn't captured the public imagination as vividly as its cousin, climate change, the “other CO2 problem” is just as insidious. One-quarter of CO2 in the air diffuses into the surface layer of the ocean. There, it reacts with water to create carbonic acid, which in turn splits into negatively charged bicarbonate ions and positively charged hydrogen ions that lower the water's pH. (pH measures available hydrogen ions [H+] in solution; the more hydrogen, the lower the pH value.) Bicarbonate ions lose another H+ to become carbonate ions, which oysters, clams, and other organisms use to build their shells. But as acidity increases, less bicarbonate changes into carbonate, and some of the carbonate that is around recombines with H+ to reform bicarbonate. The upshot is that lower pH means more bicarbonate and less carbonate.

    Since preindustrial times, ocean pH has dropped from 8.2 to 8.1. That might not sound like much, but the pH scale is logarithmic, like the Richter scale for measuring earthquakes. The 0.1 pH unit decline therefore corresponds to a 30% rise in acidity. By 2100, ocean pH is expected to drop to about 7.8, increasing the surface ocean's acidity by 150% on average.

    Even with this distinct change, strictly speaking, the world's oceans will not become acidic. For that to happen, ocean pH would have to drop below neutral pH of 7.0, something no one is forecasting will happen. An alkaline pH of 7.8 or 8.1 is more acidic than the preindustrial baseline, however, so the process is popularly known as ocean acidification.

    As the pH of seawater drops, it has other effects. The lower carbonate availability drops a measure known as the saturation state of different mineral forms of calcium carbonate, such as calcite and aragonite. Aragonite saturation is particularly sensitive to rising acidity, because that mineral form is more soluble. It also turns out to be the essential ingredient that oyster larvae rely on in their first days to build their shells. If the aragonite saturation state falls below a value of 1, a condition known as undersaturation, already-formed aragonite shells will dissolve. But trouble starts well before that. If the aragonite saturation state falls below 1.5, some organisms, such as oyster larvae, are unable to build shells during the first days of their lives, and they typically succumb quickly.

    In 2008, when Barton and others were facing a full-scale collapse of their oyster hatchery, they didn't initially consider ocean pH as the culprit. Instead, they blamed a common bacterial assailant called Vibrio tubiashii. Vibrio had been a scourge of oyster hatcheries for decades, commonly asserting itself in August after the summer sun had caused widespread blooms in marine plant life, such as algae and seagrass. As those plants grow, they pull CO2 out of the water to build their cells. That lowers CO2 levels in the water and thus acidity levels. When the plants die and microbes gobble up the bounty, Vibrio moves in, proliferates, and can infect oyster larvae, hampering their development.

    By the end of summer in 2007 and 2008, the number of Vibrio was “off the charts,” Barton says. So he and his colleagues emptied their 62 larvae-rearing tanks—each of which can hold 23,000 to 76,000 liters of water—scrubbed them out, and installed filters to catch the bacteria. When they refilled the tanks, however, larvae kept dying. “After 2008, we thought we were done,” says Sue Cudd, the hatchery's owner.

    Later that year, they called in Feely, a specialist in ocean acidification. Feely, in turn, called in Waldbusser and Burke Hales of Oregon State University, Corvallis. Waldbusser and Hales brought sensitive detectors to track ocean pH as well as the partial pressure of CO2 (pCO2) in the water. They found that Netarts Bay was experiencing wild swings in both pCO2 and pH. In the May 2012 issue of Limnology and Oceanography, they reported that the low-pH swings were the primary cause of the oyster larvae die-offs.

    After figuring out the source of the problem, Whiskey Creek and other oyster hatcheries in Washington state enlisted the help of Senator Maria Cantwell to secure $500,000 from the U.S. government's economic stimulus program. The hatcheries used the money to set up a network of detectors to closely monitor pH, pCO2, temperature, salinity, and dissolved oxygen levels in Netarts Bay and two other prominent oyster-rearing grounds in Washington. “It was like putting headlights on a car,” says Bill Dewey, a shellfish biologist and public affairs director for Taylor Shellfish Farms in Shelton, Washington. The detectors showed that pCO2 levels plunged to as little as 200 microatmospheres in the afternoon, as algae and other plants pulled CO2 out of the water for photosynthesis. Overnight, when photosynthesis stopped but respiration continued, pCO2 levels spiked to 2800. So now the hatcheries make sure to draw their seawater into their tanks at the lowest point of the day. If a large upwelling draws in corrosive waters, they try to hold off filling the tanks as long as possible. The strategy has largely worked. Whiskey Creek is back up to 80% of its historic larvae production levels. Taylor Shellfish has done even better, getting record numbers of larvae in their hatchery, although the natural larvae there haven't had a successful spawning season in 7 years. Now, Cudd says, “monitors are tools we can't live without.”

    Poster child.

    Alan Barton shucks a Pacific oyster, often called the canary in the coal mine of ocean acidification.

    CREDIT: R. F. SERVICE/SCIENCE
    Rising tide.

    Natural upwelling of CO2-rich waters caused pH values along the West Coast of the United States to drop even in preindustrial times (left), a change that will increase markedly by 2050 (right).

    CREDIT: GRUBER ET AL., PHIL.TRANS. R. SOC. A, 369, 1980–96, WDOI:10.1098/RSTA.2011.0003, 2011

    Troubled waters

    But that good news looks likely to be temporary. The new computer simulations reported in this issue by a team led by Nicolas Gruber, an ocean biogeochemist at the Swiss Federal Institute of Technology in Zurich, spell trouble for shellfish in the relatively near future. Gruber and his colleagues focused on a broad region of Pacific Ocean upwelling, known as the California Current System (CCS), off the West Coast of the United States. Their regional ocean circulation model tied together the interplay of ocean and atmosphere, as well as the impacts ocean plants have in removing CO2 from the water and microbes have in dumping that CO2 back in when they metabolize algae and plants they eat. Because this model focused on the CCS, Gruber and colleagues could design it to study detailed changes at a resolution 400 times that of conventional global ocean models. The researchers considered various scenarios of CO2 emissions over the next 4 decades and compared them with CO2 levels in the atmosphere and ocean in 1750, before global industrialization (see figure, p. 147).

    They found that the buildup of atmospheric CO2 and its diffusion into the ocean will rapidly increase the amount of waters undersaturated in aragonite in the upper 60 meters of ocean, where most organisms live. Before industrialization, undersaturation of this top layer in the CCS almost never occurred. Today, Gruber says, undersaturation conditions prevail there 2% to 4% of the time. By 2050, CCS surface waters will be undersaturated for about half of the year. Just as bad, aragonite saturation levels above 1.5—the conditions under which larvae can thrive—will largely vanish from surface waters. Moreover, as increasing acidification of surface waters diffuses into the depths, undersaturation conditions (with the saturation state below 1) will exist year-round in deep waters, making life essentially impossible for shell-building organisms there. This combination could spell doom for Pacific oysters in the northwest, a $110-million-per-year industry.

    Oyster catcher.

    Sue Cudd of Whiskey Creek Shellfish Hatchery holds a vial containing approximately 100 million oyster larvae that will be sold to oyster farms.

    CREDIT: R. F. SERVICE/SCIENCE

    “The take-home message is the closeness of some of these events,” well within the life span of an individual person, Gruber says. Dewey agrees. “We're at the tip of the spear here,” he says. Other regions won't be far behind. Ocean regions with deep-water upwelling are prevalent around the globe, including sites off Chile in South America and the West Coast of Africa. Gruber says his group will next turn to modeling impacts in some of these areas.

    Even if humans manage to stop dumping CO2 into the atmosphere, the picture won't improve for decades. Past studies that track different isotopes of carbon and other elements reveal that the deep corrosive waters that wash up along the West Coast have been circulating along the ocean bottom for 30 to 60 years. The water was last at the ocean surface and exposed to CO2 from the air back in the 1950s and 1960s, when atmospheric CO2 levels were only 310 to 320 parts per million, far lower than the 390 ppm today. That means even if global societies stopped emitting carbon today, CO2-rich waters already in circulation would cause CO2 levels in the deep ocean to continue rising. “Even if we fix it, we have 50 years of it getting worse before it gets better,” Dewey says.

    Beyond oysters

    Other recent experiments suggest oysters are far from the only organisms in danger. Trouble, in fact, may be brewing along the first links in the food chain. Last year, for example, researchers led by Luc Beaufort of the European Center for Research and Teaching of Environmental Geosciences at Aix-Marseille University in France reported in the 4 August 2011 issue of Nature that as ocean pCO2 rises, the ability of photosynthetic phytoplankton called coccolithophores to build shells decreases markedly. The team sampled 180 regions of ocean surface water and compared them with historical records found in 555 sediment cores. The amount of calcite the coccolithophores added to their shells dropped as much as 30% when pCO2 levels rose from about 220 to 400 microatmospheres.

    Not all coccolithophores suffered. One species, called Emiliania huxleyi—sampled off the coast of Chile in a natural upwelling zone—fared better in CO2-rich waters. Just how a combination of reduced coccolithophore biodiversity and supercalcifier survival will play out is unclear, the authors report.

    In any case, the impacts will likely go far beyond coccolithophores. In 2009, Andrew Moy, an ice-core research scientist at the Antarctic Climate and Ecosystems Cooperative Research Centre in Hobart, Tasmania, and colleagues reported in Nature Geoscience that shell weights of other modern photosynthetic plankton, called foraminifera, are down as much as 35% from those in sediments dating back 50,000 years. Yet another class of plankton, called diatoms, is nearly as prolific. And in an article published online 6 May 2012 in Nature Climate Change, Ulf Riebesell, a biological oceanographer at the Helmholtz Centre for Ocean Research in Kiel, Germany, and colleagues reported that in the South China Sea, diatom carbon use is down by as much as 40%. So if such sinks for atmospheric CO2 decline, it could have a powerful feedback effect in the coming decades, reducing the amount of CO2 the oceans can absorb and thereby increasing atmospheric CO2 levels.

    Past lab studies have raised concerns about another vital link in the food chain: pteropods. These tiny sea snails are particularly abundant in polar oceans near the Arctic and Antarctica. Like oyster larvae, pteropods use aragonite to form their shells. But polar seas naturally harbor lower carbonate concentrations, reducing saturation levels. Ocean chemistry monitoring cruises have already shown aragonite saturation levels in the polar oceans dropping dramatically. If pteropods are unable to respond, that could imperil populations of salmon, krill, whales, and seals that depend directly or indirectly on their bounty. “Things are changing fundamentally in ways that are going to change the ecosystems of the ocean,” Dewey says.

    A revealing look at what that change might bring comes from studies of underwater CO2 seeps, where CO2 bubbles out of the sea floor near volcanoes, naturally raising pCO2 levels. Last year, researchers led by Katharina Fabricius, a coral reef ecologist with the Australian Institute of Marine Science in Townsville, reported in Nature Climate Change that they looked at three natural CO2 seeps in tropical waters near Papua New Guinea with pCO2 levels near levels expected throughout the global oceans in 2100. The biodiversity of coral species there dropped by 40%, and reef development stopped altogether in areas where the pH dropped below 7.7. In a separate study, Riebesell and colleagues found similar destructive impacts on cold-water corals.

    Back along the Oregon coast, moderate north winds have returned. And Barton and his colleagues worry that conditions will once again deteriorate to levels other ocean regions won't see for decades. “I have to admit I get a little annoyed when I hear people always talking about 2050 or 2100,” Barton says. “We're already at 2050 in Netarts Bay.” It's a future that doesn't look kind.

  5. Research Facilities

    Betting Big on Science: A Cautionary Tale

    1. Adrian Cho

    To lure federal investment, South Dakota has spent nearly $100 million to build an underground lab. Now its gamble is looking like a long shot.

    Finished basement.

    In less than 2 years, this tunnel (inset) was turned into the Sanford Underground Research Facility.

    CREDITS (TOP TO BOTTOM): ROY KALTSCHMIDT/LAWRENCE BERKELEY NATIONAL LABORATORY; MATT KAPUST/SANFORD UNDERGROUND LABORATORY

    LEAD, SOUTH DAKOTA—It takes 11 minutes and 25 seconds for the rickety lift here in the abandoned Homestake gold mine to descend the 1478 meters to the Sanford Underground Research Facility (SURF). But that slow ride is a flash compared with the 11 years it took to realize the dream of building a subterranean lab in the mine. And like a dream, the lab's existence may be fleeting.

    On 30 May, the state of South Dakota officially opened SURF, a gleaming little facility built with $40 million in state money and $50 million from a philanthropist. SURF has the potential to play an outsized role in particle physics in the United States. And two key experiments are already moving in.

    But despite that promise, SURF is a far cry from what South Dakota officials had hoped for: an $875 million national laboratory built by the U.S. National Science Foundation (NSF). Officials acknowledge that they built SURF with the intention of pressuring NSF to commit to the bigger project. Instead, NSF's governing body shot down the idea (Science, 17 December 2010, p. 1596), leaving its fate up to the U.S. Department of Energy (DOE).

    DOE has requested $10 million next year to run the place—mostly to pump ground water out of the mine and treat it. But it has made no promise of support for 2014 and beyond. So South Dakota's investment could end up, literally, under water.

    South Dakota's strategy was inherently risky, according to those who track how innovation can spur regional economic development. It's best to think small, they say, and to target research that provides a direct connection to industry. Also, don't depend on the federal government alone for your return on investment. “Given the fairly dismal recent history, it's better to begin with a fair amount of skepticism whether the federal government is going to follow through on its commitments,” says Daniel Berglund, president of the nonprofit State Science and Technology Institute in Westerville, Ohio.

    Predictably, South Dakota officials remain upbeat. “The future is still wide open,” says Republican Governor Dennis Daugaard. “As landlords we've built the building, and I think we'll start attracting tenants now that we've seen a few begin to occupy their improved space.”

    But T. Denny Sanford, the lab's patron and a Sioux Falls businessman who made a fortune in the credit card industry, doesn't mask his frustration with the way things have played out. “I've never seen the federal government do anything right—except write the Constitution,” he says. Asked if he wishes he'd specified that his donation couldn't be spent before NSF had committed to the project, Sanford smiles ruefully. “Oh yes,” he says. “Live and learn.”

    A heady wager

    To understand what went wrong, it helps to know why South Dakota bet so heavily on a lab in an abandoned mine. Prospectors struck gold here in 1876, and the mine eventually yielded 1.1 million kilograms of the precious metal. For scientists, however, the most valuable discovery came from a mind-boggling experiment conducted in the mine almost 50 years ago.

    In the 1960s, Raymond Davis Jr., a chemist at Brookhaven National Laboratory in Upton, New York, used a crude detector to spot elusive subatomic particles called neutrinos emanating from the sun. In a bare cavern where SURF now stands, Davis filled a tank with 380,000 liters of chlorinated dry-cleaning fluid. The neutrinos converted the chlorine nuclei to argon, and Davis extracted and counted the argon nuclei, produced at the rate of one every few days.

    Chipping in.

    Several states have contributed to major projects at DOE national labs, boosting local economies as well as enhancing the facilities.

    CREDIT: ARGONNE NATIONAL LABORATORY

    The feat earned Davis a share of the 2002 Nobel Prize in physics and showed the benefits of going underground to avoid interference from background radiation and cosmic rays. So when the company that ran Homestake announced in 2000 that it would close the mine, physicists immediately proposed converting it into a lab.

    Their original pitch to NSF was for a $281 million lab reaching as deep as 2255 meters. There, ultrasensitive detectors would hunt for particles of the mysterious dark matter whose gravity binds the galaxy. Other detectors would search for a type of radioactivity called neutrinoless double beta decay that would prove that the neutrino is its own antiparticle. Such a finding would put a dramatic new twist on the relationship between matter and antimatter. The lab could also hold a huge detector to study neutrinos shot through Earth from DOE's Fermi National Accelerator Laboratory (Fermilab), 1300 kilometers away in Batavia, Illinois. It could even host work in geology, microbiology, and engineering.

    Such labs already exist elsewhere. European researchers are pursuing similar physics experiments in Italy's Gran Sasso National Laboratory, at a depth of 1400 meters beneath the Apennines. Researchers in Japan work in the 1000-meter-deep Kamioka mine in Hida in central Japan. U.S. scientists use two smaller labs, one 700 meters deep at the Soudan mine in Minnesota and the second 670 meters below the surface at the Waste Isolation Pilot Plant, a nuclear waste repository in Carlsbad, New Mexico.

    The effort to develop Homestake turned into political football, however. The Homestake Mining Company (which later merged with the Barrick Gold Corporation in Toronto, Canada) refused to sign the mine over to the federal government unless it was freed from any liabilities. South Dakota's congressional delegation, led by then–Senate Majority Leader Tom Daschle, a Democrat, crafted a deal to do that. But fiscal conservatives complained that it saddled taxpayers with the uncertain cost of environmental cleanup, and the deal fell through. Meanwhile, the company said it would stop pumping ground water out of the mine, which would cause it to flood.

    In spite of its rocky road in Washington, D.C., the plan was popular among state politicians. A new national lab could spawn up to 8000 jobs and a billion dollars of commerce, promised Michael Rounds, a Republican who was South Dakota's governor from 2003 to 2011. The project also hit a political sweet spot, says Bernie Hunhoff, a Democrat and minority leader in the South Dakota House of Representatives. Liberal legislators from the eastern part of the state liked the investment in jobs, he says, and conservative legislators in the West liked the fact that, thanks to the mine's location, their districts would reap the benefits. “I think it would have been very hard to sell the project had it been in the eastern part of the state,” Hunhoff says.

    In January 2004, the state and Barrick agreed to transfer ownership of, and liability for, the mine to the South Dakota Science and Technology Authority, which state legislators created especially for this project. The next month, legislators appropriated $14.3 million to restart the pumps in Homestake, which had been flooding since the previous June.

    But NSF took a step back from what was then called the Deep Underground Science and Engineering Laboratory (DUSEL): Officials decided its location should be determined in a competition and called for proposals. To get a jump on the seven other competitors, South Dakota officials and the team from the University of California, Berkeley, that was developing Homestake decided that the state should build an “interim lab.” “If we believed that the project would hold long-term potential, then we would have to take that risk,” Rounds says, “because it was pretty clear that Washington wasn't prepared to make that decision [to start building].”

    Much of the money for the project would come out of one wallet. Rounds had discussed the idea with Sanford, and at the 2005 Governor's Invitational Pheasant Hunt the billionaire pulled the governor aside and committed to a $50 million gift. “It was explained to me that the significance of this would be larger than the significance of [Ellsworth Air Force Base] in Rapid City,” which houses 9000 people, Sanford recalls.

    In October 2005, the state appropriated $19.9 million for the interim lab. The gamble seemed to have paid off: Two years later, NSF chose Homestake as the site for DUSEL. By June 2009, workers had drained the 1478-meter level and begun work on the lab.

    But the state's plans for DUSEL sprung a fatal leak after South Dakota had spent another $5.4 million on pumping. In December 2010, the National Science Board, which sets policy for NSF, declined to continue design work for DUSEL, whose cost had climbed to $875 million. The board was concerned about such a large investment in infrastructure to support DOE experiments. The board's decision has forced officials at DOE's Office of Science to decide how much, if any, of the project they can afford.

    Swinging for the fences

    South Dakota's predicament underscores the risks in investing in large projects. “A lot of states get into project envy,” says Robert Atkinson, president of the Information Technology and Innovation Foundation (ITIF), a technology policy think tank in Washington, D.C. “Governors often want to see something tangible. It's in the ground, it's big, and they can say ‘I did this.’”

    South Dakota is not the first state to spend big to beef up its research capacity. In 2003, Florida pledged $310 million to cover the first 10 years of operating expenses for a new branch of the California-based Scripps Research Institute in the city of Jupiter, Florida. The next year California voters approved a $3 billion bond issue to create the California Institute for Regenerative Medicine to fund stem-cell research. It remains to be seen if either investment will pay off, says Atkinson, who argues that states are more successful when they invest in smaller projects and cultivate an “ecosystem” of technological development. “You're a lot better off with a bunch of singles than with one home run,” he says.

    Opening day.

    VIPs get a crash course on how the LUX detector, to be housed in the cylindrical tank, will hunt dark matter.

    CREDIT: ROY KALTSCHMIDT/LAWRENCE BERKELEY NATIONAL LABORATORY

    States also do better to focus on fields with direct connections to industry, experts say. That is why officials with the Division of Science, Technology, and Innovation (NYSTAR) in New York state's Empire State Development department insist that researchers line up industrial partners before they apply for support. “There are very few technology investments that the state has made without showing that somebody else has skin in the game,” says NYSTAR director Edward Reinfurt.

    That philosophy hasn't prevented New York state from thinking big. Since 1993 it has invested more than $1 billion in the College of Nanoscale Science and Engineering at the University at Albany, which officials claim has leveraged more than $13 billion in mostly private investments from companies such as IBM and Intel. But that gargantuan investment was really a series of targeted investments that began with one $500,000 grant, Reinfurt says.

    It also helps if a state already has a strong research base on which to build. “There's no doubt that having assets in place gives you a critical advantage,” Reinfurt says.

    The payoff

    South Dakota went all in when building SURF. The facility consists of two large halls connected by a long hallway lined with gleaming silver vents, gray electrical conduits, and white water pipes. The spotless epoxy floor shines under the fluorescent lighting. A visitor can quickly forget that the lab is not on the surface.

    Lab officials are hoping that once scientists see the new lab, they'll flock to it. “It's here, it's world class, and the doors are open,” says Kevin Lesko of Lawrence Berkeley National Laboratory in California, principal investigator on the project.

    Lesko's confidence is bolstered by a report last year from the U.S. National Academies' National Research Council. It deemed the three main physics experiments to be done in a lab like DUSEL—a dark-matter search with a detector weighing between 1 and 10 tonnes, a search for neutrinoless double beta decay with a tonne-scale detector, and the study of neutrinos shot from a distant accelerator—“of paramount and comparable scientific importance.”

    Two DOE-funded experiments are already moving in. The Large Underground Xenon (LUX) detector will sit in the same spot as Davis's original detector and will search for evidence of dark-matter particles bumping into atomic nuclei in 350 kilograms of frigid liquid xenon. Down the hall, the MAJORANA Demonstrator will search for evidence of neutrinoless double beta decay in 60 kilograms of the isotope germanium-76. Both experiments are meant to be steppingstones to larger detectors. Scientists are hoping that biologists and geologists will jump at the chance to work underground at SURF.

    It's equally plausible, however, that SURF will wither and die. The effort to develop Homestake has long been driven by plans to build a huge detector to field neutrinos shot from Fermilab. As originally conceived, that Long-Baseline Neutrino Experiment would use a 34,000-tonne detector filled with liquid argon in Homestake. But in March, officials at DOE's Office of Science said they could not afford to finance the $1.9 billion experiment in one shot and asked Fermilab researchers for a plan to build it in stages, and for less money (Science, 30 March, p. 1553). Current options include a 10,000-tonne detector on the surface of Homestake or a larger detector in Minnesota's Soudan mine. (For a surface detector, physicists would limit interference from background radiation by timing the arrival of the neutrinos.)

    So SURF's fate may rest with the outcome of the dark-matter and neutrinoless double beta decay experiments. However, the lab may not be deep enough for the full MAJORANA experiment, meaning that the LUX dark-matter search might be the only experiment in the lab. DOE would then face the question of whether to spend $15 million per year to run the lab for one $1.5 million experiment and its $50 million follow-on effort. “Exactly what happens depends on the outcome of the [early] measurements,” says James Siegrist, DOE's associate director for high-energy physics.

    Even if DOE decides to support the lab over the long term, it seems likely to remain a research outpost occupied by a couple of dozen graduate students and postdocs and a small staff. (SURF currently employs 120 people.) That reduction in scope doesn't unduly bother state officials, who say they won't regret making a wager on the lab even if it were to close.

    “The South Dakota psyche and culture is that we're risk takers and gamblers,” says minority leader Hunhoff. “These are ranchers and farmers, and there are no bigger risk takers than ranchers and farmers.” If the lab fails, it won't be one of the state's top 10 problems, he says. Of course, it also won't yield the economic jackpot that state officials were expecting.

  6. Profile: Anthony Fauci

    The View From the Top of the HIV/AIDS World

    1. Jon Cohen

    Science spends a day with immunologist and clinician Anthony Fauci, head of the single largest funder of HIV/AIDS research.

    Front runner.

    Anthony Fauci has headed NIAID for 28 years and tries to fit in a run every day to let off steam.

    CREDIT: MALCOLM LINTON

    Anthony Fauci runs a marathon every day.

    Fauci heads the single largest funder of HIV/AIDS research, the U.S. National Institute of Allergy and Infectious Diseases (NIAID), and the job requires an early start and a late finish. Part of the U.S. National Institutes of Health (NIH), NIAID will dole out nearly one-third of its $4.5 billion budget to HIV/AIDS researchers in 2012—and Fauci's imprimatur is visible at every level. An immunologist who made fundamental findings about HIV's destructive ways, Fauci was also a key architect of the President's Emergency Plan for AIDS Relief that provides anti-HIV drugs to millions of the world's poor.

    NIAID funds a wide portfolio of research, and controversies repeatedly erupt around Fauci. A native of Brooklyn, New York, who studied at a Jesuit college, Fauci, 71, enjoys a good debate, and this past year alone has found him at the center of hot topics such as mutant forms of the H5N1 bird flu virus that scientists engineered to transmit in mammals and a mouse retrovirus erroneously linked to chronic fatigue syndrome. He is just as comfortable doing rounds with patients as he is testifying to Congress. He's a go-to source for journalists, and photos that clutter one office wall show Fauci hobnobbing with the likes of presidents Bill Clinton, George H. W. Bush, and George W. Bush, and Mother Teresa, Elizabeth Taylor, and rock star Bono.

    Fauci's critics say he is an obsessive-compulsive autocrat with a serious limelight addiction. But in his 28 years occupying the NIAID director's office on the seventh floor of NIH's Building 31 in Bethesda, Maryland, no serious charge against him has stuck—and no one has challenged his commitment.

    On 10 May, reporting for the special issue HIV/AIDS in America (see p. 167), Science jogged alongside Fauci for the day.

    6:30 a.m. Fauci answers the flood of e-mails that poured in overnight, reads briefing material, and puts finishing touches on a few papers. It's the only peace he'll have all day.

    8:15 a.m. A dash to the first-floor cafeteria for a croissant egg sandwich includes brief chats with secretaries, janitors, cashiers, and scientists—but no stopping. “Things are going to seem kind of hectic, because that's my life,” he says. “We don't waste time here. I'm a bit of a grump.”

    8:22 a.m. Back in his office, Fauci's three assistants bounce in and out, sitcom fashion. He swears like a scientist, and his rapid-fire patter mixes the demanding and caustic with a dollop of charm. Boston on the 22nd for a New England Journal of Medicine panel! NIH Director Francis Collins at exactly 6 p.m. to talk about the H5N1 thing! Get the staffer on the phone who attached a three-page memo in an e-mail! “You violated Fauci rule number 26,” he barks at the staffer over his speaker phone. “No e-mail longer than one page!” But he likes the memo, which describes a new independent report about NIAID.

    “We couldn't look better if we wrote it ourselves,” Fauci crows. “Don't ever send me more than a one-page memo again.”

    He's kidding. But he's not.

    8:51 a.m. Fauci speed-walks up the hill to the NIH Clinical Center to see patients, which he does 3 days a week. The center recently started treating difficult HIV/AIDS cases from the local community. “It's like the '80s again,” he says. “It's great for the fellows.” He first sees a woman, 51, who presented with zero CD4 cells—normal is above 600, and 200 is the cutoff for AIDS—and a skin rash diagnosed elsewhere as cutaneous T-cell lymphoma. “When they told me I had full-blown AIDS, that hurt me,” says the woman, explaining that she had been diagnosed 10 years earlier. “I said to the doctor, ‘What you telling me? I'm going to die?’ And he said, ‘Yeah.’” Clinical Center doctors started her on antiretroviral treatment, her rash resolved, and she now has a CD4 count of 122. Before leaving, Fauci notes that she used to live in Brooklyn. “Bensonhurst,” she says. “I was born in Bensonhurst!” bellows Fauci, whose Brooklyn accent remains undiluted. “It's inexcusable for somebody to present here with zero CD4s,” he says as he exits. She is hardly an anomaly.

    9:06 a.m. Fauci visits five more patients who have been close to the brink: lymphoma in the stomach, acute renal failure, blinding retinopathy caused by cytomegalovirus. One patient is a nurse who, apparently in denial about his disease, had only 23 CD4s when he presented. Another is a wheelchair-bound man who had a rare case of TB that spread to his knee and an even-rarer complication called chylothorax after starting on antiretroviral drugs. Lymph fluid drained from his lungs filled two 1-liter bottles. “You almost never see this,” Fauci said. “This is the 1940s.”

    9:43 a.m. Fauci checks in with his wife, Christine Grady, chief of the Clinical Center's Department of Bioethics. On the speed walk back down the hill to Building 31, he's sorting out the bioethical dilemma he's just witnessed in the clinic. “It's unconscionable in the capital of our nation,” Fauci says. “What's going on here?”

    10:02 a.m. Fauci's inner circle meets for a daily powwow about his schedule, including a commencement address at the University of Miami, an Institute of Medicine meeting on H5N1, and a request to sit on a panel about a revival of the AIDS play The Normal Heart, which was written by pioneering AIDS activist and Fauci-basher-turned-best-friend-forever Larry Kramer. “I said I'd only participate if he had De Niro play me,” Fauci says.

    11:07 a.m. “Hugh!” Fauci hollers, calling for his top deputy, the mild-mannered Hugh Auchincloss Jr. Fauci wants to make sure the ExCom—the executive committee meeting later today with his division directors—runs like clockwork. “I have a phenomenal impatience for people who go over their allotted time,” Fauci says. One of his three adult daughters phones, and he speaks to her as though time does not exist.

    12:00 p.m. Fauci changes into a T-shirt, shorts, and sneakers and heads off campus for a 5-kilometer run, which is followed by a quick shower and a stop at the cafeteria for a yogurt and hummus with pretzels. He eats lunch at his desk, which is followed by a meeting with an investigator in his lab who updates him about cutting-edge HIV cure research.

    1:47 p.m. “Patty!” Fauci, reviewing his schedule for his commencement talk in Miami, is pissed that he has to kill time at his beachfront hotel. “I have 5 hours of doing nothing,” he complains to Patricia Conrad, his right-hand woman, who formerly worked at the White House. He then puts finishing touches on slides for the opening plenary that he will give at the 19th International AIDS Conference. Fauci may be the only presenter at the meeting who has finished preparing for his talk 2 months early.

    Political office.

    Fauci's job blends science and medicine with diplomacy and policy.

    CREDIT: MALCOLM LINTON

    3:30 p.m. The ExCom gathers 30 of NIAID's top brass in a conference room, and the bland review of budgetary issues segues into a spicy discussion about H5N1 and the ripple effects of the bird flu controversy. NIAID funds studies of many other pathogens, and Fauci asks whether it should continue to support any “gain-of-function” experiments that aim to better understand how a bug transmits or causes disease. “We have to get this aired out,” Fauci says. “I would love to do this in a very transparent way.”

    5:00 p.m. At a gathering of Fauci's own lab members, a researcher reviews a study of a promising experimental hepatitis C drug. Fauci is wowed by possibilities: There are three times as many people in the United States infected with the hepatitis C virus as with HIV, and the new drugs have little toxicity and can outright cure many infections.

    6:01 p.m. NIH Director Collins summons Fauci to his office for a private meeting to discuss H5N1.

    6:30 p.m. Two high school girls interview Fauci about global ethics. “What's the most important issue you are now facing?” one of the girls asks. “My hope is that in the next 5 years, if we as a nation and a world have the political will to implement what we already have, we're going to probably see a dramatic turnaround in the AIDS epidemic,” he says. The girls notice a photo of Fauci with Paul Farmer, the Harvard clinician widely celebrated for his HIV/AIDS work in Haiti. “What was it like meeting him?” one of the awestruck girls asks. Fauci, amused, dryly says that they met in the late 1980s when he spoke to Farmer's medical school class at Harvard. When they ask him to name his favorite person, he graciously embraces their exuberance and offers that Farmer is one of them. “He really walks the walk,” says the man who really runs the run.

    7:12 p.m. A network television producer wants to preinterview Fauci for a possible appearance early tomorrow morning. “She said she wants you to send her home with something solid,” Conrad says. Fauci phones the producer, who has a shaky grasp about HIV/AIDS and needs a 101 lesson, which he obligingly gives. By the time he hangs up at 7:30, he's spent. “It's going to be one of those days tomorrow,” he says.

  7. The Many States of HIV in America

    1. Jon Cohen

    Treatment as prevention promises to help the infected and dramatically slow the spread of the virus, but the epidemic's changing demographics present myriad challenges in this diverse country.

    In the spring of 2006, a year after Joshua Alexander took part in an HIV testing day at his college and found out he was infected, he tried to kill himself. He did not do it with a gun, a noose, or the tailpipe of a car. He chose instead to gulp down his entire supply of the anti-HIV drugs Truvada and Viramune.

    Detention/retention.

    HIV-infected inmates such as Rhode Island's Robert Quintana benefit from programs that link care on the inside and outside.

    CREDIT: MALCOLM LINTON

    Alexander, then 19 (pictured at right with his family), had taken time off from Delta State University after he learned of his diagnosis and moved back to his mother's home an hour away in Greenville, Mississippi, a small town bordered by cotton fields, catfish ponds, and an oxbow lake that branches off “Old Man River.” About one-third of the town lives below the poverty line, and an abundance of boarded-up shotgun shacks and cottages tilt on the clay soil. But Alexander's mother had provided well for her five children, and money wasn't his main issue—his version of the Delta blues came from what he called “the double negative” of his life. “On the one hand, I had the stigma of the virus itself, and on the other hand, people in church said you're damned because you're gay,” says Alexander, a devout Baptist. “There were some very, very gloomy times when I'd sit at home and get to thinking, ‘Why is this happening to me? I'm fighting a constant battle that I can't win.’”

    Alexander soon vomited the overdose of antiretroviral drugs, and he now laughs about his “oxymoronic” attempt to commit suicide with the very drugs that he depends on to stay alive. But he, like many others, struggles to take antiretroviral drugs day after day, year after year. Efforts to help people like Alexander deal with their challenges have now moved to the top of the HIV/AIDS agenda in the United States.

    Taking antiretroviral drugs as prescribed can fully suppress an HIV infection, keeping disease at bay for decades. There's another huge benefit, as well: A large study completed in 2011—Science's “Breakthrough of the Year” (23 December 2011, p. 1628)—provided irrefutable evidence that people who have undetectable levels of the virus in their blood rarely spread the infection to others. Yet as wealthy as the United States is, antiretroviral drugs are having nowhere near the treatment or prevention impact they could have on the country's epidemic. “We only have a little more than 1 million infected people in the United States, and per case, we probably have one of the highest expenditures in the world,” says Carlos del Rio, a clinical researcher based at Emory University in Atlanta. “We ought to be able to do something to stop the epidemic. But the problem is that it's not just a medical disease. In fact, the least of the difficulty is the medical part of the disease. It's the social, structural things that are driving the epidemic.”

    This spring, Science met with HIV-infected people, at-risk communities, researchers, caregivers, health officials, and advocates in 10 cities, traveling to the Deep South and the West and East coasts to see the varied epidemics and the local responses up close. The package of stories on the following pages looks at everything from the social and structural issues to the medical and scientific challenges through the eyes of people on the front lines, as well as the research efforts under way to try to slow, if not one day bring to a halt, the spread of HIV.

    Treatment cascade

    When AIDS surfaced in the United States 31 years ago, it was largely a disease of economically stable, white, gay men living in big cities on the West and East coasts. But today, HIV disproportionately infects African-American men who have sex with men (MSM), like Alexander, and the epicenter of the epidemic is in the poverty-stricken Deep South. In addition to confronting deep-rooted homophobia and stigma for being infected, many face the added burdens of unemployment, homelessness, mental illness, incarceration, substance abuse, and lack of medical insurance and access to qualified care providers—all of which pose obstacles to even getting an HIV diagnosis, much less taking pills every day. “What's happening among young, black MSM in the United States jumps out and screams,” says Phill Wilson, a leading HIV/AIDS advocate who founded the Black AIDS Institute in Los Angeles. “We have the richest country on the planet, and you have a population impacted more than the poorest parts of the planet.”

    Del Rio's work has helped popularize the notion of a “treatment cascade,” a series of factors that create a vast gap between HIV infection and control of the infection. Roughly 20% of infected people in the United States do not know their HIV status. Among those who do, many never seek care. Some see a doctor but fail to show up for subsequent appointments. Of those who start taking antiretroviral drugs, many have difficulty staying on them. Building on del Rio's earlier work, the U.S. Centers for Disease Control and Prevention (CDC) highlighted the treatment cascade in its 2 December 2011 issue of Morbidity and Mortality Weekly Report (MMWR), showing that of the estimated 1.2 million infected people in the country, only 28% receive medication, adhere to their prescriptions, and have fully suppressed viral loads (see graph, p. 171).

    Sitting tall.

    With his family's support, Alexander (right) has overcome his HIV-induced gloom.

    PHOTO: MALCOLM LINTON
    MAP SOURCE: AIDSVU.ORG

    In July 2010, the Obama Administration issued the first-ever National HIV/AIDS Strategy, which lays out a plan for increasing the proportion of diagnosed MSM with undetectable viral loads by 20% within 5 years. The plan has the same goals for blacks and Latinos who are not MSM. “We need to focus our resources where the epidemic is,” says Grant Colfax, who directs the White House Office of National AIDS Policy. An openly gay clinician who formerly ran the prevention and research section of the widely praised San Francisco Department of Public Health, Colfax says hard-hit locales also have to spend more of their own money addressing the problem in their most affected communities. “There is no magic bullet here,” Colfax says. “Every epidemic is local, and we need to look at local solutions.”

    Diverse drivers

    With an adult HIV prevalence of 0.6%, the United States ranks 39th in the world, on par with many countries in Europe and Latin America. But because of the relatively large U.S. population of 311 million, only six countries have more HIV-infected people, and its burden matches that of Zimbabwe and Uganda. “I'm always taken aback by that,” says Wafaa El-Sadr, an epidemiologist at Columbia University's Mailman School of Public Health in New York City. “We don't see it that way because it's not evenly distributed: There are hot spots. There also are some populations, especially MSM, who have risks of acquiring HIV that are higher than in sub-Saharan Africa. Ask people on the street, and nine of 10 would say, ‘We took care of HIV, it's not a problem any more.’ And that's the problem.”

    MSM accounted for 61% of the estimated 50,000 new infections in the country in 2009, according to the latest CDC figures. Heterosexuals made up the second-largest risk group, with 27% of new infections, and the remaining 12% were injecting drug users, or IDUs (3% of whom were also MSM). Although blacks make up only 14% of the population, they accounted for 44% of new infections. Rates of infection are six times higher for black males than white males, and black females have a whopping 15 times higher rate of infection than white females. Black MSM between the ages of 13 and 29 were the only group that saw an increase in new infections between 2006 and 2009; the number climbed by 48%. One in five newly infected people were Latino, which is also disproportionately high compared with whites.

    CDC divides the United States into four regions—Northeast, South, West, and Midwest—to assess HIV/AIDS. “There are striking geographic differences,” says CDC epidemiologist Jonathan Mermin.

    The Midwest has the fewest cases. In the West, five small neighboring states that together are home to under 5 million people—Wyoming, North and South Dakota, Idaho, and Montana—each report fewer than 1000 people who have a diagnosed HIV/AIDS infection, but California has 106,000, making it second to only New York (128,000). The South has the heaviest burden, with 43% of the country's HIV-infected people. A recent report about the HIV/AIDS “crisis” in the South by the Duke University Center for Health Policy and Inequalities Research in Durham, North Carolina, analyzed CDC data and found that the region has eight of the 10 U.S. states with the highest rate of new infections and the highest death rates from AIDS. Several cities outside the South have been hit especially hard by HIV, including New York, Los Angeles, San Francisco, Chicago, Philadelphia, and Baltimore, which together in 2007 accounted for 30% of all people living with HIV/AIDS. The virus also readily moves back and forth across the U.S.-Mexico border.

    The drivers of spread in the country similarly differ from place to place. “It's not one U.S. epidemic; it's multiple microepidemics,” says Kenneth Mayer, medical research director at the Fenway Institute in Boston, which specializes in HIV-prevention studies. Mayer notes that transmission in many white and Latino MSM has links to methamphetamine and cocaine use, but drugs play only a small role in the Southern epidemic in black MSM, who often have their own insular subcultures and sexual networks. Women accounted for nearly 70% of the heterosexual spread, and 60% of those infections in 2009 were in black females, who have distinct sexual networks themselves. Needle-exchange programs have dramatically slowed the spread among IDUs in some cities, but bans on the use of federal and state funds for such efforts means that they are scarcely used elsewhere. Commercial sex work does not seem to be a major factor in the country, but recent studies are “sorely lacking,” Mayer says. Studies of transgenders are few, too, but those that exist indicate extremely high prevalence.

    Plan man.

    Grant Colfax oversees the Obama White House's HIV/AIDS strategy.

    CREDIT: DARROW MONTGOMERY
    Reaching out.

    As men at the Sippi Citi club in Jackson, Mississippi, do a “strolling” line dance, a table in one corner staffed by My Brother's Keeper promotes HIV prevention.

    CREDIT: MALCOLM LINTON

    A plethora of research has focused on analyzing why black MSM and heterosexual women, particularly in the South, have become especially vulnerable to HIV. CDC's Gregorio Millett has closely examined the spread in black MSM, and his findings have challenged many hypotheses. As Millett and co-workers explained in the 15 May 2011 issue of AIDS, no studies have shown convincing evidence that black MSM have more partners or more frequently have receptive anal sex without a condom, both known risk factors for HIV infection. Citing data from a survey of nearly 10,000 white and black MSM who agreed to take HIV tests, the researchers concluded that the racial disparity in HIV prevalence had no link to incarceration or circumcision, either.

    Several studies have reported that black MSM are more likely to have partners of their own race than are white MSM, and Millett's group concluded that this played a key role in explaining their higher prevalence. The researchers found a link between risk of infection and not knowing a partner's HIV status, and they also discovered that black men who knew that they were infected before the study were less likely to be on antiretroviral drugs than white men. This double whammy means that uninfected black MSM are more likely to have sex with a highly infectious man than are their white counterparts. Studies have also shown higher rates of sexually transmitted infections such as syphilis in black MSM, which eases spread.

    Epidemiologist Adaora Adimora of the University of North Carolina, Chapel Hill, contends that the high rate of HIV in Southern black women reflects higher rates of concurrent partnerships—relationships that overlap—which is linked to the frequent incarceration of men that splits couples. In the July 2006 issue of Sexually Transmitted Diseases, Adimora and colleagues describe several studies that support this thesis, including one they did that surveyed HIV-infected women in North Carolina who had no link to IDUs or MSM. Of these 128 women, 37% had had concurrent partnerships within the past year, 89% said one of their last three partners was having sex with someone else, and 82% said one of these men had been incarcerated. According to the U.S. Bureau of Justice Statistics, one in three black men will be incarcerated during their lives, in contrast to one in 17 white men.

    As racially skewed as the epidemic is, important factors in the spread of HIV are not confined to race, cautions Kevin Fenton, who directs CDC's National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention. “When I think of the U.S. epidemic, it's easy to be seduced into the narrative of the epidemic in African Americans,” Fenton says. “But the real narrative is poverty, disenfranchisement, and a fragmented healthcare system weaving together to create big social challenges.”

    Fenton points to a CDC study published in the 12 August 2011 issue of MMWR of nearly 15,000 heterosexual, non-IDU adults in 24 high-poverty urban areas. Study participants were predominantly black (72%), followed by Latino (18%) and white (5%). Nearly 2% turned out to be infected. The highest prevalence was seen in men and women who had lower socioeconomic status—regardless of race. Lack of a high school degree, household income below the poverty level, and unemployment were each independently associated with higher prevalence. “The social drivers are so powerful, and what's exciting about this is when you think through the social-determinants lens, the solutions become different,” Fenton says. “You can't just rely on testing, linkage to care, and treating people. It's necessary but not sufficient. Unpack these social determinants and there are new ways to tackle the epidemic.”

    Rebooting

    In response to the National HIV/AIDS Strategy, CDC has begun to reallocate how it supports U.S. HIV/AIDS work. In 2012, CDC shuffled $40 million of its $338 million budget to have more of an impact in harder-hit locales, and plans call for similar shifts over the next 4 years. CDC also launched the 12 Cities Project that, by the end of 2012, will have pumped $30 million of new money into improving the response in urban areas that have 44% of the AIDS cases. There's a concomitant push to cut funding to behavioral modification programs and ideology-driven work such as abstinence education. Instead, CDC wants more high-impact, cost-effective, evidence-based programs that link people to care, target MSM and drug users, and conduct testing at high-incidence locales.

    Wilson of the Black AIDS Institute praises the national strategy for spelling out clear, interrelated goals, but he also worries about unintended consequences of the “medicalization” of prevention, as many of the black groups he works with don't yet have the technical capacity to work with clinics and may lose funding, Wilson says. “With HIV and AIDS, the messenger matters. Having institutions that are from the community and have its trust are critically important,” says Wilson. In May, the Black AIDS Institute's African American HIV University held a week long teach-in for community-based organizations from around the country to help them adapt to this new world in which treatment as prevention is king.

    Homecare.

    San Francisco General found patient Vanessa Romo this housing.

    PHOTO: MALCOLM LINTON
    Drop everything.

    Of the nation's 1.2 million HIV-infected people, only 28% fully benefit from treatment

    GRAPH SOURCE: MORBIDITY AND MORTALITY WEEKLY REPORT/CENTERS FOR DISEASE CONTROL AND PREVENTION
    Cascade brigade.

    Nurse Diane Jones's team at San Francisco General Hospital specializes in retaining patients in care.

    PHOTO: MALCOLM LINTON

    A key challenge for everyone working in the HIV/AIDS field is to find novel interventions that better address the treatment cascade. More and more clinics have begun working with navigators or mentors to help people overcome issues with housing, food, drug use, incarceration, and transportation. An increasing number of emergency rooms routinely test everyone for HIV. One large-scale clinical trial in Washington, D.C., and the Bronx funded by the U.S. National Institute of Allergy and Infectious Diseases (NIAID) is investigating whether offering financial incentives can help people control their infections. “This is a solvable problem,” says NIAID Director Anthony Fauci (see News Focus). “I mean, c'mon. It's a finite problem with a finite solution. So we can do it.”

    Fauci, whose lab has made fundamental discoveries about HIV and the immune system, says researchers also have to adjust to this new era that is striving to figure out the best ways to apply existing tools. “The rush that you get out of discovery of something that you didn't know before is a very different feeling than the excitement you get when you see that if you implement proven things that you can actually turn the thing around,” Fauci says. “It isn't that kind of eureka moment. It's more of a cause.”

    The cause also includes HIV-infected Americans, who from the start of the epidemic have had an astounding influence on both science and society's response to the disease. Alexander, who is majoring in social work, is part of the new generation of advocates, and he sees himself devoting his career to his version of the cause. “When I first found out I was positive, the social workers were awesome,” he says. “Now there are no text messages, smoke signals, nothing.” If he were a social worker, he's confident he could use his own experiences to help people through their tough times and to stay on their medication. “I'd like to do outreach to make people not feel bad about being infected,” Alexander says. “That's where my heart is.”

  8. HIV/AIDS in America

    A Tale of 10 Cities

    This spring, Science met with HIV-infected people, at-risk communities, researchers, caregivers, health officials, and advocates in 10 U.S. cities, traveling to the Deep South and the West and East coasts to see the varied epidemics and the local responses up close. The package of stories looks at everything from the social and structural issues to the medical and scientific challenges through the eyes of people on the front lines, as well as the research efforts under way to try to slow, if not one day bring to a halt, the spread of HIV.

    Birmingham, Alabama: Southern HIV/AIDS Program with All the Fixins

    Jackson, Mississippi: By the People, For the People

    Atlanta, Georgia: And the Band Played On, Vol.

    San Francisco, California: A Concerted Effort to Lighten the Load

    Los Angeles, California: Life in the Fast Lane: HIV and Meth

    San Diego, California and Tijuana, Mexico: My Virus is Your Virus

    New York, New York: Miracle on 34th Street: Success With Injectors

    Bronx, New York: Pay Now, Benefits May Follow

    Providence, Rhode Island: HIV and the Cell: A Prisoner’s Dilemma

    Baltimore, Maryland: Dancing the Night Away; Keeping HIV at Bay

    Washington, District of Columbia: HIV/AIDS Response Renovated in Capital

  9. Birmingham, Alabama

    A Southern HIV/AIDS Program With All the Fixins

    1. Jon Cohen

    Here in the heart of the Deep South, the University of Alabama, Birmingham, has built a full-service HIV/AIDS center modeled on the widely praised program at San Francisco General Hospital.

    Few people would confuse this city, dubbed the Pittsburgh of the South because of the iron and steel industry that once boomed here, with San Francisco. Yet here in the heart of the Deep South, Michael Saag and his team at the University of Alabama, Birmingham (UAB), now the state's biggest employer, have built a full-service HIV/AIDS center modeled on the widely praised program at San Francisco General Hospital. Not only does UAB's 1917 Clinic, named after its original street address, perform cutting-edge research and pivotal clinical trials, but it has also helped patients overcome the stigma about HIV that is all too prevalent in this part of the country and stay in treatment and on their drugs.

    Test everyone.

    The ER at UAB's hospital checks the HIV status of all adults unless they opt out. Jamey Daniel came in for a toothache.

    CREDIT: MALCOLM LINTON

    Virologist Robert Schooley, an HIV/AIDS clinical researcher at the University of California, San Diego, says one of the most remarkable aspects of the 1917 Clinic is that it's in his hometown of Birmingham—which is not known for embracing diversity. “Mike has done a great job in putting together something in a place that had the potential to be incredibly hostile to HIV and anybody with it,” Schooley says.

    The 1917 Clinic treats 2000 patients in a multiservice building that features a dentist, social workers, peer mentors, counseling, a pharmacy, and a chaplain. A research team led by Saag, who started the clinic in 1988, has run trials that have helped bring almost every antiretroviral drug to market, tested vaccines, and analyzed critical issues such as stigma and retention in care. “It provides comprehensive, state-of-the-art care in a good environment, and it's one-stop shopping,” says Steven Deeks, a clinician and researcher at San Francisco General Hospital, who recently visited the 1917 Clinic.

    In December 1986, Saag spent a day at Deek's hospital to learn from the best. During his visit, he noted how they trained providers all over the city and worked closely with the community. Their clinic, Ward 86 (see p. 175), had an unusually warm, welcoming environment. He asked what they would do differently if they were starting over, and they said they would create a computer database to track patients, and keep specimens frozen for later study.

    The 1917 Clinic now has electronic medical records on 8000 people. As a result of this close monitoring, Saag and his team can easily tap demographic and health information about their entire patient population: nonwhite (55%), white (45%), men who have sex with men (52%), heterosexuals (34%), and injecting drug users (8%). Overall, 71% of the patient population has a fully suppressed viral load, which is similar to San Francisco General's success rate.

    UAB's Michael Mugavero has used the database to study retention and linkage to care and assess how the 1917 Clinic and the rest of the country can do better. “We've focused a lot on testing and treatment and forgotten about what's in between,” says Mugavero, a clinical behavioral epidemiologist. A study he co-authored in the 15 January 2009 issue of Clinical Infectious Diseases assessed the 60% of patients who missed appointments in the year following their first one—an indicator of health behavior—and found that they subsequently died at twice the rate of patients who kept all appointments. “The fundamental challenge is that at a local, state, and national level we've had inadequate surveillance of individuals after diagnosis, which makes it difficult to determine who is retained in care and then take action,” he says.

    Mugavero and other HIV researchers at UAB, which until 2011 included the powerhouse husband-and-wife team of George Shaw and Beatrice Hahn, have made their mark in almost every part of the field from the lab to the clinic to shaping guidelines and policies. Saag has published 240 papers about HIV/AIDS, co-authoring landmark studies about the diversity of viral genotypes in each infected person and the value of measuring viral levels to help manage a person's disease.

    Clinicians and staff members at the 1917 Clinic have taken several progressive approaches to addressing the local epidemic. UAB's hospital emergency room runs HIV tests on all patients 19 to 64 years old unless they opt out. “It's an unusual opportunity to counsel, test, and link to care,” says ER specialist James Galbraith, who spearheaded the program. A new machine at the hospital, the Abbott ARCHITECT, can detect signs of HIV in people within 8 days of infection, during the acute phase in which people have extremely high viral loads and are more likely to transmit. The nonprofit group AIDS Alabama provides housing for clinic patients, drives them to medical appointments, helps recruit people for AIDS vaccine trials the clinic runs, and conducts media campaigns for testing.

    Each week, the clinic holds a discussion group for patients, called Heartsong@1917, and the people who attend tell heartbreaking stories of stigma and discrimination. Lisa J., an African American who served in the Army, says she travels 137 kilo meters to come to the clinic because she lives in a small, white town that has enough trouble with her race. “I'm from New York City and everything is open,” Lisa says. “Come down to the Bible Belt and everything's not like that. I have two children, and I don't want them to be shunned.” She says if people in her town knew she was infected, “I'd have to watch how I crossed the street.”

    Peer mentor.

    Janet Johnson (center) with two HIV-infected peers she helps.

    CREDIT: MALCOLM LINTON

    Janet Johnson, who sits on the clinic's patient advisory board, says she became infected by injecting drugs, transmitted the virus to her newborn in 1986, and then went clean. She lived in the small town of Arab, 105 kilometers from Birmingham, where “I had to fight for him to go to school and go to the Baptist Church because he might scratch, bite, or poop,” she says. Their infections caused such divisions in their church that they left for a Pentecostal congregation. “My little boy passed away in '99 from AIDS, and he never weighed more than 50 pounds [23 kilograms],” says Johnson, whose husband also died from AIDS. She started using again. By 2002, her CD4 white blood cells, which HIV destroys, had dropped from the normal range of more than 600 per microliter to a life-threatening four.

    Johnson started on antiretroviral drugs, entered drug treatment, and found housing with AIDS Alabama. Today, she has an undetectable viral load and a normal CD4 count. She joined a clinical trial at 1917 Clinic, which subsequently began to provide her dental care, and she then joined the staff as a peer mentor who helps others find housing, transportation, and the like. “For us to win the HIV battle, we have to take care of the whole person, not just bits and pieces,” Johnson says.

    That could be 1917 Clinic's motto.

  10. Jackson, Mississippi

    By the People, For the People

    1. Jon Cohen

    My Brother's Keeper is the only community-based organization in Mississippi that focuses on those who bear the brunt of the HIV/AIDS epidemic in the state: young black men who have sex with men.

    Around midnight on a recent weeknight, a gay club on the west side of town called Sippi Citi suddenly came alive with troupes of dancing men. Some appropriated choreographed routines called J-setting from the majorettes at Jackson State University, while others line-danced in the strolling fashion made popular by the Greek sororities and fraternities at historically black colleges. Adding to the wild incongruity, they shimmied and strutted to a misogynistic hip-hop song about a scheming woman taking advantage of her boyfriend. All in all, it was a perfect place to have outreach workers from My Brother's Keeper stationed in front of a table littered with pamphlets about HIV and other sexually transmitted diseases, advertisements to get tested, and male and female condoms.

    Community center.

    My Brother's Keeper taps the bar scene to get out its message.

    CREDIT: MALCOLM LINTON

    My Brother's Keeper is the only community-based organization in the state that focuses on those who bear the brunt of the HIV/AIDS epidemic in Mississippi: young black men who have sex with men (MSM). At the end of 2009, 78% of Mississippi's 8142 people living with HIV were black, even though blacks make up only 37.5% of the population, according to the latest data from the U.S. Centers for Disease Control and Prevention (CDC). A 2008 report from the Mississippi Department of Health found a 48% increase between 2005 and 2007 in HIV in young black men. Mississippi has a higher rate of gonorrhea and chlamydia than any state, and according to a report in the 2 January 2012 issue of AIDS co-authored by CDC researchers, it had the country's highest HIV case fatality rate between 2001 and 2007.

    Mississippi is one of the poorest states in the nation, and as Human Rights Watch noted in its 2011 report on HIV/AIDS in Mississippi, Rights at Risk, half of the residents who know their HIV status do not receive basic health care for their disease. “Save yourself a transatlantic airline fare to a developing country,” Craig Thompson, head of the STD/HIV Office for the state's health department, told Human Rights Watch. “Just come to Mississippi, where we have a vast underserved population.”

    In addition to doing outreach work at clubs like Sippi Citi, My Brother's Keeper offers HIV counseling and testing, trains young men to modify their risky sexual behavior, and partners with CDC and others to do research about the vulnerable young black MSM the group serves. Founded in 1998 by HIV/AIDS advocate Mark Colomb (who died last year), the group has also tried to combat homophobia in this most conservative city, holding an annual gay pride event—but they do it at a hotel, not in the street. “To be gay here is just not the thing to do,” says June Gipson, who runs My Brother's Keeper and has a Ph.D. in urban higher education. “We had our biggest Pride last year, and we had 200 people in the room. We hadn't had but 20 in the past. We probably never will have a parade.”

    To better address the health-care needs of African-American MSM, Gipson has teamed up with Leandro Mena, an infectious-disease specialist and researcher at the University of Mississippi Medical Center. Together, they're creating the state's first clinic designed for lesbian, gay, bisexual, and transgender people. “We want to establish a culturally competent, logistically appropriate place to transfer information,” Mena says. They hope to open the clinic by year's end. “There's a significant gay-identified, younger population that has stigmas about accessing health care because of prejudices and a lack of cultural sensitivities,” he says.

    Overtime.

    June Gipson (left), shown here outside of a gay club, does prevention education late into the night.

    CREDIT: MALCOLM LINTON

    Mena says he's collaborating with My Brother's Keeper because of their credibility. “I don't see any other organization in this state that has a similar potential to establish a relationship with that community,” Mena says. “And that's because they are part of it.”

  11. Atlanta, Georgia

    And the Band Played On, Vol. 2

    1. Jon Cohen

    If its large public hospital, Grady Memorial, is any measure, Atlanta currently has one of the most out-of-control AIDS epidemics in the country.

    And the band played on, the 1987 EPIC tome about the early years of the AIDS epidemic, featured Atlanta prominently, largely because what is now called the U.S. Centers for Disease Control and Prevention (CDC) is based here. But author Randy Shilts, who died of AIDS 7 years later, made nary a mention of the city's epidemic: At that point, the virus had made little headway here. Today, if its large public hospital, Grady Memorial, is any measure, Atlanta has one of the most out-of-control epidemics in the country. “We see a lot of people coming in with three or four T cells and life-threatening opportunistic infections,” says Jeffrey Lennox, chief of infectious diseases at Grady. “We're seeing a surge in very young men who have sex with men [MSM] who, like most teenagers, don't take many precautions.”

    Grassroots messaging.

    Evolution Project's Markese Sanders, prevention promoter.

    CREDIT: MALCOLM LINTON

    On a balmy morning in late May, Lennox, who is also on the faculty at Emory University, leads the daily rounds at Grady with eight young doctors rotating through what's called the Special Immunology Service. Grady, which receives patients from all over the state, averages about 40 beds a day occupied by AIDS patients. The cases today include horrific opportunistic infections that, since the advent of powerful antiretroviral drugs, are rarely seen in U.S. hospitals nowadays: the skin-blotching Kaposi's sarcoma, blinding Mycobacterium avium complex, seizure-inducing toxoplasmosis, and brain-damaging progressive multifocal leukoencephalopathy. Several patients have dementia and mumble, one is on a respirator, and a few have dangerous forms of tuberculosis that require the doctors to don facemasks. “It's the ignored epidemic,” Lennox says. “Atlanta is the black San Francisco. It's a huge mecca for gay black men.”

    Pregnant HIV-infected women provide another window into the severity of the local epidemic. Ponce de Leon Center, Grady's sister outpatient HIV/AIDS clinic that treats a staggering 5000 patients a year, has seen six women in the past 6 months who recently transmitted the virus to their babies—which antiretroviral drugs coupled with C-sections can almost always prevent.

    Clinic pediatrician Rana Chakraborty says the root of the problem is that Georgia doesn't enforce its own laws. He points to a study presented at the American College of Obstetrics and Gynecology meeting in 2010 that surveyed 64 obstetrical hospitals in the state to see whether their HIV-screening policies comported with Georgia law. More than half of the hospitals did not have the proper HIV rapid test needed during labor and delivery, and fewer still had the proper antiretroviral drugs on hand to intervene. “It goes hand in hand with stigma down here,” Chakraborty says, noting that this is the Bible Belt. “It's just one of those things people don't want to talk about.”

    Similar issues complicate prevention work with MSM. “It's really difficult to get people involved in prevention,” says Markese Sanders, who recently completed a neuroscience undergraduate degree at Emory and now works at the Evolution Project, a drop-in center for young, black MSM. “You can't convince them that HIV is a problem and that it's their community. I had a trans lady get offended when I offered her a test.”

    Scant data are available from Grady and Ponce to help Lennox and his colleagues assess whether treatment might be having an effect on prevention, as they've just started to build an electronic patient database, Lennox says. “We have this overwhelming tidal wave of patients hitting us day after day,” he says. “We could have written a ton of papers, but we're drowning.”

    Yet researchers here do often collaborate on national studies that are helping to clarify why so many patients have difficulty fully suppressing HIV. Emory's Carlos del Rio, who heads clinical research at Ponce, co-authored a widely referenced paper published online 15 March in Clinical Infectious Diseases that closely examines the gaps in the continuum of care, or “treatment cascade” (see p. 168). For the difficult populations they treat—including young black MSM, teens who were infected at birth, and many crack cocaine users—del Rio says they need new models of care, such as clinics that don't require appointments and that offer food or coffee. He is now helping to run a 10-city study, Project Hope, that asks how best to achieve viral suppression in HIV-infected substance abusers. The study will evaluate the effectiveness of adding a “patient navigator” to the standard care, to help patients deal with clinic visits and the like, and giving financial rewards for treatment compliance. “We need to rethink our approach to the epidemic,” he says.

    Lennox says Atlanta clearly has benefited from the introduction in late 1995 of potent combinations of antiretroviral drugs: AIDS deaths peaked at Grady in 1994, dropping from 990 a year to about 200 now. Still, he's disappointed that the city hasn't made more progress. “As frustrating as it was back then to try and help people you couldn't help, it's more frustrating now because a significant part of our populations are those who are hardest to engage in treatment,” Lennox says. “If they had been tested earlier when they weren't sick and there was a network to get them into treatment and give them rides to the clinic and not lose them to follow-up, none of this would be necessary. I would love to close down the AIDS ward at Grady Memorial Hospital. I just don't see it happening anytime soon.”

  12. San Francisco, California

    A Concerted Effort to Lighten the Load

    1. Jon Cohen

    The San Francisco Department of Public Health has mapped the amount of virus in every neighborhood and risk group, which helps guide both treatment and prevention efforts.

    Moupali Das and her colleagues at the San Francisco Department of Public Health (DPH) were struck by something missing in a provocative article, “AIDS in America—Forgotten but Not Gone,” that ran in the 18 March 2010 issue of The New England Journal of Medicine. A bar graph in the perspective made a stark point: The prevalence of HIV among men who have sex with men (MSM) and other at-risk populations in some U.S. cities on the East Coast approaches that seen in eight sub-Saharan African countries. But if the graph had included San Francisco MSM, as Das and her colleagues later showed in an adaptation of the figure, the bar would have stood taller than the hardest hit country on the graph, South Africa.

    San Francisco has a population of 800,000, which is tiny compared with South Africa's 50 million, but the city has suffered as mightily from HIV as anywhere in the world. As of 2010, 15,861 HIV-infected people lived here, 85% to 90% of whom are male. According to DPH studies, 87% of the males infected with HIV are MSM, and one in four MSM in the city lives with the virus. “This is very different from other epidemics in the United States,” says Das, who directs HIV-prevention research for DPH. So is the response.

    The city has made great strides on several fronts over the past few years. After DPH ramped up testing efforts, the percentage of HIV-infected MSM who didn't know their status dropped from 23 in 2004 to six in 2011. The average CD4 count of 400 at diagnosis is more than twice as high as the rest of the nation, where many people seek treatment at such late stages that it becomes difficult to save them. DPH works closely with San Francisco General Hospital—Das sees patients there once a week—and, following its lead, issued a policy in 2010 that made San Francisco the first U.S. city to endorse antiretroviral treatment for all HIV-infected people, regardless of their CD4 counts. The hospital's venerable HIV/AIDS clinic, Ward 86, has pioneered aggressive efforts to link some of the city's poorest and most troubled people to top-notch care and keep them on the antiretroviral drugs. And in one of its latest innovations, DPH has mapped the amount of virus—the so-called community viral load—in every neighborhood and risk group, which helps guide both treatment and prevention efforts.

    Residency requirement.

    Stable housing helped Connie Sprinkle stay on meds.

    CREDIT: MALCOLM LINTON

    California requires labs to report viral load tests of all HIV-infected people, which allowed Das and colleagues—including Grant Colfax, who has since become the Obama Administration's top domestic HIV/AIDS official (see p. 168)—to analyze community viral load between 2004 and 2008. In a groundbreaking study published in June 2010 in PLoS ONE, they reported a drop in the city's HIV levels that corresponded with a decrease in the number of new infections. But transgenders, who predominantly live in the neighborhoods known as the Tenderloin and South of Market, had a three times higher viral load than average. “Community viral load is one marker that gives a snapshot of the whole continuum” of success and failures, Das says. “We're doing a little bit better than the rest of the United States in getting people to undetectable HIV levels, but we still have a long way to go.”

    Wards of Ward 86

    Some of the challenges facing the campaign are evident in General Hospital's Ward 86, which takes only patients who have no insurance—and that puts the doctors, nurses, and social workers there on the front line.

    First thing on a Friday morning in May, as patients start to fill the waiting room at Ward 86, a team known as PHAST begins to hunt for people who missed their appointments the day before. PHAST stands for Positive Health Access to Services and Treatment, and for the past 10 years, the program has singled out HIV-infected people who have had trouble taking care of their disease or who are newly diagnosed. PHAST enrolls people who live in a fog in Fog City, sleeping on the streets, shooting heroin and smoking meth, or wrestling with paranoia and schizophrenia. “People get lost,” says Diane Jones (see photo, p. 171), the nurse who runs the program. “Their lives are very chaotic.”

    Takes a village.

    San Francisco Department of Public Health's Moupali Das charts community viral load to guide treatment and prevention.

    CREDIT: MALCOLM LINTON

    After reviewing the previous day's appointment log, Sandra Torres, a social worker, discovers that half of the 20 PHAST patients scheduled for a visit didn't show up. A few rescheduled, and a few others called and said they couldn't make it. “But three are absolutely no-shows,” Torres says. “We don't know what's going on.”

    Torres phones the first no-show, a 49-year-old man who found out he was infected 10 years ago after a PCP overdose hospitalized him. She leaves a message on his voice mail. “He's problematic,” she says after hanging up. “He hasn't had labs since October, and his CD4 count was 68 and his viral load was 54,000. He hasn't been here since February. He reports 100% adherence.” His blood work suggests anything but.

    The second no-show, who like the first is an MSM, has a full voice mailbox. “He's concerning because he likely has anal cancer,” Torres says. In September, PHAST's outreach worker went to his house and spoke with him. Torres phones his pharmacy and learns that he hasn't picked up any medication in 3 months. They'll send the outreach worker to his house again.

    The third patient is/was an injecting drug user; Torres e-mails him and also leaves a message at his methadone clinic.

    Sometimes, the no-shows die, or they move or change clinics without telling anyone. But the PHAST team frequently locates the patients and then connects them to housing, substance treatment, transportation, counseling—or whatever else helps them help themselves. During the past year, 529 people enrolled in PHAST, and 79% of them initially were not receiving antiretroviral drugs. Now, 71% of these patients are taking the drugs. More than a third of the patients “graduated”: They kept appointments, refilled medications, and used the emergency room and urgent care appropriately. Another 129 moved on to long-term residential care, switched clinics, or are locked up. Seven died, and 47 did not contact the program for 6 months and fell into the “lost to follow-up” category.

    Diane Havlir of the University of California, San Francisco, who heads the HIV/AIDS program at the hospital and is also a co-chair of the international AIDS conference that will be held next week, notes that when they look at all 2669 patients who received treatment at Ward 86 last year, only 75.4% had undetectable viral loads. “We don't know all the answers,” Havlir says. “We have to study what we're doing and better understand the science of delivering care.”

    Connie Sprinkle, 58, shows the challenges faced by both the PHAST patients and the Ward 86 staff. “Most of my life has just been running and doing what I have to do to survive,” says Sprinkle, who is also known as Mama Peaches. Sprinkle told Science that molestations by a relative led her to start running away from home at 10 and using heroin at 13. She had her own child at 16 and the next year began dancing in strip clubs. Forgery soon sent her to the penitentiary for a 3-year stint. She was diagnosed with an HIV infection at Ward 86 in 1985, the first year the test became available. It came as little surprise, she says. “I was a hooker and did IV drugs. I was homeless. I did everything that was wrong.”

    Sprinkle took AZT when it came to market 2 years later, but the drug made her sick and she stopped after a week. Same thing happened with ddI, the second antiretroviral that came to market. “That made me sicker,” she says. “What's the benefit of being sick when you don't feel sick?” By the early '90s, she'd stopped dancing and selling sex and was living in cars and surviving on Social Security income. She rarely visited Ward 86.

    Three years ago, suffering from a serious case of Clostridium difficile, Sprinkle returned to the ward for help. “My boyfriend of 24 years said he'd had enough of the smell, and he brought me up with my bags and everything,” she says. “And he left.” Tests showed her CD4 cell count was just 14.

    The PHAST team found Sprinkle housing at the city-run Laguna Honda, which has 24-hour care for residents, and she eventually moved to a permanent-care facility, Leland House, supported by the federal Housing Opportunities for Persons with AIDS program. The staff dispenses the antiretroviral drugs and watches her take them each day, which Sprinkle bluntly says she wouldn't do on her own. “There's some ambivalence about the will to live,” she says.

    Today, Sprinkle's CD4 count is 275 and her viral load is undetectable. So in addition to stabilizing her life and her HIV infection, with PHAST's help, Sprinkle has done her small part to decrease the community viral load—a concept, she says, that had never crossed her mind.

  13. Los Angeles, California

    Life in the Fast Lane: HIV and Meth

    1. Jon Cohen

    Methamphetamine use on the West Coast has become intimately linked to HIV in men who have sex with men (MSM). HIV prevalence in MSM has climbed in lockstep with the intensity of meth use.

    Steven Shoptaw recently had a case that flapped this unflappable clinical psychologist—and dramatically explains how methamphetamine use on the West Coast has become so intimately linked to HIV in men who have sex with men (MSM).

    Shoptaw* works at the University of California, Los Angeles (UCLA), and runs the Vine Street Clinic, a center for meth research and treatment. He says a longtime patient put an ad on Craigslist that effectively offered men the chance to use him and leave. The rules: No condoms, he was the bottom, and he wore a blindfold. Hyped on crystal meth for 3 days, the HIV-infected Latino man in his 30s reported that dozens of men came to his hotel room and helped him live out his fantasy. “For many MSM, when they get under the influence of stimulants, particularly meth, it's all accelerator and no brake,” says Shoptaw, who has worked closely with his UCLA colleague Cathy Reback, a research sociologist, to document meth's role in the LA epidemic and test interventions. “There's no way they can stop engaging in some extreme form of sexual activity. Meth facilitates extreme sexual behavior that's just not there when men are not high.”

    Meth, which comes in both a crystalline form (“ice”) and a fine powder (“speed”), is typically smoked or snorted; some users inject it, but there's scant evidence that sharing of syringes occurs and contributes to the spread of HIV. Studies show that meth has gained little popularity in black MSM communities or in MSM who live in the Northeast, Midwest, or South. “It's a real West Coast phenomenon,” says Shoptaw, whose clients are evenly split between Latinos and whites. Although the drug is also used by many heterosexuals and leads them to extreme sex, Shoptaw says they have such low levels of HIV in their communities that it hasn't been a factor in transmission. “Even in the presence of a lot of risky behavior, if it's not where the virus is circulating, meth is just a drug problem,” he says.

    Shoptaw and Reback received widespread attention when they reported in the November 2006 Journal of Urban Health about studies in Los Angeles that showed how HIV prevalence in MSM climbed in lockstep with the intensity of meth use. At one extreme, 86% of MSM at a residential treatment facility for drug addiction reported that they were HIV-infected; among recreational users, it was a still-high 23%. Studies have also shown that HIV-infected meth users on antiretroviral drugs (ARVs) have trouble sticking to their treatment regimen. “The simplest explanation is that meth makes you forget to use your ARVs,” Shoptaw says.

    Shoptaw, Reback, and others have shown that cognitive behavioral therapy—especially if it's “gay-specific”—and a “contingency management” strategy that financially rewards people for staying clean can cut meth use in MSM. Text messaging, which sends notes like “2 much tweak & freak is harsh 2 ur body” at strategic times, can decrease use, too. Several different types of drugs are also being studied, including some that try to boost the dopamine levels that meth depletes and others that reduce inflammation in the brain caused by the drug. Reback says more men are coming into treatment, but the prevalence of HIV in regular meth users stubbornly remains around 60%. “We haven't put a dent in it.”

    Taking it to the street.

    Bienestar's mobile testing unit outside Hollywood gay bars surveys people about meth use.

    CREDIT: MALCOLM LINTON
    • * Steven Shoptaw is married to the author's cousin.

  14. San Diego, California, and Tijuana, Mexico

    My Virus Is Your Virus

    1. Jon Cohen

    An 8-year-old U.S.-government-funded HIV/AIDS research study has shown how readily the virus makes a mockery of the U.S.-Mexico border and creates one regional epidemic.

    The Tijuana river canal, a concrete edifice that abuts the Mexican side of the border here, has a sidewalk along its upper ridge that sports a view of what to many locals represents both heaven and hell. Heaven is the opulent Land of Plenty, which stretches as far as the eye can see to the north. Hell is immediately below in the canal's basin—a fetid, garbage-strewn horror that has become home to heroin addicts, many of them deportees from the United States, some infected with HIV.

    Breaching borders.

    Steffanie Strathdee (left) and Thomas Patterson track regional spread of HIV.

    CREDIT: MALCOLM LINTON

    Men gather in clumps along the sidewalk, putting lighters to spoons that hold the local heroin known as black tar, burning off the impurities in this version of the opiate. They cook and inject openly, despite the border guards on the San Diego side, who, stationed on a hill in an SUV to deter fence jumpers, watch them through binoculars. Some of the heavily tattooed men have ink on their faces, and several wear syringes balanced behind their ears like pencils. But when they see Susi Leal, a health promoter who stopped shooting up herself 12 years ago, they smile wide, and there is nothing unsettling about them at all. Leal works with a U.S.-government-funded HIV/AIDS research study in which these men are participating, and it has shown how readily the virus makes a mockery of the border and creates one regional epidemic.

    The 8-year-old project, El Cuete—slang for both syringe and being high—is run by a binational team of researchers from the University of California, San Diego (UCSD), located less than 50 km north. “The epidemics of HIV, TB, and syphilis are linked between San Diego and Tijuana,” says UCSD epidemiologist Steffanie Strathdee, principal investigator of the project. “You can't just draw the line and say it's their problem, it's not ours.”

    Strathdee and her husband, UCSD psychologist Thomas Patterson, have published a flood of studies that take a cross-border perspective on HIV, examining the histories and viral status of 3000 injecting drug users (IDUs) in Tijuana, including the canal dwellers. A second, overlapping study they run has done similar work with more than 1000 sex workers in Tijuana. And Patterson conducted a third study that has involved 800 men who buy sex in Tijuana, half of whom live in San Diego. A common theme in all of their studies—which they review in a policy forum they co-authored for the June Annals of Epidemiology—is that many of these people, by force or free will, go back and forth between Tijuana and southern California, sometimes carrying the virus with them.

    Painful reality.

    Many deported heroin users who live in the Tijuana River Canal consider California home.

    CREDIT: MALCOLM LINTON

    Their studies have shown that more than half the male IDUs in Tijuana were deported from the United States. In the canal, several men say they went to America as toddlers and were kicked out in their 20s or 30s after being arrested, most on drug-related charges. “I think more in English than in Spanish,” explains one man, who says he was a San Diego resident for 28 of his 30 years. Another says he was a pastor in Los Angeles for 10 years. Most feel the pull of children and wives back in California; several have multiple deportations on their records. A comparison of male IDUs who had been deported to those who had not found a fourfold higher risk of HIV infection among the deportees, underscoring that mobility and the attendant social upheaval puts people at risk. Patterson says deported women engage in higher risk behavior, too, including sex work. “They get down here in the middle of the night and don't have any language skills or context to work,” he says.

    Strathdee and Patterson have found that fewer than half of the sex workers and IDUs in Tijuana had been tested for HIV before they joined one of their studies—a huge missed opportunity both to treat and prevent spread (see p. 168). Female IDUs who sold sex and had a sexually transmitted infection such as syphilis have the highest prevalence documented, 12%, which dropped to 10% if they only injected drugs. IDU sex workers said they shot up with clients more than half the time. Patterson's study of male clients from San Diego and Tijuana found a 5% prevalence in both groups. Interestingly, in the largest study they did of male IDUs, only 4% of them tested positive for HIV, which is high, but not for IDUs. (They suspect that female IDUs in their study had much higher prevalence primarily because they have higher syphilis rates.)

    Although sharing needles is the norm in Tijuana, Daniel Ciccarone, a clinician and researcher at University of California, San Francisco, notes in the May 2009 International Journal of Drug Policy that users of black tar heroin—the most popular form of the drug throughout the western United States—have a lower prevalence of HIV than that of those who shoot white or brown versions. He contends that the main factor likely slowing HIV's spread is that black tar gums up needles and syringes, which frequently have to be cleaned before reuse or thrown out.

    Strathdee notes that there were more than 40 million legal crossings from Tijuana to San Diego last year—it is the world's busiest land border—and she says the two countries have to stop pointing fingers at each other when it comes to HIV/AIDS. She hopes her team's research will help end the “blame game” and lead both countries to develop a more coordinated approach for treatment and prevention. “We're absolutely sitting on a time bomb,” Strathdee says. “All of these people are going to fall through the cracks, and it's going to blow back to both countries. If we don't do something soon, it's really going to get out of control.”

  15. New York, New York

    Miracle on 34th Street: Success With Injectors

    1. Jon Cohen

    Although New York City's population of injecting drug users has dwindled to an estimated 100,000, the main reason for the steep drop in HIV incidence, currently only 1%, is that users stopped sharing needles.

    HIV typically spreads more readily between people who share needles than in sexual networks, which means a large community of injecting drug users (IDUs) can mark the emergence of an epidemic with great precision. This dense city of about 8 million residents had an estimated 200,000 IDUs in the late 1970s, more than any city in the world. In 1978, Beth Israel Medical Center collected blood samples of users to study liver disease. A retrospective analysis of the samples conducted by Beth Israel's Don Des Jarlais and colleagues found that 10% were already infected with HIV. By 1981, the prevalence had jumped to 50%, which helped make the Big Apple the center of the country's AIDS epidemic. “Over half the injectors were infected before we even knew about AIDS,” says Des Jarlais, as he walks up to the Lower East Side Harm Reduction Center for a visit. New infections occurred in this IDU population at the staggering rate of 13% per year.

    Today, studies by Des Jarlais and others have shown that the incidence of HIV in New York City IDUs is 1%. “We're running out of new infections,” says Des Jarlais, a social psychologist who directs research at Beth Israel's Baron Edmond de Rothschild Chemical Dependency Institute.

    Although the city's IDU population has dwindled to an estimated 100,000, that doesn't explain the steep drop in incidence. The main reason is that users stopped sharing needles, Des Jarlais says—thanks in large part to this Harm Reduction Center and many other groups doing similar work. “In the beginning, there was nothing at all like this,” Des Jarlais says about the center, which last year took in 200,000 used syringes and gave out 250,000 clean ones. The 24-person staff also offers HIV testing, help finding housing, and counseling. “This is a full-service organization, and that's the key to its success,” Des Jarlais says.

    Swap, meet.

    Don Des Jarlais at Lower East Side Harm Reduction Center, which runs a popular needle exchange and hangout.

    CREDIT: MALCOLM LINTON

    As Des Jarlais and colleagues explain in an article in the January 2011 issue of Substance Use & Misuse that looks at HIV in IDUs in New York City over the past 25 years, the logic of providing clean needles to people who shoot up heroin, cocaine, and other illicit drugs did not immediately win over the public or politicians. “Syringe exchange was considered as early as 1985 but encountered very strong opposition,” they note. An article in the same issue recounted that police, conservative politicians, and heroin-weary African-American communities were wary of seeming to condone drug use. Indeed, the U.S. Congress in 1988 outright banned the funding of needle-exchange programs. “With such strong resistance to syringe exchange, punitive drug laws, and the federal ban on syringe exchange funding, it is, in fact, quite remarkable that so much was subsequently accomplished,” wrote Daliah Heller and Denise Paone, who worked on the issue at the New York City Department of Health and Mental Hygiene.

    Local laws and policies began to change in the early 1990s in response to vocal AIDS activists who illegally distributed clean needles and confronted lawmakers, citing scientific evidence that syringe exchange slowed HIV's spread. As Des Jarlais and colleagues detail, the increase in syringe-exchange programs directly correlates with a precipitous drop in HIV incidence among IDUs. Heller, who is now a visiting scholar at the City University of New York, says there was also a “diffusion of benefit” from the prevention message that came along with syringe-exchange programs. “Syringe exchange was strong at getting the word out, which was almost as important as getting the needles out,” Heller says.

    Des Jarlais says syringe exchange did not single-handedly turn around New York's HIV/AIDS epidemic in IDUs, stressing that the growth of programs that provide opiate addicts with substitution drugs such as methadone and buprenorphine, which are taken orally, has played a major role. “In the early days of the epidemic, drug-treatment programs didn't want anything to do with people with HIV,” he says. “People were scared.” Today, Beth Israel runs 18 methadone clinics around the city, the largest such program in the world.

    Des Jarlais says to take the next step and eradicate the spread of HIV in IDUs would require more effectively coupling drug substitution, counseling, and antiretroviral treatment with syringe exchange. But he says it offers a huge payoff for a small investment. “If I had limited money, and a lot of places in the world have extremely limited money, I'd do syringe exchange first,” Des Jarlais says. “It's the cheapest intervention and can be done with a wide variety of staff. You don't even need M.D.s.”

    To Des Jarlais's “profound regret,” the lesson of New York City and syringe exchange has fallen on deaf ears in too many locales—including in the U.S. Congress, which lifted the ban on federal funding in 2009 only to reinstate it 2 years later. “I'm extremely frustrated that people are not applying what we know,” he says. “HIV prevention for people who inject drugs can be remarkably effective. It's about having the political will to apply what we know.”

  16. Bronx, New York

    Pay Now, Benefits May Follow

    1. Jon Cohen

    When people reduce the amount of HIV in their bodies, they are less likely to infect others. Now, an innovative and ambitious follow-on trial seeks to see if it can build on its sister study.

    As a celebrated study known in shorthand as HPTN 052 unequivocally proved last year, antiretroviral treatment is prevention: When people reduce the amount of HIV in their bodies, they are less likely to infect others. But for it to work, people, of course, have to learn that they are infected, seek care, and then take their medicine—and there's a steep drop-off between each of these steps, which collectively is called the “treatment cascade” (see p. 168). Now, an innovative and ambitious follow-on trial, dubbed HPTN 065, is taking place both here and in Washington, D.C., to see if it can build on its sister study. “We have to make a dent at every step of the cascade,” says Wafaa El-Sadr, the study's principal investigator and an epidemiologist at Columbia University's Mailman School of Public Health.

    Rewarding experience.

    Wafaa El-Sadr (left) and a patient who earned a gift card by suppressing HIV.

    CREDIT: MALCOLM LINTON

    The HIV Prevention Trials Network (HPTN), sponsored by the U.S. National Institute of Allergy and Infectious Diseases, will spend $32 million on HPTN 065. The study began in September 2010 and will ultimately involve 10,000 people in the Bronx and D.C., both of which are hard-hit by HIV/AIDS, particularly in African-American and Latino communities. In addition to launching major testing campaigns, the study will assess whether giving cash incentives to people who test positive will encourage them to seek care, thereby reducing their viral loads. Only half of the nearly 40 sites that provide testing and care will offer the incentives, which allows HTPN 065 to determine whether they have an impact. As an added control, the study is also examining data from patients in Houston, Texas; Chicago, Illinois; Philadelphia, Pennsylvania; and Miami, Florida, which have no similar large-scale campaigns to test and treat. Health departments in each city are collaborating with the study investigators.

    The HPTN 065 team recognizes that paying people to take care of their own health might seem absurd, but weight-loss and smoking-cessation programs have successfully used “contingency management” or “conditional cash transfers.” El-Sadr adds that the designers of HPTN 065 consulted closely with the community and thought long and hard about how best to do this. “Before we introduced our financial incentive, we had to think so carefully about what can happen that's good and what can undermine what you're trying to do,” El-Sadr says. “And we want to use incentives that, if they are effective, will be cost-effective for health systems.”

    The study offers no financial incentive for testing—as El-Sadr points out, the same negative people might keep coming back just for the cash. Instead, it gives people who find out they are positive a coupon they can redeem for $125 worth of Visa gift cards if they show up for a clinic visit and complete laboratory tests. Patients who keep their appointments, take their antiretroviral drugs as instructed, and reduce the amount of HIV in their blood to undetectable levels receive gift cards loaded with $70 up to four times per year. The reward gives new meaning to the credit card company's tag line, “Life Takes Visa.”

    The researchers plan to complete the trial by February 2014.

  17. Providence, Rhode Island

    HIV and the Cell: The Prisoner's Dilemma

    1. Jon Cohen

    Josiah Rich has helped Rhode Island create one of the most progressive and effective programs to help HIV-infected people both behind bars and when they're on the outside.

    Josiah Rich believes that one of the most important places to stanch the AIDS epidemic is in the nation's prisons. “If you think that treatment can get us out of this HIV epidemic, which I think it can, these are exactly the people we need to focus on,” says Rich, a clinician and researcher here at Brown University who treats HIV-infected inmates in the cluster of correctional facilities in nearby Cranston.

    Time heals.

    With help from Josiah Rich (left), Robert Quintana's health improved when he was locked up.

    CREDIT: MALCOLM LINTON

    As Rich notes, the United States incarcerates roughly 10 million prisoners each year—the most in the world—and people behind bars disproportionately come from the highest risk groups for HIV infection: injecting drug users, heterosexuals who have concurrent relationships, the impoverished, the homeless, and African Americans and Latinos. Some 150,000 HIV-infected people are released from jails and prisons each year. That's 12.5% of all the infected people in the country.

    Over the past 18 years, Rich has conducted pioneering research about HIV/AIDS in prisoners and helped Rhode Island create one of the most progressive and effective programs to help people both behind bars and when they're on the outside. “Many prisoners are not getting treated, and even ones who are getting treated, we're not keeping them in treatment when they get out,” Rich says.

    People unaware of their HIV status are three times more likely to transmit their infection, and they also, obviously, will not seek treatment for it. Since 2006, the U.S. Centers for Disease Control and Prevention has recommended “opt-out” testing for all prisoners, noting in a “guidance for correctional settings” that less than half of all state prisons that year reported that they offered it. Rhode Island, in contrast, a small state of just over 1 million people, began mandatory testing of all convicted prisoners in 1989 and has an opt-out policy for people in jails who have not yet been sentenced. One-third of all HIV diagnoses in the state during the following decade were made while people were locked up, Rich reported in the October 2002 issue of AIDS Education and Prevention.

    Although transmission can occur in prison, Rich has helped document that few people become infected behind bars. Much more typical is a patient he saw one morning this spring. Robert Quintana has struggled with heroin addiction since he was a teen and is now doing a 5-year stint for a drug-related burglary. As Rich palpates Quintana's liver, the 43-year-old patient says there's no comparison between the medical treatment he's receiving at this minimum-security facility versus that at the Massachusetts prison he called home between 1991 and 2000. “It's a really big difference,” says Quintana, who takes antiretroviral drugs for his HIV and a treatment that he hopes will cure his hepatitis C infection. “They actually care over here. There, it was take it or leave it. ‘You don't take medicine now? Fuggedaboutit.’ Here, I've only missed a couple of doses.”

    For Quintana and HIV-infected prisoners in Rhode Island—and in many other locales—prison becomes a place to improve their health. But that progress typically evaporates soon after release. A study Rich co-authored that examined Texas prisoners between 2004 and 2007 asked whether they filled their prescriptions for antiretroviral drugs upon release. After 2 months, 70% had not picked up their pills, as Rich and colleagues reported in the 25 February 2009 Journal of the American Medical Association.

    Rich and his Rhode Island colleagues have shown how to extend the benefits from inside to outside through Project Bridge, which began at Miriam Hospital in Providence in 1996. The project has a social work team that helps inmates for the first 18 months after release. At the end of that period, 90% of participants were still in care.

  18. Baltimore, Maryland

    Dancing the Night Away; Keeping HIV at Bay

    1. Jon Cohen

    In Baltimore, strip clubs and clubs that stage "house/ball" events popular with African-American men who have sex with men are receiving increased attention from researchers and public health officials.

    To understand the spread of HIV and effectively intervene, researchers have long sought out people at risk, from gay men and injecting drug users in some populations to young women and migrant men in others. But there has been a push in the past few years to focus on venues where the uninfected and infected mingle. And in Baltimore, two venues that are receiving increased attention from researchers and public health officials have little in common other than the fact that they both involve dancing: clubs that stage “house/ball” events popular with African-American men who have sex with men (MSM), and bars that feature strippers who cater to all races of heterosexual men. “They are such different populations and the dynamics are so different,” says Susan Sherman, a behavioral scientist at Johns Hopkins Bloomberg School of Public Health (JHSPH) here, who studies exotic dancers. “The link is we try to meet people at places where risk is generated.”

    The house/ball community, made famous in the 1990 documentary Paris Is Burning, draws hordes of young MSM to jam-packed clubs to watch dancers strut down runways in front of a panel of judges. The dancers often belong to different “houses” and compete in gender-bending competition categories including butch queen and schoolboy. “Go to a gay bar in Baltimore, and there are two black guys,” says Chris Beyrer, an epidemiologist at JHSPH, who recently attended his first ball with a younger researcher now working with the house/ball community. “At the ball, there are hundreds of people dancing.”

    The Baltimore City Health Department has a youth outreach coordinator, Keith Holt, who is part of the community and stages an annual ball called Know Your Status. “Some people have made ballroom their life, and there's a lot of risky behavior,” Holt says. On 13 June, Baltimore Mayor Stephanie Rawling-Blake announced a new HIV/AIDS awareness campaign, Status Update, that features posters of people in different category costumes with this ribald pun: “Have Balls. Get Tested.”

    No studies have specifically analyzed the HIV/AIDS prevalence in the house/ball community here, but researchers have included the events in venue-based testing in Baltimore, which helped reveal that the city has a severe epidemic in MSM. As JHSPH behavioral scientist Danielle German and colleagues reported in the 1 May 2011 Journal of Acquired Immune Deficiency Syndromes, they did surveys and testing in MSM venues as part of the National HIV Behavioral Surveillance, a system organized by the U.S. Centers for Disease Control and Prevention (CDC) to assess prevalence in different high-risk communities. The results of the first survey, which took place in 2004 and 2005, caught the city off guard. “Baltimore has this striking black MSM epidemic that nobody had any idea about,” German says.

    Site visits.

    Baltimore's HIV prevention efforts target—and stage—competitive dances at gay clubs.

    CREDIT: MALCOLM LINTON

    A second survey in 2008 tested 448 men, 71% black and 23% white, regardless of whether they had tested positive before. The prevalence was 37.5%, and a startling 78.4% of the men did not know their status. German has done intensive studies to understand why so many of the MSM did not know their status, noting that it is more of a problem here than in other test cities. Jamal Hailey, an African-American MSM who manages HIV-prevention programs at the University of Maryland, Baltimore, and conducted field research for the study, says he thinks the rampant poverty and depression in Baltimore are the main factors. “A lot of people are just trying to make it,” says Hailey, whose own father died from AIDS 13 years ago. “So getting an HIV test isn't at the top of their to-do lists.”

    In the past 2 years, JHSPH's Sherman has published four papers about the dancers who work at the two dozen strip clubs on East Baltimore Street—an area called “The Block.” One study of 98 strippers, published in the 1 April 2011 issue of Drug and Alcohol Dependence, found that although the women don't see themselves as sex workers, 42% of those surveyed traded sex for money or other valuables, and they were three times more likely to do this if they smoked crack cocaine. Half of the women said they started to smoke crack or shoot heroin after they became exotic dancers. “These women have limited negotiating power,” says Sherman, stressing that this puts their health at risk. “They come and they go, and there's no union.”

    No researchers have systematically tested the exotic dancers on The Block for HIV, but then there's little sex-worker research done in the United States. “We don't really talk about sex workers because we somehow feel it's not a major driver of HIV spread, but we're not tracking it,” says Kevin Fenton, director of CDC's National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention.

    Sherman now hopes to conduct both HIV incidence and prevalence studies of women who dance on The Block and elsewhere in the state—if the clubs and women see that it's in their best interests. “If we could just create some sort of council where different people could talk together—dancers, managers, and owners—then maybe they could make it routine that condoms are part of sex acts,” Sherman says. Their goal is not to “save women from dancing,” she says, but to reduce the risks they face from HIV and other diseases when they step down off the stage.

  19. Washington, District of Columbia

    HIV/AIDS Response Renovated in Capital

    1. Jon Cohen

    Although Washington, D.C., remains among the hardest-hit cities in the nation, a recent report says it "has made steady and significant improvements in its overall response to HIV/AIDS."

    Seven years ago, a public-policy nonprofit called DC Appleseed issued a scathing report about the sorry state of the response to HIV/AIDS in the nation's capital, which it said “lags far behind that of many other cities across the nation.” The report called the epidemic in this city of 600,000 people a “public health crisis” and faulted the government for its fragmented leadership, marginal attempts to distribute condoms, weak programs for people with substance-abuse problems, and nonexistent surveillance data. “This challenge is of life-and-death importance,” the report concluded. “Simply put, business cannot go on ‘as usual.’”

    Patient pursuer.

    Robin Thomas of Recapture Blitz tracks down no-shows and returns them to care.

    CREDIT: DARROW MONTGOMERY

    It hasn't. And that's coming from DC Appleseed, a nonpartisan group with outposts around the country that organizes teams of attorneys and other volunteers to analyze local problems and then take action.

    Although D.C. remains among the hardest-hit cities in the nation, the nonprofit's most recent report says it “has made steady and significant improvements in its overall response to HIV/AIDS.” Condom distribution jumped from 115,000 in 2006 to more than 5 million in 2011. The number of publicly supported HIV tests performed tripled between 2007 and 2011, making the District “a national leader.” Surveillance updates have “improved greatly” in both quality and regularity, and all these actions have had results.

    According to the 2011 annual report from D.C.'s Department of Health, newly diagnosed infections in general dropped by nearly 24% between 2006 and 2010, and the decrease was 71% in injecting drug users. Other recent improvements include chlamydia and gonorrhea cases leveling off, AIDS deaths decreasing, and people learning of their infections at an earlier stage of the disease when they are easier to treat.

    The city also has more HIV/AIDS research projects under way than ever before, including a massive study funded by the U.S. National Institutes of Health (NIH) called HPTN 065 (see p. 179) that aims to find and treat infected people. “Before 2006, there was virtually no research in the District,” says epidemiologist Manya Magnus, who works here at George Washington University (GW).

    Angela Fulwood Wood, who runs a large clinic that's participating in HPTN 065, the Family and Medical Counseling Service (FMCS), credits the city's progress to the nexus of the health department, academia, and providers. “We've all grown,” Wood says.

    Heralded as the changes have been, the city still has a serious HIV/AIDS problem. More than 14,000 HIV-infected people lived in D.C. in 2010, an adult prevalence of 2.7%. African Americans are much more heavily affected, accounting for 91.5% of the female cases and 67.6% of the males. The main modes of transmission are men who have sex with men, or MSM (40.5%), heterosexual contact (28%), and injecting drug users (15.1%).

    In the wake of the 2005 DC Appleseed report, D.C.'s Department of Health hired an up-and-coming epidemiologist, Tiffany West, from the U.S. Centers for Disease Control and Prevention (CDC) in Atlanta to right its surveillance ship. GW's Magnus and Alan Greenberg, who previously ran CDC's HIV epidemiology, soon teamed up with West and her staff. “Public-private partnerships really did help us get a different level of technical support that was required to build this program from scratch,” West says. In 2010, NIH also formed the D.C. Partnership for HIV/AIDS Progress, which links its researchers to the Department of Health and also helps fund the city's role in HPTN 065 and other multisite studies.

    Wood's team from FMCS works with the health department on several innovative interventions. The group now offers HIV testing at both the Department of Motor Vehicles and the Income Maintenance Administration (welfare) office in the most economically strapped part of the city. Based on Wood's idea, FMCS launched Recapture Blitz to track down patients who disappear. Robin Thomas, an FMCS community health worker, phones missing patients and also drives to their homes to see why they haven't come in for care. “My job is to settle people down,” says Thomas, who is HIV-infected herself. “I try to see what's getting in their way and how we can help, whether it's transportation or going to the doctor's appointment with them.” A half-dozen clinics now do this in D.C., and in 2010, they found about one-third of the lost patients, half of whom made and kept appointments.

    Taking a page from the health department in San Francisco (see p. 175), West and her staff gather data from mandated reporting of lab tests of HIV-infected people to calculate “community viral load,” which theoretically should give them a better handle on which neighborhoods are having success or difficulty controlling their infections.

    When West took the job here, she dreamed of creating a surveillance program that, like the health departments in San Francisco and New York, was science-driven, understood the community, and could use its findings to inform policies and programs. Recently, she says, people from those cities have knocked on her door. “I never would have thought in a million years that they'd come ask us for technical assistance, but they're doing that right now,” she says. “We've literally went from worst to first.”

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