The face of the city's epidemic has changed. A disease that once disproportionately affected gay white men has shifted to heterosexuals and people of color; 55 percent of the city's new HIV infections are among heterosexuals, and nearly 70 percent are among African Americans.
In spite of these high infection rates and disparities, too few Philadelphians have been tested for HIV. There are several reasons for this.
First, most Philadelphians underestimate their risk of contracting HIV, in spite of studies showing high rates of risky behavior. In addition, there has been little local media coverage of HIV and AIDS in recent years, contributing to the lack of awareness of the epidemic. Perhaps most important, there is still an overwhelming stigma associated with HIV and AIDS, particularly among African Americans.
Young people are also increasingly at risk in Philadelphia; 15 percent of all new infections are among those 13 to 24 years old. But the city schools still do not offer comprehensive, routine sexual education to all students.
The documented prevalence of risky sexual behavior among adolescents prompted the city's Department of Public Health to offer gonorrhea and chlamydia screening to Philadelphia high school students, a program now recognized as a national model. But the behaviors that put young people at risk for gonorrhea and chlamydia also put them at risk for HIV, so the city should add HIV testing to its routine high school screening. The city also should integrate comprehensive sexual education into the junior high and high school curricula.
The city also must expand HIV testing in high-incidence zones. Historically, CDC interventions to address the AIDS epidemic have focused on behavior, including sex and intravenous drug use. But such measures alone have failed to stem the widening racial disparities in HIV infections in Philadelphia and the rest of the nation. Moreover, mounting evidence suggests social and structural factors, not just behavior, are driving racial disparities in HIV infection.
For example, geography and sexual networks - that is, groups of people connected directly and indirectly through their sexual partners - may be as important as behavioral risk factors, if not more so. This is illustrated by the geographic clustering of new HIV infections in North Philadelphia, Southwest Philadelphia, and Germantown.
The city's HIV prevention strategy should address the critical role of sexual networks. A good start would be dramatic expansion of HIV testing in high-prevalence zones, in partnership with community organizations that are based or already working in those areas.
In recent years, public officials in New York and Washington have taken extraordinary measures to address their AIDS epidemics, launching media campaigns and massive testing programs in the hardest-hit areas. These programs help to raise awareness and destigmatize HIV and AIDS.
Philadelphia also should launch an aggressive media campaign to address its alarming rates of HIV infection. It should be tailored to address the populations most affected in Philadelphia, including African Americans, heterosexuals, men of color who have sex with men, and, increasingly, children and senior citizens. It should use conventional media outlets, including television, newspapers, billboards, bus ads, and radio, but also new media, such as social-networking sites and text messaging.
Thirty years into the epidemic, we can't sit idly by while our communities are devastated by AIDS. Washington and some neighborhoods in Philadelphia now have HIV rates on par with parts of sub-Saharan Africa.
The time to act is now, before citywide infection rates reach pandemic proportions. Mayor Nutter should start by declaring the city's AIDS epidemic an emergency. And he, City Council members, and the city's clergy should publicly take HIV tests, which would help raise awareness and reduce the stigma of HIV and AIDS in Philadelphia.
Amy Nunn is an assistant professor at Brown University Medical School who conducts HIV prevention research in Philadelphia. Gary J. Bell and Robert K. Burns are the executive directors, respectively, of BEBASHI and COLOURS, which provide services to people of color living with and at risk for HIV and AIDS in Philadelphia.