Steven W. Thrasher Discusses the HIV/AIDS Crisis in the US

CHRISTIANE AMANPOUR: And we turn now back to the United States, where an estimated 1.1 million people are living with HIV. And it’s gay black men who are most at risk right now. Steven W. Thrasher is the Daniel Renberg chair of social justice journalism at Northwestern University. He says that, while new HIV infection rates are dropping in cities around the United States, the virus is actually on the rise in rural America. And he told our Hari Sreenivasan why the U.S. is not prepared to deal with this crisis.

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HARI SREENIVASAN: So, Stephen, it says that there are 1.1 million people in the U.S. living with HIV today. And you had a recent article in “The Times.” How is it that cities like New York, San Francisco, Chicago, the HIV rates are declining, but, in rural areas, they’re climbing, and you’re saying it’s going to get worse?

STEVEN W. THRASHER, NORTHWESTERN UNIVERSITY: It probably is going to get worse in rural areas. Cities have been very proactive about addressing the crisis and trying to do things about it that are effective. And this has happened at all kinds of levels. So, at one level, they just have better public infrastructure in the first place in terms of dealing with health. And even though cities are places where HIV rates have been very dense, they have had decades of working on ways to address it, and then very directly trying to address the populations that are at risk. The biggest population at risk are young men who have sex with men, particularly of color. And so cities are very aggressively trying to create interventions around those people, getting drugs to them. The drugs that we can get to people, once they have become HIV-positive, not only help their health, but it prevents onward transmission to other people, so getting those drugs them, also getting them preventive medication. Truvada is the brand name for this drug PrEP that people can take as a preventive measure.

SREENIVASAN: Yes.

THRASHER: And then also just having ways to get people tested in the first place. And cities, particularly in New York, they’re very aggressive about trying to get people tested at all kinds of levels. And that just simply doesn’t exist in rural parts of the country. The infrastructure doesn’t exist. The culture of getting people tested — I have talked to sources in West Virginia and rural America where they will say that they know doctors who’ve never done an HIV test in their career.

SREENIVASAN: Wow.

THRASHER: And cities are just much more aggressive about doing those things. And, also, they have been really good about addressing the specific health challenges of these populations, having queer-specific sex education, having trans-specific sex education. And then the epidemic that’s really taking the country right now, they’re also going after the drug crisis and having safe needle exchanges. And some cities or even having safe injection sites. And very little of that exists in rural America.

SREENIVASAN: So, really, the opioid crisis is having an impact on HIV rates?

THRASHER: Very much so around the country. I tried to think — as an AIDS story, an AIDS scholar, I tried to think about how the story of AIDS is a story of deindustrialization. LaToya Ruby Frazier talks about how industrialization uses workers’ bodies up. And when their bodies have been used up, what has been left behind? And so when you look at places where — where the mill has closed or coal mines have closed, people’s bodies have been — had a huge toll taken on them. They have had lots of injuries. They have had lots of pain. And as that’s happening, Purdue Pharma is sending in all these drugs. You can see towns where 100 pills per person have been sent into these towns. And this is happening as people are losing their jobs and they’re losing their health insurance. And when they lose their health insurance and their bodies are in pain and they can’t get that prescription high anymore, they often turn to injection drug use. And so this happened — kind of most saliently, we saw this happen in Scott County, Indiana, in 2014 and 2015, in Southern Indiana. Mike Pence, the now vice president, was the governor at the time. And, infamously, his health people came to him when they started to see that there was a crisis happening and said, we need to do some kind of needle program. And he infamously — infamously said that he needed to pray about it and took some time to pray about it before he had an answer. And two of my colleagues at the Yale School of Public Health, Forrest Crawford and Gregg Gonsalves, did research looking at, that years before, they had really cut all the surveillance mechanisms for even looking at HIV in the first place. And so, at that time, the Centers for Disease Control outlined that there were 220 such counties throughout the United States that were like Scott County. They were sort of sitting ducks waiting for the potential hepatitis or HIV outbreak to occur, because they didn’t have prevention measures. They didn’t have proper harm reduction programs. They didn’t have education around these things. And so they are just sort of waiting for an outbreak that could occur in those places, because there’s — there’s not really counting happening until you know that there’s something bad is going on. And that’s what’s now happening in West Virginia.

SREENIVASAN: So you’re saying, essentially, that the culture clash and the conservatism ends up fueling policies that actually endanger communities?

THRASHER: Yes, that’s very much true. And it happens at various levels. So, at the emergency level, the thing that needs to happen quickly when we understand something like this happens is getting clean needles into people’s hands, particularly because injection drug use is one of the fastest ways that HIV and also hepatitis can move between people. And there’s a lot of conservative misinformation about what these programs do. They will say that they make people more likely to use drugs. They will say that it makes unclean needles more likely to be left out in public, and that it’s going to bring crime. And we actually know all of these things are not true. Research has been pretty consistent for decades that these kinds of harm mechanisms get people into care, make them less likely to have needles out in the open, and they don’t increase crime or anything like that. So that’s sort of at the emergency level. And then, at the bigger cultural level, there are these things that are really putting people at harm. One is that many of these states — and I see this in my own research in Missouri, where I have been studying the criminalization of HIV for about five, six years now. I have seen this in Missouri as well, is that, when you have states and localities that have abstinence-only education, STI, rates are going to go up, HIV rates are going to go up. And so there are huge parts of the country, particularly where these 220 counties are, that have either abstinence-only education, or they have pregnancy-only education. And we’re not teaching the young people what they need to know to be able to protect their bodies as they become sexual beings.

SREENIVASAN: There seems to be kind of a geographic cross-section here. I mean, on the one hand, Georgia has the highest rates of new HIV infections in the country. I mean, the South is only responsible for a little more than a third of the population, but more than half of the new HIV diagnoses are happening in the South. Why?

THRASHER: Yes, that’s a really interesting and sad story. So, cities have some infrastructure, and these rural parts of the country really don’t. And the South has had some of the worst rates of HIV that have to be read in the context of a bigger health crisis in the country, which is access to medication, access to health care. So, in the South, where you have some of the lowest rates of access to medication at all — or health care at all, you have the cases not just going — not just being a matter of HIV exposure. If someone is exposed to HIV, and we find out about it, and they had an HIV test at their annual physical, and we got them the medication, they would go on and live the rest of their life normally. It’s actually easier to deal with in diabetes or any other number of chronic conditions. But when somebody doesn’t get access to the medication, it can progress on to AIDS. And during that time, they’re also trans — the transmission can happen through them, because we’re not able to suppress their viral load. So, the South is a real — is a real vector of places where people don’t have access to the medication. They don’t have access to regular health insurance. And so the rates are going up and up. And there’s such stigma and shame that even people who probably know what’s going on, the symptoms have gotten so bad, they’re just so frightened to get care, that they don’t until it gets too bad. And then the virus keeps moving and getting more prevalent within their communities.

SREENIVASAN: Let’s talk a little bit about the medication that is available. How is this rolling out around — across the United States?

THRASHER: So, since 1996, we have had a drug called — they’re most often called antiretrovirals, or ARVs. And these very effectively not only save people’s lives, but they make transmission not happen through sex once people are on them. And 1996 is the banner here that we have to look at, because the AIDS rate — the AIDS death rates dropped precipitously that year. But they moved out. And they got rolled out very unequally racially and geographically. And that’s why we’re seeing very different stories in cities and in the rural South. So, for people who got the medication, the virus started to cycle out of the population, and the rate went down. And for people who didn’t go — didn’t get the medication, groups that didn’t get it, the viral rate actually got dense around them and went up. And from the CDC’s own data, you can look at the rate of AIDS in the population amongst white people and black people in 1995, before there were drugs, and 2015, almost 20 years after there are drugs. The rate for black America in 2015 was actually slightly higher than it was for white people when there were no drugs.

SREENIVASAN: Wow.

THRASHER: And that’s not because black people have more sex or unprotected sex or use I.V. drugs more. They actually engage in those activities less. But because black people en masse did not get the drugs, the virus — the rate has actually gone up in black America. So we have these drugs that are available, and they’re extraordinarily and unconscionably expensive. The drug is up to $2,000 a month for people to get. So, at an emergency level, we need to get it into these places where these outbreaks are happening, but also, very proactively, we need to get it into young men who have sex with men and people of color who are in communities where the rate is very high, because if we can just start — if we can just start addressing it, then the rate HIV will start cycling down in those populations.

SREENIVASAN: Some of your reporting lays out this racial dimension to this. If I was a straight white man, I have a one in 2,500 chance of getting HIV, but one in every two black, gay and bisexual men in the U.S. are projected to become HIV-positive in their lifetimes.

THRASHER: That’s correct. It’s really — it’s extraordinary. And so who has power in this country and who’s affected by this are very different populations. My colleague Linda Villarosa, who I believe has been on this show, wrote the “New York Times” cover story about black gay men in the South. And she phrases it very poetically, pointing out that Swaziland, the tiny country in Southern Africa, which has about a million people, has the highest rate of HIV on Earth. It’s about 28, 29 percent of the population. But black gay man, we’re on record to go to 50 percent. If black gay men and men who have sex with men, bisexual men, were a country, we would have the highest rate of HIV on the Earth. And it’s not because — as I said before, it’s not because we engage in riskier sex or drug use. We don’t. But, because we didn’t get the drugs, the rate has continued to keep going up and up in our — in our network. And this has both to do with not having access to the drugs, with also because black people have sex with other black people across age. So, someone who’s 25, 30 might have a sexual partner who’s 50 who’s in the group that was around when HIV was much higher. Unlike the 50-year-old white person and their group that got the drugs, a 50-year-old black person isn’t — in a group that largely didn’t get the drug, so the risk is more, and engagement and activity is more. And it’s really heartbreaking that this is not front-page news all the time. I can’t imagine if one in two white women were going to become HIV- positive that it would be such an uncovered story most of the time.

SREENIVASAN: Do we care less about it today because we feel like, well, there’s medical out there, it’s suppressing it, we don’t really have to worry about it? We don’t have the same level of, oh, my gosh, this person died, this person died, this person died.

THRASHER: It is a — it’s a hard thing to battle when people think, I can just take a pill to manage it. You have to be on that pill for the rest of your life, which means not only having health insurance in this country, but also housing and a lot of other things with that. And it’s also really hard, because there has been almost a revanchist idea around sex education in this country, that we need broader sex education. And the cities that are doing well not only have sex education that includes sex, pregnancy, and queer and trans sex, they also are looking at broader things that help. So, in Illinois, where I now live, Illinois is rolling out next year a comprehensive LGBTQ curriculum statewide for public schools. And that’s great, because it will help young people feel less bad about their bodies and will help them understand their bodies and that there’s nothing wrong with them. That will decrease stigma and help them be able to make the decisions they need when they are becoming sexual beings that need to protect themselves.

SREENIVASAN: Let’s talk a little bit about the global picture as well; 37.9 million people around the world are living with HIV. About 1.7 million people became newly infected. That’s just ending in 2018. Where are most people or more of the people that are infected with HIV living now?

THRASHER: So, about two-thirds of the people are living in sub-Saharan Africa. And there’s variations within that, but a good concentration of people are living in sub-Saharan Africa, some in Central Asia. The United States are about a million of the 37, 38 million people globally.

SREENIVASAN: Are the new infections also in sub-Saharan Africa, because that’s where the largest population is, or are we seeing it in other parts of the world where we weren’t seeing it before?

THRASHER: We’re seeing it all over the world. And it’s hard to paint a general picture. Things change from year to year as countries try different approaches. Deaths are down. That’s good news.

SREENIVASAN: Yes.

THRASHER: The peak deaths, I think, in 2004 were about 1.8 million. They’re down to about 750,000 now. But new infections are either stagnant or rising in certain places in the world.

SREENIVASAN: But one of the things that the U.N. AIDS stats reveal is that more young women are getting infected than men. Why does that happen?

THRASHER: Well, in the United States, we tend to think of the HIV moving through populations of people who use intravenous drugs and men who have sex with men. Those are the primary ways they have happened in this country. But in other parts of the world, the vectors have moved very differently. They have moved through heterosexual sex. They have moved through what’s called vertical transmission, where it goes from a parent to a child in birth. And in the same way, in the U.S., gay men were often thought to be promiscuous. We actually are often the ones who are protecting ourselves the most. People who are married often — of course, they often don’t use birth control or they don’t use STI control. So, for women, one of the things global that can be the most dangerous for them is to have a husband, to have someone they’re having sex with, where they’re not having any kind of protection. So that’s one of the reasons we see things moving internationally in that direction. And there’s a similar dynamic happening globally and in the U.S., that one of the largest areas where transmission is happening as people who don’t know their status. So, I think UNAIDS said recently that about one in five people living with HIV globally don’t know their status. In the U.S., that differs by the populations you’re looking at. I believe that’s about normal here. But then, when you go young, when you look at young people, maybe half of people don’t know their status. And my colleague Brian Mustanski at Northwestern in the Institute of Sexual and Gender Minority Health and Well-Being, he was — he’s been doing research recently where they have seen that only one in five young men who have sex with men under 18 have ever had an HIV test. They have just never had one. And they’re the population that is most likely to transmit in this country. He also found, which I found really disturbing, he was telling me he had conducted a focus group with teenage boys who had sex with other boys. And they asked them about their sex lives. And they said they’d never — they weren’t ever using condoms. And when Brian asked them why, they said, well, we knew we couldn’t get pregnant. So they had been taught that the only use for condoms was pregnancy, and they’re not being taught that this is something that protects people from diseases. And, of course, it is very specifically a concern of LGBTQ young people.

SREENIVASAN: Steven Thrasher, thanks for joining us.

THRASHER: Thank you so much for having me.