America’s most dramatic success in HIV prevention has been the reduction in transmission from mother to child. The estimated rate of infections among babies peaked at 1,650 in 1991 and fell to around 144-236 in 2002.5 This decline was caused by the use of antiretroviral drugs and avoidance of breastfeeding. Routine (opt-out) screening of pregnant women for HIV helped to maximise the impact of these interventions.
The success of routine screening of pregnant women has encouraged the US to move towards routine HIV testing in all medical settings, and to target more prevention work at people who are already infected with HIV, as part of an initiative called Advancing HIV Prevention. The Centers for Disease Control and Prevention – a US government agency – hopes that this change of approach will help to reduce the rate of new infections, which has remained at around 40,000 per year since the early 1990s. Among the new developments is greater support for partner notification schemes.
One subject not included in the Advancing HIV Prevention strategy is harm reduction for injecting drug users. In particular, it does not advocate for more needle exchanges, even though studies have shown that these reduce the sharing of injecting equipment and reduce HIV transmission without encouraging drug use. Experts believe that an expansion of needle exchange services helped to reverse an extensive HIV epidemic among drug users in New York City during the 1990s.6 Nevertheless, the US is the only country in the world that prohibits federal funding of needle exchanges; they are illegal in some states, and poorly funded in most others.
As of May 2006, there were 185 needle exchange schemes operating in 36 states, as well as Washington D.C., Puerto Rico, and Native American Lands.7 This is fewer schemes than in Scotland, where the population is around sixty times smaller.8 Many US politicians object to harm reduction, despite its proven benefits, because they think it involves condoning illegal drug use.
Ideological objections also hamper HIV prevention for young people. Much federal money is spent teaching “abstinence only”, which studies have found to be less effective than comprehensive sex education at preventing sexually transmitted infections.9