During most of the past twenty years of the AIDS epidemic, drug treatment has been too expensive for most people living with the virus to afford it. Governments and aid agencies have focused on preventing the spread of HIV, the AIDS virus. Now drug costs are coming down and major international efforts are underway to deliver drugs to more people who need them. With all the new attention on treatment, concern is growing that the message of prevention will be lost. As VOA's Steve Baragona reports, experience in the United States shows that when more people live with HIV, prevention becomes more important than ever.

Late last year, the U.S. Centers for Disease Control and Prevention (CDC) released a disturbing report. After declining and leveling off in the 1990s, new HIV diagnoses rose by 5 percent between 1999 and 2002 in the United States. Experts say the reason, paradoxically, may be the success of powerful drug cocktails introduced in the mid-1990s.

The new drugs helped cut AIDS deaths by more than half in less than two years, after reaching a high of 50,000 deaths in 1995. While this is clearly a good thing, those on the front lines of the epidemic say people are starting to get careless about the disease. At Washington, DC's Whitman-Walker Clinic, HIV testing program director Cureton Johnson said that's because the worst of AIDS is less visible now.

"A lot of young people don't see, again, the people who are affected by this disease in the later stages and how this disease can devastate your body," he explained. "So there's still not really a picture for them to look at that tells them this is something they don't want to get."

With the ravages of AIDS becoming less visible, the American public is becoming less concerned about the disease. Kaiser Family Foundation polls conducted since 1991 show the number of Americans who say they are very or somewhat concerned about becoming infected has dropped by 15 percentage points, to just one-third of respondents. Attitudes among the HIV-positive are changing too, according to the CDC's deputy HIV prevention director, Ronald Valdisseri. Dr. Valdisseri told a recent Washington, DC conference on prevention that a study of clients at a New York City AIDS clinic turned up some startling results. "In this survey, 33 percent of the clients agreed that being [HIV] positive and I quote from the study, 'isn't a big deal' now that the treatments are better," he said.

Treatments today are less complicated and have fewer serious side effects than in the old days, but back at Whitman-Walker Clinic, prevention director Nestor Rocha said that what he hears people saying today suggests they're getting the wrong idea about the disease.

"People are not dying anymore so it's nothing to worry about," he said. "The message always was one of a positive mind, is to tell people, 'This is not a death sentence.' What's forgotten is there is also no cure."

The CDC's Dr. Valdisseri said that another misconception has taken root among Americans. "Although most of the American public takes in this information about improved treatment and translates that in their mind into, 'we don't have to worry about prevention anymore,' the reality is that in this era, prevention is even more critical than it was in the early days of the epidemic," she added.

That's because there are now more people living with HIV. Frank Beadle de Palomo is an HIV prevention expert at the Academy for Educational Development, the Washington, D.C. based social development organization that hosted the prevention conference. He said that more people living with HIV means more people who can spread HIV.

"This is a difficult concept," he said. "If we are successful in keeping people alive, it means that we are potentially creating the seeds of a greater epidemic. How do we keep this increased prevalence from serving as a multiplier effect for transmission? That is really going to be one of the major next challenges of this epidemic."

For the Whitman-Walker Clinic and the CDC, that challenge requires more creative and aggressive prevention strategies. Studies show that people who know they are HIV positive are less likely to engage in unprotected sex or injecting drug use or other risky behavior. So the CDC is helping the clinic's Cureton Johnson start a program to send a van out to do HIV testing in high-risk neighborhoods.

"Which would be drug areas, which would be areas of prostitution, lower income areas," he explained. "Basically, what that would allow us the opportunity to do, is to bridge a lot of those gaps between people who are in those neighborhoods and clinics such as ours."

The CDC is also funding a project at Whitman-Walker to try to find more people at risk of HIV infection by connecting with them through their social network. The clinic's Nestor Rocha said that it starts with one person who tests HIV positive.

"It's about following that trail, just like a bloodhound," he said. "Just picking up the scent and just follow it. You engage this one person who connects you with, say, two, three, or four people. And one of those four, hopefully, will be able to open up the door to another group."

By finding and testing more groups of high-risk people, Mr. Rocha said, more people will know their HIV status and can act on it.

These are just some of the ways public health officials are boosting their prevention efforts, because they know the success of HIV treatment has made HIV prevention more important than ever.