Amid fresh reports that more Americans are infected each year with HIV/AIDS than previously thought, 2,300 grantees and clinicians participating in the Ryan White Program convened last month for HRSA's 5th biennial conference.

From the opening moments at the Marriott Wardman Park on Aug. 25, the mood of the group was somber.

In a cavernous ballroom draped with quilts memorializing those who died in "those terrible days in the beginning," a visibly moved HRSA Administrator Elizabeth Duke recalled: "One of my dearest friends I ever had in my whole life suffered from this awful disease and has gone on to another world -- and this world is poorer for his loss.

2,300 grantees, clinicians and researchers packed the main ballroom on the opening day of the Ryan White meeting.

HRSA Administrator Duke spoke of losing a friend to AIDS, and praised frontline providers for helping to cut the death rate by 85%.

HAB Associate Administrator Parham Hopson warned that two out of five patients are not diagnosed in time to prevent the onset of AIDS.

HAB Deputy Associate Administrator Cheever reported that HIV clients require more primary care services as they live longer lives.

Jeannie White-Ginder, Ryan White's mother, is joined by (left) Carmen Zorilla, MD, Professor of Obstetrics and Gynecology, University of Puerto Rico School of Medicine, and (far right) Allan Rodriquez, MD, Associate Director of Adult HIV Services at the University of Miami School of Medicine.

That means about half of the estimated 1.1 million HIV-positive individuals nationwide are treated each year through the Ryan White Program, and many patients receive care at a HRSA-funded health center site.

Thanks to health care from 2,300 Ryan White providers and the introduction of new anti-retroviral drugs in recent years, the annual death rate has been slashed from 100,000 in the mid-1990s -- when the program first took hold -- to a current level of about 15,000.

"How many people can get up in the morning," Duke asked the grantees, "and say, I am making a difference in the lives of half a million people?"

More clients, living longer

With the success of the program and increasing diagnostic sophistication among providers has come new data on the progress of the disease that point to several trends, Duke said.

Citing a recent report from the U.S. Centers for Disease Control and Prevention, which adjusted its estimate for the number of new HIV cases annually from 40,000 to 56,000, Duke said HRSA now faces rocketing demand for services in an era of "level or nearly level funding."

Not only will there be more clients in the future, they will be living longer -- long enough, in fact, to develop all of the usual ailments and afflictions of middle age and beyond.

Dr. Deborah Parham Hopson, HAB's associate administrator, called the new life expectancy data "absolutely astounding," but added that "with hundreds of thousands of people still not in care, we have so much more to do."

"Twenty-seven percent of our patients have no insurance, public or private," she said. "Fifty-seven percent are living below the federal poverty level. We are reaching the very populations most likely to suffer health disparities in this country... the historically underserved."

Dr. Michael Saag, director of the University of Alabama's Center For AIDS Research, told the grantees that 86% of HIV patients ages 20-44 can now expect to live as long as people who do not have the disease.

"Things have improved dramatically over the last couple of years," Saag said. "People who enter care today can live almost a normal life expectancy... There is one caveat to this: finding people and getting them into care early."

"When you look at all of the causes of mortality -- all of the reasons that people infected with HIV die today -- AIDS is only a small part of the reason," added Dr. Laura Cheever, HAB's deputy associate administrator.

Cheever presented recent benchmarks from an ongoing study of some 10,000 patients in treatment across Europe, Australia and Canada, which established that only 27 percent of deaths within the population were attributable to AIDS. Indeed, fatalities from non-AIDS-related cancers, diabetes, cardiovascular disease, substance abuse, suicide and violence were more common.

Those findings mirror other studies in the U.S., but Parham Hopson observed that the picture can be starkly different inside Health Profession Shortage Areas -- where "people are coming into care so late that nearly two out of five patients newly diagnosed with HIV progress to AIDS within one year."

Virus "Incubates" in Underserved Areas

Throughout the conference, researchers and clinic directors warned repeatedly that the disease continues to incubate in underserved areas, where early detection and follow-up are less likely to occur. And certain hard-to-reach populations within those areas, particularly African-American men and young men of color who have sex with men, have proven to be resilient "reservoirs" for the virus.

Despite declining rates of infection among men over 40 in many jurisdictions, infections among young males continue to rise.

In an ongoing HRSA "special project," which seeks to identify infected adolescents and get them into treatment, physicians reported that more than half of their young clients regularly consume alcohol and drugs; routinely test positive for multiple sexually transmitted diseases; and often drop out of treatment at some point -- all ideal conditions for the development of antibiotic-resistant mutations.

Dr. Julia Hidalgo of George Washington University, which oversees the project for HRSA, said that even after these young men receive repeated notices of positive test results for HIV they often do not show up for treatment for weeks, or even months.

"They're too busy partying to come to clinic," she said, "and if you want them to come to clinic, you have to intervene in that partying behavior -- which is what got a lot of them into trouble in the first place."