ANNAPOLIS – Michael Palaia knows exactly when and how he contracted HIV.
It was August 1, 1999, from protected sex with another man. Palaia’s sure the sex was safe — he’s never had unprotected sex.
He was not especially concerned when he went to be tested in April 2000 — he tested himself about every six months, ever since he ended a long-term relationship in 1995. Palaia saw the HIV tests as a chance to help out Centers for Disease Control and Prevention researchers. He’d fill out a questionnaire, give a blood sample, and pocket a quick $50 thank you.
But this time his test came back positive. At age 30, Palaia began living with HIV.
Palaia is one of the many faces of HIV/AIDS in Baltimore, a city known for its high incidence rate of the disease, but also for its excellent treatment. The city ranks fourth highest among all the nation’s metropolitan areas for new cases of the disease.
Human Immunodeficiency Virus, or HIV, spreads via blood and other bodily fluids. HIV can turn into Acquired Immunodeficiency Syndrome, or AIDS, which severely weakens the immune system, making it more susceptible to disease. It is fatal, and there is no known cure.
Today Palaia does outreach work with AIDS Action Baltimore, helping others in the city who suffer from HIV/AIDS. He’s sat on patient advisory boards at Johns Hopkins, and given presentations on alternative medicine. He’s even participated in more than three dozen scientific studies in the past four years.
“I figured since I couldn’t donate my body to science — like an organ donor — I would donate my body to research while I was still in it,” he said.
In 2002, Maryland had the 19th-largest state population, but the ninth-most cumulative AIDS cases, with 25,358. The state also had the nations’ third-highest AIDS incidence rate, with 34 new cases per 100,000 people, according to the Maryland AIDS Administration.
The number of new HIV/AIDS cases in Maryland doubled between 1992 and 1993, from 1,201 to 2,528, a jump echoed nationwide. That was the result of changes in AIDS case definitions, according to the Maryland AIDS Administration.
Since then, Baltimore has accounted for a steady two-thirds of all new Maryland AIDS cases each year, even as the city’s population has declined, according to the CDC. The city has a new incidence rate of 48.7 per 100,000.
The CDC reported 1,028 new cases of HIV in Baltimore in 2003, out of 1,570 overall in Maryland.
Experts see many reasons for Baltimore’s high numbers, but point to injection drug abuse as the most common culprit. Sharing needles can easily spread HIV.
“Substance abuse has always been the predominant cause of HIV/AIDS in Baltimore City,” said Dr. Peter Beilenson, the City Health Commissioner of Baltimore.
In the 20 years between 1981 and 2001, 53 percent of the 15,580 reported cases of HIV in Baltimore were the direct result of injection drug use, according to the CDC. In Maryland overall, just 24 percent of its 7,957 new HIV cases during the same period were due to injection drug use.
“The reason for that is that the primary drug of choice in Baltimore for decades has always been heroin,” Beilenson said. The drug has been refined in the past few years, but in the past it could only be taken by injection. About 70 percent of drug users in Baltimore report heroin use, he said.
Beilenson noted that the number of new HIV/AIDS cases in Baltimore from drug abuse has dropped in the past few years.
“It’s decreased a little because we’ve done such a good job of getting people into substance abuse programs and needle exchange programs,” he said.
Leslie Leitch agrees with Beilenson, and sees Baltimore’s high incidence rate as a natural result of a city in economic and social despair. Leitch is the executive director of AIDS Interfaith Residential Services Inc., which provides housing and supportive care to people with disabilities, including those with HIV/AIDS.
“You get people who are drug-addicted, unemployed — obviously poor — not accessing the services they need,” she said.
Baltimore has a poverty rate of 23 percent — one of the worst in the nation — and the fifth-least affordable housing stock in the United States, said Leitch. She points to the mantra of the health care community: “Housing is health care.”
“Access to drugs is for many their only outlet to deal with their problems,” Leitch said. “You’re poised perfectly for the growth of this epidemic.”
She said what Baltimore needs is increased funding for “pure education” on HIV/AIDS: more education in schools, public service announcements, street outreach programs, drug treatment centers, needle exchange programs, and free condoms.
Other experts note that the high numbers of HIV/AIDS cases could be a sign of something else. While the link between drug abuse and HIV/AIDS in Baltimore is “clearly true,” Baltimore is also very good at reporting new cases of the disease, which would raise the city’s incidence rate, said Dr. John G. Bartlett, the chief of the Division of Infectious Diseases at Johns Hopkins University School of Medicine.
“You’re going to get the highest rates where people are the most efficient in reporting,” Bartlett said. Incidence rates can only be compiled through voluntary disclosure, he said, so the rate reliability depends on the diligence of patients and doctors.
“Baltimore is pretty darned good at delivering care for HIV infections,” he said.
Maryland and Baltimore doctors also have a major incentive to ensure they report all new HIV/AIDS cases, Bartlett said: Medicaid helps half of all HIV/AIDS patients in Maryland.
The Maryland Medicaid system places HIV patients into two categories of eligibility, said Susan Tucker, executive director of the Maryland Office of Health Services. For those in the Family and Children Eligibility Group, Medicaid reimburses doctors $651 per month for each patient. For those in the Disabled Eligibility Group, Medicaid reimburses doctors $1,713.40 per month.
The payouts jump dramatically when HIV progresses to the more serious AIDS. In Baltimore, Medicaid reimburses doctors $2,967.94 per month. The state average is $2,645.92.
“There’s a great benefit to the patient to report because of benefits and assistance,” Bartlett said. “So the health care system really wants you to report every case.” – 30 –