The Scope of the Epidemic and Target Populations.

As in every state, the Maine Department of Health has only a finite amount of resources at its disposal to divide among what seem to be an infinite number of public health issues.  Thus, in order for Maine’s HIV/AIDS plan to be successful, despite this limited funding, it is crucial for money to be allocated where it is most needed.  In order to determine the most effective use of HIV/AIDS funding, one must first define the scope of the epidemic and target the populations most at risk.  Only then can specific prevention and treatment solutions be identified that will most efficiently and effectively satisfy the needs of these populations. 

Compared to the national cumulative AIDS rate of 339 cases per 100,000 people, Maine’s far lower rate of 95 cases suggests that the disease is not as much of a problem in Maine as it is for the United States as a whole.  Since 1987, only 1,400 positive HIV diagnoses have been reported to the Maine Bureau of Health, and as demonstrated in Graph 1, each subsequent year has seen a gradual decline in annual incidences of the virus, that eventually leveled off in 1997 at approximately 48 cases per year (7).  However, despite this overall decrease in HIV diagnoses since the late 1980s, breakthroughs in research and new drug treatments have resulted in a continued increase in the number of Maine residents living with AIDS over time.  As described in the 2004-2005 State of Maine Epidemiological Profile, “there are more people living with HIV/AIDS in Maine than ever before, with an estimated 477 persons living with AIDS at the end of 2003” (7).

In Maine, White MSM from the Southern region of the state are at the highest risk for contracting HIV.  According to the Maine CDC, 86% of all new 2006 HIV diagnoses were male, while only 14% were female (12).  Additionally, 84% of these diagnoses were White individuals, while only 16% were Black or African American.  Furthermore, 65% of new HIV diagnoses in this same year were a result of male-male sexual contact (MSM), and as illustrated in Graph 2, the percentage of MSM HIV transmission has been increasing since 2000, despite the fact that other high-risk groups (i.e., IDUs and heterosexuals) have experienced a fairly constant decrease in transmission (12).  Although White MSM are unarguably at the highest risk for contracting HIV in Maine, it is also important to acknowledge a new potential risk-group; namely, the Somali refugee population.  Data discussed later in this paper clearly indicates that this particular population deserves at least some attention and funding by the Maine Bureau of Health.

What is Being Done? The Current HIV/AIDS Funding Plan and the SAFE Model.

            After defining the target populations as well as the severity of the HIV/AIDS epidemic in Maine, it is necessary to discuss where the state’s HIV/AIDS funding is currently being spent, along with the specific initiatives already being pursued to fight the disease.  As demonstrated in Table 5, the Maine CDC has prioritized MSM, IDU, and heterosexual females in order of highest risk of contracting HIV and has subsequently divided funding according to this prioritization.  The Maine CDC has also divided the state itself into three distinct regions (i.e., Southern, Central, and Northern) and has further allocated funding based on which of these regions are home to the most newly diagnosed cases of the virus.  Thus, in accordance with the primary target population discussed in the previous section, 50% of all available HIV/AIDS resources are currently being allocated to Southern Maine, with approximately 53% of total statewide funding being targeted solely towards MSM (13). 

            Maine also presently has a wide range of HIV/AIDS services available throughout the state (see Table 6) and has adopted the federal CDC’s Serostatus Approach to Fighting the HIV/AIDS Epidemic (SAFE) Model as the primary basis for all prevention planning.  In an article describing the benefits and components of SAFE, Janssen et al. explain how the SAFE model expands on previous prevention programs by targeting individuals who are already infected with HIV, along with those at high risk for contracting the virus (15).  Specifically, the model includes five essential steps: 1) To increase the number of HIV-infected individuals who know they have the disease, 2) To increase healthcare and preventative services, 3) To increase the quality of care and treatment, 4) To increase adherence to HIV treatment plans among those infected with the disease, and 5) To increase risk reduction behavior among individuals infected with HIV (15).  As illustrated in Figure 1 and described by the State of Maine Community Planning Group, prevention activities in Maine follow the basic SAFE format by first recruiting individuals at high risk for HIV to participate in counseling, testing and referral services (CTR) and then addressing the specific needs of those who test HIV-positive, as well as those who remain HIV-negative, but are still at extremely high-risk (16). 

            As evidenced by the declining number of new HIV diagnoses from 1987 to 1998 (see Graph 1), Maine has a strong record of successful HIV/AIDS prevention and treatment efforts.  However, in recent years, new HIV diagnoses have leveled out to approximately 48 cases per year, instead of continuing to decrease.  Although 48 cases is hardly a high number, new HIV diagnoses in Maine still have the potential to be reduced even further if the proper planning initiatives are adopted.  In order to achieve this decrease, while at the same time continuing to provide much-needed treatment services for those already living with the disease, I propose a five-part solution for Maine, advocating the following new strategies:

1)      Increased capacity building activities;

2)      Education aimed at reducing complacency towards the virus;

3)      Greater access to and awareness of HIV/AIDS services;

4)      Services geared specifically towards Maine’s Somali refugee population;

5)      The ratification of two testing bills and a syringe bill, all of which are currently being considered by the Maine State Legislature. 

Developing a Solid Foundation of Care: The Need for More Capacity Building Activities.

            In order to ensure that adequate HIV/AIDS services continue to be provided to high-risk populations in Maine, it is necessary to start at the foundations.  As outlined in the “Maine HIV Prevention Program, 2007 Summary,” capacity building activities include: 1) training HIV prevention/treatment providers and counselors so that they are able to offer their clients the best possible care, 2) providing the technical assistance needed to implement prevention efforts such as the SAFE model, and 3) maintaining an effective monitoring system to update statewide HIV/AIDS data (13).  Currently, the Maine CDC is understaffed and poorly funded and capacity building efforts are desperately lacking in many of the smaller community-based HIV/AIDS organizations throughout the state (13).  It is crucial that a portion of funding be set aside to meet these infrastructural needs, because without technical expertise and properly educated providers, Maine cannot hope to further stem the progress of the HIV/AIDS epidemic.

Promoting Education Aimed at Reducing Complacency.

            In a 2003 Portland Press Herald article discussing HIV surges among gay men and the need to revamp prevention messages, Miles Rightmire, a public health educator for Maine’s Department of Health and Human Services described how a young Portland man in his mid-20s once snapped his fingers in his face and said, “‘Don’t you know that AIDS is over?’” in response to his counseling efforts (17).  Although the young man’s outburst may seem absurd, it is actually disturbingly symptomatic of a national trend towards HIV/AIDS complacency that is leading health officials to worry that recent rises in reckless sexual behaviors may lead to a second wave of the epidemic (17, 18).  Since the late 1980s, AIDS-related deaths have declined nationally, and in Maine, this decrease has been even more dramatic.  For instance, from a high of 66 in 1995, AIDS deaths in Maine plummeted to only 16 in 2004 (7).  This decrease in AIDS deaths over time has been attributed to the invention of new and effective antiretroviral treatments for HIV that are slowing the progression of the disease and giving some individuals hope of regaining normalcy in their lives (5, 10, 17, 18, 19, 20, 21, 22, 23, & 24). 

However, these same drug therapies that are lengthening the lives of some may also be leading to misperceptions about the continuing threat of HIV, particularly among young MSM in Maine.  Instead of being an automatic death sentence, AIDS is now increasingly viewed as a chronic and manageable disease, much like diabetes or some types of cancer (18, 21 & 22).  Young MSM are particularly prone to complacency towards HIV/AIDS because they never personally dealt with the fear of not knowing what was killing so many of their peers in the early 1980s (17).  As one gay man commented during a focus group session led by the Maine CPG, “Younger men are less concerned about HIV today because it’s treatable and because they haven’t seen their peers dying.  Ads showing very healthy HIV positive guys taking their medications reinforce these beliefs” (29).  Indeed, many have blamed the pharmaceutical industry for further compounding the problem of growing complacency through misleading advertisements depicting HIV-positive men climbing mountains and scuba diving just by taking one pill a day (17, 22).  In actuality, highly active antiretroviral therapy (HAART) is extremely complex, involves many pills a day, and “usually consists of triple therapy, including two nucleoside analogues and a protease inhibitor (at a cost for the medicines of about $10,000 to $12,000 a year)” (26).  Furthermore, these HIV drugs do not work for everyone, and when they do, they often produce such severe side-effects (i.e., nausea, diarrhea, headache, abnormal distribution of fat, abdominal pain, hepatitis, and weakness, to name a few) that many individuals have trouble adhering to their prescription regimens (23, 26, 27, 30, 31 & 32).  As one HIV-positive man commented in a Portland Press Herald article warning against putting too much trust in HIV drugs, “‘I’m not going to as many funerals as I used to…On the other hand, we’re not all sitting around jumping for joy because there are people who are very sick.  It may well be that they’re not going to die right away, but the quality of their life is not good’” (23).

            Thus, with complacency on the rise and approximately 50% of rural HIV-positive men and women across the nation continuing to engage in unprotected sex despite their infection, current prevention messages in Maine clearly need to be rethought (25).  New ways to educate Maine citizens about the seriousness of the disease must be developed, so that individuals are no longer blinded by misconceptions that HIV drugs are a cure.  Current educational messages should include detailed information about HAART and the fact that treatment plans are extremely complicated, that these drugs do not work for everyone, and that they often involve extremely adverse side-effects.  As Charles Dwyer, coordinator of Maine’s HIV/STD program suggested in a Portland Press Herald article, new prevention approaches should call “on people living with HIV to talk about how the disease is ‘no piece of cake,’” (17) despite the availability of antiretroviral treatment.  By incorporating these new educational messages into existing SAFE model interventions, high school health curriculums, and other prevention programs, Maine public health officials may start seeing a further decline in HIV diagnoses, particularly among MSM (see graphs 1 & 2).

Increasing Access to and Awareness of HIV/AIDS Services Throughout the State.

            As discussed previously, Maine has a broad range of HIV/AIDS services available throughout the state (see Table 6).  However, just because these services exist does not mean that they are being fully utilized; trouble accessing them and a lack of awareness have both prevented many HIV/AIDS services from reaching their full prevention and treatment potentials.  The implications of these barriers to obtaining services in Maine are worrying, as many studies have found that unmet prevention and treatment needs are linked to negative outcomes, such as poor adherence to HAART regimens (30, 31 & 32), waiting until the diseases progresses to acute stages before seeking care (33, 34), and increases in HIV transmission.

Maine is geographically large and sparsely populated, with much of its small population concentrated in the Southern and Central regions of the state.  Unfortunately, for these reasons, access to medical services in many areas of Western, Northern, and Downeast Maine is extremely difficult for some residents (7).  However, as a 2006 survey of 263 MSM living throughout the state revealed, transportation issues are not the only barrier to HIV/AIDS services in Maine.  Specifically, 22.7% of those surveyed claimed that they did not think services existed in their area, 20.3% did not know where to get services, 27.0% did not think they were eligible to get the services for free, and 22.2% said that there are not any evening or weekend hours available near them (29).

            In light of these perceived barriers to HIV/AIDS services throughout the state, it is clear that Maine public health officials must develop a way to increase access to and awareness of existing prevention and treatment organizations.  In an article comparing barriers to care among rural and urban residents in Wisconsin, it was suggested that telephone-linked support groups may offer an easier way for individuals living far away from HIV/AIDS organizations to have access to a form of counseling.  These telephone-linked support groups could range “from informal conversations between two HIV-infected persons, to more structured and therapeutic sessions facilitated by mental health professionals,”(34) and would be fairly simple to implement in Maine if based out of one the state’s major HIV/AIDS prevention and treatment organizations, such as the Frannie Peabody Center in Portland.  Additionally, in a focus group discussion following the 2006 MSM survey, participants were asked to suggest potential ways to eliminate perceived barriers to services and their responses indicated the need for greater HIV/AIDS advertising.  Many suggested running a media campaign using the internet, radio, TV and newspapers, one man commenting: “Maine TV keeps sponsoring advertisements during the flu season about where to get flu shots or about flu shot availability and what not, but you never see the TV sponsoring anything about where you can go to get tested [for HIV] or suggesting that people go get tested” (29).  Other participants recommended increasing HIV/AIDS advertising at places frequented by gay men, such as the Maine Mall in Portland, Ogunquit during the summer, and various public sex environments in Mount Desert Island, Bangor, Portland, Lewiston and Auburn (16, 29).  This same suggestion for increased HIV/AIDS service publicity could also be used to target other high-risk populations, such as IDU and heterosexual females by advertising at drug treatment centers, homeless shelters, prisons and health clinics (16).

Introducing Services Geared Towards Maine’s Somali Refugee Population.

            Over an 18-month period in 2001-2002, the small city of Lewiston experienced a rapid influx of approximately 1,000 Somali immigrants.  This sudden 3% increase in Lewiston’s population severely threatened the city’s ability to provide a range of social services to its residents.  A statistical analysis conducted comparing cumulative AIDS rates and the percent of foreign-born citizens in Maine revealed a significant positive relationship between these two variables (see “percent of foreign-born citizens” webpage), but still to this day, the state has practically no funding allocated for minorities and its increased immigrant population (13).  Indeed, in Appendix F of the CDC’s 2004 “HIV/AIDS Special Surveillance Report,” Maine’s Somali refugee population is explicitly listed as an “immigrant group for whom states have little or no data (14).  At first glance, the lack of data concerning this population may not seem worrisome, since Blacks in Maine already comprise such a small percentage of new HIV diagnoses (see Table 3).  However, when comparing the cumulative AIDS rates for Blacks is compared to that of Whites, it becomes quite apparent that HIV/AIDS among minorities is being wrongfully neglected in Maine.  Specifically, the cumulative AIDS rate for Blacks is 828, an astounding nine times the rate for Whites (see Table 3).  As documented by the World Health Organization, UNICEF, and UNAIDS, Somalia had an approximate population of 822,800 people, with an estimated 44,000 of these individuals living with HIV/AIDS in 2005 (35).  According to these numbers, Somalia’s HIV/AIDS rate in 2005 was 5,348 cases per 100,000 people, a figure that is slightly over 58 times Maine’s cumulative AIDS rate of 92.  Thus, if one out of 20 Somalis are predicted to have HIV/AIDS and 1,000 refugees came to Lewiston a few years ago, then approximately 50 of these refugees were affected by HIV/AIDS.  In the entire state, only 40 citizens were diagnosed with HIV in 2001, so the potentially negative implications of not having documented HIV/AIDS data for an estimated 50 refugees infected with the virus who immigrated to Maine during this time period are enormous.  As a result, it would be wise for the Maine Bureau of Health to use a small portion of its overall state HIV/AIDS funding to institute a program in Lewiston targeted at providing culturally competent HIV/AIDS services for the Somali immigrant population residing there.  Without any ongoing education, testing, or opportunities to seek treatment, these refugees may pose enormous difficulties for long-term HIV prevention and AIDS treatment, relative to the state’s current problem.

New Legislation: The Testing Bills and the Needle Exchange Bill.

Currently, the Maine State Legislature is in the process of hearing three new pieces of legislation advocating for changes in the state’s current HIV/AIDS policies.  If passed, the first two bills would remove regulations requiring written consent for HIV testing, as well as requirements for pretest and posttest counseling, allowing for easier and more widely performed HIV testing (36).  These new HIV testing laws would follow a federal CDC recommendation, released in 2003, which suggested that states should strive to expand routine, but voluntary HIV testing, in order to treat cases early, decrease the number of infections that remain undetected, and in effect, limit transmission among individuals who are unaware that they have the virus (37, 38).  Although some critics have argued that routine testing is an invasion of privacy, the number of lives that could be spared from contracting the disease far outweighs the potential consequences (38). 

The third bill currently being considered by the State Legislature would allow for the legal limit on the number of syringes possessed and transported in Maine to be either increased or eliminated altogether.  Although the number of HIV cases in Maine attributed to intravenous drug use is far lower than the national figure (4, 7), IDU are still classified by the Maine CDC as the second highest risk group in the state, so their needs deserve to be paid some attention to (4).  A number of previous studies have suggested that needle exchange programs are instrumental in decreasing the spread of HIV (39, 40), but given that much of Maine is extremely rural, drug users may have to travel long distances to reach one of the four needle exchange sites in the state.  Since current Maine statutes only allow for a one-to-one exchange of a maximum of 10 syringes, the average IDU is forced to exchange equipment far more often than possible in order to consistently use sterile syringes.  By allowing drug addicts to exchange an unlimited number of clean syringes, advocates of the syringe bill hope that these individuals will be less likely to reuse needles, consequently reducing the possibility of transmitting HIV to others.

Conclusions

 compared to the national figure, (see Table 1) changing features of the epidemic have posed new challenges for further eradication of the

 virus.  Past prevention and treatment efforts have been extremely successful and should continue to be pursued, but novel and innovation

 solutions must also be implemented in order to meet these new challenges.  Specifically, the dynamic nature of the HIV virus has calls for

 constant capacity-building activities, such as the training of HIV/AIDS providers and the adoption of new technology to test for the virus

 and to record new data.  Additionally, scientific progress in antiretroviral treatment has produced new medications that are effective in

 prolonging the lives of those infected with HIV.  However, at the same time, these drugs have also led to complacency among some

 individuals who mistake them for a cure.  Although many HIV/AIDS services have been instituted throughout the state, much still needs to

 be done to raise citizens’ awareness of these services and to ensure that they are more accessible, especially to those residing in extremely

 rural areas.  It is also crucial that current services be expanded to include culturally-competent prevention and treatments efforts targeted

 specifically at Maine’s presently neglected Somali refugee population.  Finally, it is essential that Maine lawmakers vote to change outdated

 legislation that is only serving to complicate and hinder HIV/AIDS prevention efforts.  An ultimate ratification of the two testing bills and

 the syringe bill that are under consideration this year would encouragingly demonstrate Maine’s capacity for progress and change with the

 times.