In 2009, Washington, D.C., officials announced that the district's HIV rate, hovering around 3 percent of the population, was higher than that of West Africa.
Just six years later, thanks to a host of new policies at the federal, local, and nonprofit level, there has been a nearly 60 percent decrease in new diagnoses.
Mayor Muriel Bowser announced the new numbers at the Whitman-Walker Health Center, the storied HIV clinic, noting that the newly diagnosed rate fell 57 percent since 2007, that there's been more than an 80 percent reduction in intravenous drug use transmission since 2007, and that in 2013 there were no babies born with HIV. The city's prevalence rate is still high, at 2.5 percent, which qualifies it as an epidemic, but Bowser hopes to reduce that even further by 2020.
Bowser also announced her goal of completing a "90-90-90-50" plan, in which 90 percent of people know their HIV status, 90 percent of people who are living with the virus are in care or receiving treatment, 90 percent of people with HIV have an undetectable level of the virus in their bodies, and the number of new diagnoses in DC will be reduced by 50 percent by 2020.
Bowser did not return requests for comment on Thursday. Her office told VICE News that in addition to local policies such as increased testing and awareness campaigns, changes to healthcare policy have helped: Medicare and Medicaid, along with private health insurance, now pay for routine HIV testing, resulting in a decreased demand for public HIV funding.
Michael Kharfen, senior deputy director for HIV/AIDS at the city's Department of Health, said that city leaders were spurred to greater action following a 2005 report that showed the city's HIV response was lacking. Their focus on rapid testing and condom distribution were complemented by a 2010 national strategy on HIV/AIDS prevention and treatment, which Kharfen said "furthered our blueprint for policies to fight it."
Matthew Rand, health educator and self-test project coordinator at the Whitman-Walker center, said a combination of condom distribution, which increased tenfold since 2007, a needle sharing program that removed contaminated needles from the streets, and an increase in testing all contributed to the progress.
"We've done a very good job at capturing people who test positive earlier, and then what's really important, probably the most important point, is that we are doing better at our continuum of care," he said.
Rand said that 80 percent of positive patients are now linked to care. The viral suppression rate of the positive population is now 47 percent, he said, about 15 percent higher than the national average.
Rand said that his organization began testing at night clubs and other community events, and created a service called Red Carpet, which immediately sets up patients who get a positive test result with a medical appointment. "It definitely helps people engage in care," he said.
Ron Simmons, president of the HIV outreach group Us Helping Us, said that around 2007 there was a concerted effort to widely expand HIV testing, making it possible to get tested "even at the Department of Motor Vehicles."
"So we tested hundreds of thousands more people, found thousands more positive people, and got them into treatment, and lowered the transmission of infection," he said. "DC is one of the top three testing cities in the nation."
The expansion in testing led to a spike in new diagnoses in recent years, but officials say that they were able to get those otherwise-undiagnosed individuals into treatment to help prevent further transmission.
The district also has a robust AIDS assistance program, funded in part by the Ryan White Care Act, which helps individuals who earn up to 500 percent of the poverty level to pay for treatment.
"We still have more HIV in DC than almost any comparable city," Susan LeLacheur, who works in HIV clinical and public policy work at George Washington University, pointed out to VICE News. The rate will remain high even with new infections going down because patients in treatment are living longer with the disease, she said.
"I think DC has done a spectacular job of getting people into treatment, but there are still pockets of people we need to get into treatment," she said.
LeLacheur said that an increase in federal funding for treatment programs, including a robust community clinic program that operates mobile vans and testing in the community, has helped bring more people into treatment. But for those who remain untreated, other public policies will be needed, including making sure patients have stable housing and food and mental health care so that they are more likely to continue taking HIV medicine.
Simmons said there are some — cynics, he called them — who say the decrease in infection rates is attributable to gentrification: uninfected white people moving in and replacing infected black people in Washington in recent years.
"But I believe that it's because for so many years we've been very actively testing people and linking them to care," Simmons said.
"I think the city is being gentrified, but there are plenty of areas in DC that are not, and if you look at the amount of people that have come into DC even, the population increase and the decrease in the HIV rate doesn't make sense. There's something else going on there," Rand said.
Though the rate has gone down among the general population and specific groups like intravenous drug users and women, a stubbornly high number remains among young black men who have sex with men, Simmons said. And though in the past that was attributable to individual risky behaviors — lack of condom use, mainly — it is now thought to be because there is a higher infection rate in the gay black male population, increasing any participant's risk of infection.
"It's not because of individual behavior but because there have been so many undiagnosed men in the sexual networks," he said.
Simmons and Rand said that one of the most important elements of achieving the 90-90-90-50 goal is further reducing the infection rate, particularly in that group of young black men who have sex with men. And both say that PrEP, Pre-Exposure Prophylaxis, could make that a reality.
PrEP, or Truvada, contains tenofovir and emtricitabine, which are used to treat HIV. In someone who's not infected but exposed to HIV, the drugs can help to keep the virus from creating a permanent infection.
"PrEP can be something that breaks the cycle of infection among gay black men," Simmons said. "So any HIV positive men in sexual networks, the only way we're going to break that cycle of having to test every generation is if men can stop the infection."
"I think these goals are achievable, but there needs to be more of an investment," Rand said. "And one thing they could invest in would be PrEP, offering that to people who are high risk."
Rand said that he hopes to see an infusion of funding for HIV prevention and treatment programs now that many gay rights organizations no longer need to funnel money to passing gay marriage.
"Once organizations have stopped putting money towards that, where it will go? I really hope they put that money into things like fighting HIV, and PrEP, and retaining people in care, and providing more services," he said.
Simmons said that important medical research into whether PrEP could be taken only on weekends or injected once for an efficacy period of a few months could help broaden its use among at-risk populations.