WTOP's Thomas Warren recently traveled to Germany for a fellowship with the RIAS Berlin Kommission. While there, he conducted research on the history of HIV in Germany, including the governmental policies aimed at handling the disease and how the virus is treated medically. As we continue our series, he takes a look at the German system and how it compares to the U.S.
Thomas Warren, wtop.com
WASHINGTON - Washington, D.C. and New York City both are recognized as having an extremely high prevalence of HIV infections in the U.S. Out of their combined populations of just under 9 million people, 123,000 are living with the virus, according to health department statistics from both cities.
By comparison, that's 56,000 more than in the entire country of Germany, which has a population of nearly 82 million people.
The number of new infections that occur in the U.S. each year also is 56,000, according to the National Institute of Allergy and Infectious Diseases.
"It's a small disease in Germany, but we know it's a dormant tiger," says Dr. Rolf Rosenbrock, a member of Germany's national AIDS advisory board.
Though Berlin is Germany's capital city, more cases are found in other cities such as Cologne, Dusseldorf and Frankfurt. The first cases of HIV/AIDS in Germany popped up in the southeast section of Munich in 1982.
Much like in the U.S., there was a societal stigma attached to HIV in Germany.
Rosenbrock -- who helped develop Germany's HIV/AIDS health care system with new training and treatment platforms -- says early policy discussions included talk of setting up separation camps and even tattooing people who were infected, though that never happened.
To keep HIV from becoming an epidemic, experts in Germany credit the creation of advocacy organizations within the gay community.
"The so-called 'gay men's movement' was to a certain degree strengthened," says Dr. Elisabeth Pott, director of the German Federal Center for Health Education in the Federal Ministry of Health.
She says strong collaboration between the gay community and federal agencies was central to helping keep infection rates low, as the virus began to spread to other German cities in the mid- to late 1980s.
As D.C. Councilmember Jim Graham points out, that did not happen in the U.S.
"At the heart of it all was homophobia. 'Distaste' is too kind a word. It was a hatred of gay people," he says.
German medical officials say the structure of their almost universal health care system is also a tool that has helped a large number of HIV-positive people get treatment early.
"Around 95 percent of the population has some kind of health care," says Dr. Ulrich Marcus with the Robert Koch Institute, which also is part of Germany's Ministry of Health.
The District, for all of its struggles in combating the HIV epidemic, is on par with Germany when it comes to its residents having health coverage.
"Ninety-three percent of adults have health insurance," says Dr. Gregory Pappas, senior deputy director of the District's HIV/AIDS, Hepatitis, STD, and TB Administration.
Pappas also says the city is tops in the nation in health care for kids under 18.
Germany, meanwhile, had just over 3,000 new infections in 2009, according to the Ministry of Health. The country has been able to stabilize new infections at around 3,000 since 2007.
But a concern in the German medical field is that the attention devoted to HIV/AIDS over the last 20 years has allowed other sexually transmitted diseases to become potentially major issues.
"We have Hepatitis C, which is not much easier than the HIV thing," Rosenbrock says.
Doctors say they're also seeing other AIDS-related illnesses, like lymphoma and heart disease, become bigger problems in patients they're treating.
Europe is known for its liberal views towards sexuality, and Pott says a central theme in Germany's strategy to prevent the spread of HIV/AIDS is a straightforward approach when discussing the consequences of risky sexual behavior.
"We do not try to patronize people. We tell them there are risks. We give you the information, but it is in your responsibility," Pott says.
THE SCHONEBERGER MODEL
In Germany, there's a three-pronged approach to care for HIV-positive patients.
First, a newly diagnosed person is not typically treated in a hospital, unlike in in the U.S. Instead, they're treated by a private doctor in the patient's own home.
"The private office does the primary care. If something goes wrong, and the patient needs to go to the hospital, then the hospital doctors and team take it over," says Dr. Keikawus Arasteh, chief physician at the Vivantes Auguste-Viktoria-Klinikum Hospital in Berlin.
There is also not much contact between private doctors and hospitals.
"They have a contact, of course, but it's a very light contact, not comparable to the U.S.," Arasteh says.
The contact they do have includes reports and updates on a patient's condition.
The treatment model is not one-size-fits-all. Arasteh, who has worked in HIV/AIDS research in Berlin since 1984, says the lower the T-cell count, the more likely a patient will be admitted to a hospital. He credits the development of new treatment drugs with aiding the model's success.
Having nurses able to administer treatment in a patient's home, in the absence of a doctor, is another unconventional facet of the Schoneberger Model.
"This was, for Germany, a revolution that nurses do treatment without a doctor on their side," Arasteh says.
The second tier of the model deals with treatment measures. As anti-retroviral drugs to treat HIV have been developed over the years, along with medications to treat other sexually transmitted diseases, infected patients are given priority to receive those treatments.
The third part of the Schoneberger Model involves when patients are admitted to the hospital. At one time, patients needed to show three to four AIDS-related illnesses before they were taken to a hospital, Arasteh says.
However, when doctors noticed patients were coming in seemingly on death's door, that requirement was modified.
"Now, we have patients who have 1.3 AIDS-related illnesses when they're transferred to the hospital," Arasteh says.
The dynamic of the model was created from the tragic early days when HIV/AIDS first appeared in Germany.
"In the former times we don't have many medical things to offer, and often patients died in the hospital," Arasteh says. "And the patients didn't like it, and we didn't like it."
- Listen to Meghan Davies of the Whitman Walker Health talk about HIV/AIDS in the District
- Whitman Walker
- Generation Positive - Part 1
- Generation Positive - Part 2
WTOP's Thomas Warren's week-long series "Generation Positive" is an in-depth look at the HIV epidemic in the U.S. and Washington, D.C. In a four-part web series and an eight-part series on-air, he will be taking a look at measures being taken to beat HIV/AIDS and breakthrough developments in the search for a vaccine.
At 12 p.m. Thursday, Feb. 2, Dr. Gregory Pappas of D.C.'s HIV/AIDS Administration will take your questions on HIV/AIDS in the District and how it's affecting your community. We will hold the live chat on WTOP's website.
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