Ending the HIV Epidemic

A federal plan aims to reduce new HIV infections in the U.S. by 90% before 2030. Meeting that bold goal will depend on addressing social determinants of health.

By Novid Parsi

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The history of addressing HIV/AIDS in the U.S. has been marked by both tremendous progress and a frustrating lack of it. Despite effective tools at hand to prevent and treat HIV, tens of thousands of Americans become newly infected with the virus every year.

It is a reality that the federal government wants to change, and so it has unveiled an ambitious new plan aimed at dramatically reducing new transmissions and halting the epidemic—by the end of this decade.

In theory, the goal is more attainable than ever, thanks to landmark biomedical advances. Antiretroviral therapy, the medicine used to treat HIV, reduces the amount of HIV in the blood and essentially eliminates the risk of transmitting the virus to others. More recently, drugs used for pre-exposure and post-exposure prophylaxis (PrEP and PEP) have also emerged as highly effective tools in preventing HIV infection among people at high risk. When taken once a day, PrEP reduces the risk of contracting HIV through sex by as much as 99%.

The number of HIV diagnoses has fallen since its peak in the 1980s—dropping 18% from 2008 to 2015. And yet in recent years, the number of new diagnoses has remained steady at about 40,000 per year.

“That’s despite the fact we have excellent tools to combat HIV,” says Dr. W. David Hardy, board chair of the HIV Medicine Association and adjunct professor at Johns Hopkins University School of Medicine. “The tools are available, but the problem is they’re not being implemented.”

For example, only about 54% of HIV-positive Americans have achieved viral suppression, meaning they are consistently taking medication that has rendered the virus untransmittable. Compare that figure with 63% in Canada, 74% in Australia and 84% in the United Kingdom.

Identifying and treating the remaining 46% will be the real challenge, he says. That goal is particularly daunting in the South, where more than half of all new HIV cases in the U.S. occur. There, curbing infection rates will require not only effective treatments, but also addressing complex social determinants of health.

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Ivan Gener

On The Attack

In 2019, the U.S. government laid out its plan to take on that challenge. At the State of the Union address in February 2019, President Donald Trump announced the goal of ending the HIV epidemic in the U.S. by 2030; that goal includes reducing the number of new infections by at least 90% within the decade. For 2020 alone, Congress appropriated $291 million for the Ending the HIV Epidemic (EHE) initiative.

The announcement was a welcome surprise to experts in HIV/AIDS care and policy.

Bruce Packett, executive director of the American Academy of HIV Medicine, called the goal an “exceptionally laudable one,” especially during a time of heightened debate about health care access for vulnerable populations.

Dr. Hardy is hopeful the plan will enable progress. “It’s how HIV should have been treated long ago—a government program to make HIV testing routine and get medication to people who need it,” he says.

In the first phase of the plan, the U.S. Department of Health and Human Services will target the geographic regions that currently carry the largest HIV burden: 48 counties, plus Washington, D.C., and San Juan, Puerto Rico, areas where over half of all new infections in the U.S. occur. Almost half of the 48 counties targeted are in the South.

The program’s primary funding recipients include the Centers for Disease Control and Prevention (CDC), which will work with city, county and state public health departments around the country to increase HIV testing, and the Health Resources and Services Administration’s Ryan White HIV/AIDS Program, which provides treatment for economically disadvantaged people who do not have private insurance and are not eligible for Medicaid.

While patients at Ryan White clinics achieve an impressive 86% viral suppression rate, the program treats only HIV-positive people. It does not provide preventive care like PrEP, which has been tied to the recent decline in HIV diagnoses. As such, the federal initiative also would fund community health clinics that can offer PrEP and other preventive care at reduced or no cost to people without private insurance or Medicaid.

“We know what works: getting people tested, getting them care if they’re HIV-positive and getting them PrEP if they’re HIV-negative.”

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Rob & Julia Campbell

In effect, the initiative will launch a two-pronged attack: treatment and prevention. It will identify and treat HIV-positive individuals and also provide PrEP to at-risk, HIV-negative individuals. That approach, HIV/AIDS experts say, is an effective one.

“A lot of people are not diagnosed and a lot of people who are diagnosed are not virally suppressed, and those two things drive the epidemic,” says Dr. Carlos Del Rio, professor of Global Health and Medicine at Emory University and co-director of the Emory Center for AIDS Research. “We know what works: getting people tested, getting them care if they’re HIV positive and getting them PrEP if they’re HIV negative.”

But implementing widescale treatment and prevention won’t be easy. “The government’s initiative will require a large infusion of resources and ramping up the health care infrastructure,” says Dr. Susan Buchbinder, director of Bridge HIV in the San Francisco Department of Public Health’s Population Health Division.

That likely means even more resources than the government has initially allocated, Dr. Hardy says. The Trump administration’s proposed $291 million initiative would include $140 million for the CDC, $70 million for the Ryan White Program and $50 million for community health centers. The U.S. House of Representatives increased the proposed amounts in legislation, providing an additional $78 million to the CDC and $46 million to Ryan White, but those funds are “probably are only the beginning” of what is needed, Dr. Hardy says.

Medicaid Expansion and HIV

Certain regions of the U.S. face steeper challenges than others. “In some parts of the U.S., just having access to health care in general is a real issue,” Dr. Buchbinder says.

In states without expanded Medicaid, the income limit for eligibility remains very low. A family of three, for instance, typically can make no more than $8,900 a year—as compared with most Medicaid expansion states that have an income limit of about $17,200 per individual. As a result, in nonexpansion states, low-income working people with HIV who do not have private insurance often don’t qualify for assistance and can’t afford their medications, which can total around $25,000 out of pocket per year.

“We’re not only going to have to keep, but perhaps expand, the ACA—or do something else that allows more people to be covered,” Dr. Buchbinder says.

Disparities in HIV Diagnoses

Access to health care varies across different groups, as do experiences of stigma and social determinants of health. The result: deep disparities in HIV rates.

HIV Diagnoses (from 2010 to 2017):

Whites: decreased 14%.

African Americans: decreased 15%.

Latinos: remained stable.

Asians: increased 40%.

African Americans

13% of U.S. population.

42% of HIV diagnoses in 2018.

Hispanics/Latinos

18% of U.S. population.

27% of HIV diagnoses in 2018.

69% of all HIV diagnoses in 2018 were among gay and bisexual men.

In low-income urban areas, Americans below the poverty line were 2 times as likely to be HIV-infected as those above the poverty line in 2016.

Source: Centers for Disease Control and Prevention (all figures the most recent availableas of 2021).

Public Health

Some areas of the country could benefit from programs that have shown success in places such as San Francisco and New York, says Packett. “We have seen local health infrastructure reduce the number of new infections and get at-risk people on PrEP,” he says.

San Francisco, for example, has hired staff specifically trained to help patients navigate the health care and insurance systems and to find public resources to pay for PrEP, Dr. Buchbinder notes. San Francisco also has benefited from PrEP-specific clinics with expedited services that allow patients to get their blood drawn and prescriptions filled as quickly as possible. “When the hassle factor rises above the perceived need for PrEP, then people stop taking it,” Dr. Buchbinder says.

Outreach campaigns are also critical for informing people about PrEP and its benefits. “Those campaigns should be marketed in a diverse way so that people of color, cisgender and transgender women, youth and older people all recognize that PrEP could be an option for them,” Dr. Buchbinder says.

Social Work

HIV infections don’t occur in a vacuum. Social determinants of health have a direct impact on infection rates.

“It will be really hard to do what needs to be done without addressing poverty, lack of employment and racism,” says Dr. Del Rio, adding that poverty has been the main driver of HIV both nationally and globally.

Add to those social determinants the intractable issue of stigma—which can keep people from getting tested and treated at all. To help combat HIV stigma, Dr. Buchbinder says, health care organizations and providers must engage in social marketing campaigns such as U=U—undetectable equals untransmittable—a campaign introduced in 2016 by the Prevention Access Campaign, an international health agency. That will help remove the stigma not just of being HIV positive, but also of engaging in HIV risk behaviors, Packett says.

“LGBT stigma is such a big part of the rise of HIV in the South and in minority communities,” he says. “We have to be able to approach people in these communities about issues and risk factors related to HIV. We have to get rid of stigma.”