Ending the HIV Epidemic in the United States: “We Have the Tools”

Despite progress, alarming HIV rates persist in the US. Ending the HIV Epidemic seeks to reduce annual new HIV infections to fewer than 3000 by 2030.

“40 years into the HIV and AIDS epidemic, the federal US government has launched a decade-long, multiagency initiative designed to accelerate progress in HIV prevention and treatment by formulating an ambitious goal: the reduction of annual new HIV infections in the US by 90% or more by 2030,” Vincent Guilamo-Ramos, PhD, MPH, LCSW, RN, ANP-BC, PMHNP-BC, and colleagues wrote. “Ending the HIV Epidemic (EHE), an initiative launched in 2019, seeks to ensure that the billions of federal dollars invested each year in the HIV response translate into tangible benefits for both the 1.2 million people living with HIV in the US and the more than 1 million additional Americans at elevated risk [for] HIV infection.”

According to Dr. Guilamo-Ramos and colleagues, in 2030, the success of EHE “will be measured primarily against the declared target of fewer than 3,000 new HIV infections a year.” They also note that, to achieve “meaningful progress” toward this goal, the number of new HIV infections recorded each year will have to decrease at a “substantially accelerated pace compared with the preceding decade.”

The paper outlines four areas of priority to regain “lost ground” in working toward the 2030 EHE goals: reducing stigma, broadening the HIV workforce, mitigating social determinants of health (SDOH), and reinvesting in health in the US more broadly.

Physician’s Weekly spoke with Dr. Guilamo-Ramos to learn more about these efforts.

PW: How are existing systems for treating and preventing HIV failing in the US?

Dr. Guilamo-Ramos: First, it is important to recognize that since the height of the HIV epidemic in the 1980s, the US has made tremendous progress by reducing new HIV infections and by enabling people with HIV to live healthy lives with normal life expectancies. These achievements are, in part, attributable to three highly effective prevention and treatment options that are available today: (1) routine HIV testing, (2) HIV PrEP—a once-daily pill or bi-monthly injection that is effective in preventing HIV acquisition, and (3) effective antiretroviral HIV treatment that prevents HIV-related mortality, morbidity, and forward transmission (ie, undetectable equals nontransmissible).

The availability of these and other effective HIV prevention and treatment options has enabled the US to set the ambitious goal of ending the HIV epidemic by 2030. However, the 2030 EHE goal can only be achieved if the available prevention and treatment options reach all people living with or at elevated risk of HIV. Within the systems for treating and preventing HIV that exist today, this is not the case. Specifically, HIV testing, PrEP, and treatment too often do not adequately reach communities and individuals in greatest need. My colleagues and I discuss these challenges in an article published in The Lancet HIV.

Consider the example of rapid HIV transmission clusters: We today have the tools to prevent all HIV transmissions in the US—if all people living with HIV receive timely testing and consistent treatment and if all people at elevated risk of HIV receive PrEP. Despite this, the US CDC continues to detect events of rapid HIV transmission across all US census regions. For example, in 2021 to 2022, five clusters of rapid HIV transmission (primarily involving Latino gay, bisexual, and other MSM) were detected in the Atlanta metropolitan area. Alarmingly, only 5% of the people linked to the five Atlanta clusters (33% of whom were born outside the US) had ever used PrEP, which highlights the failure of existing standard-of-care HIV service delivery systems to equitably reach Latino MSM and other communities that have been left behind.

Notably, similar inequities remain far too prevalent in US healthcare. We illustrate an example using the recent mpox vaccination campaign and discuss health system strategies for more equitable service delivery in our recent Nature Medicine article, and I discuss the topic further in a recent CNN opinion piece.

How is this specifically impacting priority populations?

The current HIV data that are publicly available cast doubt on whether the remaining 7 years of the national EHE initiative suffice to achieve its 2030 goal of reducing new HIV infections to fewer than 3000 annually. In particular, the inequitable reach of the available HIV prevention and treatment tools represents a threat to the federal 2030 EHE goals, given that several data points suggest that new HIV infections among key priority populations are inadequately decreasing, stagnating at elevated levels, or in some cases even increasing:

• Black communities: The numbers of new HIV infections among Black people in the US remain unacceptably elevated, despite a 24% reduction in estimated annual new infections from 2010 to 2021.
• Latino communities: Estimated annual new HIV infections for Latino people have changed by 0% between 2010 and 2021—no progress—while decreasing by 19% in the US population overall.
• Young Latino and Black MSM: Between 2010 and 2021, the estimated annual HIV incidence increased by 65% among young Latino MSM and by 67% among young Black MSM as compared with a 5% decrease among young White MSM.
• Black and Latina transgender women: More than one in four Black and Latina transgender women in the US are estimated to be living with HIV.
• People who use drugs: Estimated annual HIV infections among people who inject drugs declined between 2010 and 2014, but then reaccelerated from 2014 to 2021, eliminating the prior progress.
• Rapid HIV transmission clusters: CDC’s 2018-2021 molecular surveillance identified 38 large clusters of rapid HIV transmission, of which six (16%) primarily involved people who inject drugs, and 29 (76%) primarily involved MSM; in these clusters, 64% were Black or Latino individuals, 87% were younger than 40 years, and 48% resided in the southern US.

What are the key takeaways physicians need to understand?

We have the tools to end HIV in the US. Now we need to utilize them equitably. To achieve this goal, a lot of work remains to be done.

Physicians are essential in this effort, but we will need to engage, support, and leverage a much broader workforce to achieve the necessary scale and reach of HIV testing, PrEP, and treatment. Despite this need, qualified members of the HIV care team (eg, nurse practitioners, physician assistants, and pharmacists) too often face regulatory restrictions that prevent them from practicing at the highest level of their education and license, restricting the full deployment of their expertise and qualifications in the national effort to end the HIV epidemic.

In addition, there is a wide range of clinical and nonclinical professionals who deliver services that are crucial for comprehensive HIV prevention and management but who are too often underused or not formally considered members of the HIV workforce: these include nonprescribing nurses, mental, behavioral, and addiction healthcare practitioners, and community-based health service providers (eg, community health workers, health educators, and people with lived experience of HIV). Broadening the HIV workforce by enabling nonphysician HIV clinicians to practice to the full scope of their education and license and by formally recognizing the contributions of all clinical and nonclinical HIV service providers is particularly important to enable greater proliferation of novel, demedicalized, decentralized, and community-led models of HIV service delivery.

How can these initiatives be incorporated into practice?

HIV remains a key public health priority in the US. Yet, HIV testing and prevention are too often not prioritized in healthcare delivery for adults and adolescents. It is important that comprehensive sexual histories, HIV testing, and sexual health vaccinations are recommended as part of routine care for adults and adolescents. The CDC recommends routine opt-out HIV screening for adults and adolescents in all healthcare settings. Furthermore, the US Preventive Services Task Force recommends STI prevention counseling for all sexually active adolescents and for adults at increased risk for STIs. Moreover, the 2021 update to CDC’s PrEP guidelines recommends informing all sexually active adults and adolescents about the availability of PrEP for HIV prevention.

What would you like future initiatives to be focused on?

Without accelerated progress, the 2030 goal will soon be out of reach. But we can still succeed if we focus on equity in implementing the available HIV prevention and treatment tools. Four priorities for action stand out and are discussed in greater detail in our The Lancet HIV paper:

1. Eliminating HIV stigma, implicit biases, structural racism, and HIV criminalization in clinical practice, programming, and policy, and rebuilding the trustworthiness of public health and healthcare services (see our family-based No Fears stigma intervention for youth as a resource for providers).
2. Broadening and diversifying the HIV workforce and enabling comprehensive, team-based, and demedicalized prevention and care through leveraging all available clinical and non-clinical providers at their highest scope of practice (see our related paper in the American Journal of Public Health as a resource for providers).
3. Investing in implementation research and demonstration projects of novel strategies for mitigating SDOH that drive HIV inequities (visit the DUSONtraiblazer website for resources for mitigating harmful SDOH).
4. Ending the chronic under-prioritization and under-investment in US public health by advancing equity-focused health system transformation and meaningful community engagement (see our recent Nature Medicine article as a resource for providers).

Is there anything else you’d like to mention?

We have the tools to end HIV in the US by 2030. We need to utilize them equitably.

We have compiled a comprehensive set of resources that providers can use to advance health equity in their own work. It can be accessed here: https://duke.box.com/v/hiv-equity-resources. In addition, we encourage your readers to share the resources and call to action for HIV equity using the hashtags #StopHIVTogether and #4HIVEquity.