Despite significant progress in combatting HIV infections globally, the United States continues to face moderate declines, lagging behind many wealthy Western nations. In a recent HIV surveillance report by the Centers for Disease Control and Prevention (CDC), new transmissions decreased by 12% between 2017 and 2021, reaching 32,100 cases. By contrast, the Netherlands witnessed a remarkable annual infection rate drop of over 70%, followed by Italy with 68%, and Australia with 44%. This disparity raises questions about the efficacy of U.S. efforts to promptly diagnose and treat the virus, as well as promote the use of the HIV prevention pill, PrEP.
Experts attribute the U.S.’s slower progress in combating HIV to several factors, including the absence of a national healthcare system and a fragmented, underfunded public health infrastructure. Insufficient coordination among government agencies, academia, healthcare providers, and community-based organizations further compounds the challenges. Additionally, experts highlight the role of racism, inadequate adoption of evidence-based treatment for opioid use disorder, state laws criminalizing HIV exposure, and medical mistrust within communities of color. Dr. Boghuma Titanji, an infectious disease specialist at Emory University, notes that HIV in the United States disproportionately affects the most marginalized segments of society.
The introduction of biomedical HIV prevention in the 2010s marked a significant turning point in the global fight against the virus. Landmark studies revealed that fully suppressing the virus with antiretroviral treatment eliminates sexual transmission risk and extends life expectancy. Moreover, pre-exposure prophylaxis (PrEP), such as the antiretrovirals Truvada or Descovy, reduces the risk of contracting HIV by 99% or more among HIV-negative individuals. Nations that have achieved remarkable success in reducing new infections have prioritized early diagnosis, treatment, and PrEP utilization, particularly among high-risk populations, such as gay men.
In the United States, approximately 1.2 million individuals live with HIV. However, only 87% of them are diagnosed, and merely 58% are in treatment with a fully suppressed viral load. In comparison, countries like Australia, the Netherlands, the United Kingdom, and Italy have achieved robust national viral suppression rates ranging from 74% to 89%. The disproportionate impact of HIV on gay and bisexual men in the U.S. remains a pressing concern, as they constitute about 70% of new cases despite comprising just 2% of the adult population. Furthermore, disparities in PrEP usage persist, with higher rates among white gay men compared to their Black and Latino counterparts.
While there are encouraging signs of progress, such as a significant drop in HIV cases among 13- to 24-year-olds, challenges remain among older populations. England serves as an exemplar, having drastically reduced its HIV diagnosis rate among gay and bisexual men, outperforming heterosexuals. In contrast, the transmission rate among gay and bisexual men in the U.S. surpasses that among heterosexuals by a wide margin. Addressing these persistent divides requires addressing the racial and socioeconomic fault lines that have long plagued HIV response efforts in the country.
The intersection of politics and public health adds complexity to the fight against HIV in the U.S. Conservative politicians’ anti-LGBTQ legislation and rhetoric pose a significant threat to combating the epidemic effectively. Experts emphasize the need for better coordination and support at the national level, particularly regarding housing for individuals living with and at risk for HIV. Southern states, predominantly governed by Republicans, have lagged in allocating resources to tackle the virus, contributing to stark regional disparities. The refusal of most Southern legislatures to expand Medicaid under the Affordable Care Act has further exacerbated these disparities.
Despite these challenges, there are glimmers of hope. The South, the region with the highest HIV infection rate, saw a statistically significant decline of 12% in new infections between 2017 and 2021. Moreover, the rate of new infections across the country has shown signs of acceleration, albeit marginally. Increased spending by the federal government, coupled with targeted efforts in the most affected counties, aims to propel the HIV epidemic into a swift retreat. However, addressing social inequities, such as poverty, racism, stigma, homophobia, homelessness, and healthcare access, is crucial to achieving lasting progress in the fight against HIV in the United States.
Dr. Boghuma Titanji of Emory University emphasizes that the path to defeating HIV in the United States necessitates addressing the multifaceted social challenges that underpin transmission. Without significant progress in tackling poverty, racism, stigma, homophobia, homelessness, and improving access to quality healthcare, HIV will continue to disproportionately impact the most vulnerable communities. The urgent question that remains is whether the nation possesses the willpower to translate knowledge into effective action and bring an end to the HIV epidemic once and for all.