Ending HIV in the United States is possible with the proper leadership and sufficient and targeted resources

By: Carl E. Schmid II, Executive Director, HIV+Hepatitis Policy Institute

After 40 years of living and, sadly, dying with HIV, the United States has become rather complacent. Perhaps this is partially attributable to our own success in treating, preventing, and responding to HIV. But imagine if we allowed another deadly infectious disease, such as COVID-19, to continue to spread for 40 years without investing the attention and resources needed to wipe it out. We must end this dangerous cycle, and we can with the right tools and leadership. But will we?

It is indisputable that combatting HIV/AIDS has been one of the modern miracles of medicine and that the scientific advances made have propelled what was once a likely deadly disease into a manageable chronic condition if people have access to health care and medications. The innovative treatment advances have brought the number of yearly infections from a high of 130,000 in the mid-1980s1 to about 37,000 in 2018.2 Although this demonstrates progress, the number of annual infections has been relatively stagnant since 2014.3 It is now estimated that there are 1.2 million people in the United States living with HIV/AIDS,4 an uncurable infectious disease that left untreated can kill and infect others. Sadly, there are still nearly 16,000 people with HIV/AIDS who die each year.5 We now have the testing and treatment technologies that allow people to live with HIV, but that entails a lifetime of medications and a disruption of people’s lives and their families. We can and must do better.

FEDERAL INITIATIVES
The recent federal Ending the HIV Epidemic initiative,6 which focuses on high-priority jurisdictions and the most affected communities, provides a roadmap for potential success. It ramps up testing and prevention, including preexposure prophylaxis (PrEP) and syringe service programs, and treatment that leads to viral suppression. It builds on the existing programs that people living with HIV and their advocates have successfully created through decades of AIDS activism. This includes the Ryan White HIV/AIDS Program (https://bit.ly/2SfK4hQ), which provides care, treatment, and support services for low income people living with HIV, and HIV prevention programs at the Centers for Disease Control and Prevention,7 which fund testing, surveillance, education, condom distribution programs, and now PrEP outreach and syringe services. For people living with HIV who need housing, there is the Housing Opportunities for People With AIDS program,8 and for ongoing innovative breakthroughs, the National Institutes of Health has an extensive AIDS research program.

Altogether, the US government spends $35 billion annually for HIV.9 Although most of it is through Medicaid and Medicare, few single diseases have such a high level of dedicated resources. Even with all these resources, it is not enough to end HIV. So, what is needed to end HIV and how can we do better with the current dedicated resources?

WHAT IS NEEDED TO END HIV
The Obama administration issued the nation’s first comprehensive national HIV/AIDS strategy,10 which included the necessary elements to make positive change that was propelled with supportive policies, including the Affordable Care Act.11 There was a focus on the communities most affected, including Black and Hispanic/Latino gay men and Black women, and a better allocation of prevention funding to meet the needs of the Southern region of the United States. But because few additional dollars were allocated, progress fell short.

Despite all of its failures—including attacks on health care, transgender rights, and immigrants—the Trump administration launched the Ending the leadership and financial resources to jurisdictions and resulted in Congress appropriating more than $400 million in new funding.12 Despite well-deserved community distrust, state and local governments, along with community-based organizations, began talking seriously about ending HIV. This was particularly important in conservative Southern states, where stigma against HIV remains high. However, the COVID-19 pandemic hit HIV efforts hard and slowed the momentum. In the final days of the administration, the HIV National Strategic Plan13 was released, providing a more detailed roadmap to end HIV nationwide. Now it will be up to the Biden administration to implement it.

THE BIDEN ADMINISTRATION
President Biden’s priorities include the COVID-19 crisis, strengthening our health care system, and addressing racial, ethnic, and other inequities, such as those experienced by the lesbian, gay, bisexual, transgender, and questioning (LGBTQ) community. These priorities are conducive to continued progress in ending HIV. However, we cannot miss this opportunity to advance significant change; if we continue to do the same thing we have been doing, we will never achieve better outcomes.

In a stroke of bipartisanship, something President Biden has repeatedly said he strongly believes in, he should adopt the Ending the HIV Epidemic initiative, invest the increased resources needed to achieve its goals, and take the necessary steps to build community support and partnerships. In his first preliminary budget request (https://bit.ly/3gYwART), President Biden highlighted a number of priorities and, to the relief of AIDS advocates, included continuing the Ending the HIV Epidemic initiative. Although his proposed funding levels fell short of what the Trump administration proposed, Biden is asking Congress to increase funding for the initiative by $267 million. The budget proposal demonstrates an initial commitment to ending HIV. In the coming months, we will learn how much attention and energy the administration puts behind the initiative.

PROPOSED CHANGES FOR THE FUTURE
Moving forward, the initiative, including its resources, should focus on gay men of color and in the South, as most new infections are among this group and in this region. President Biden has issued the executive order Advancing Racial Equity and Support for Underserved Communities,14 which asks for a review of government programs and proposed changes for improvements. Existing domestic HIV programs focus primarily on racial and ethnic communities, the poor, and LGBTQ folks. But we must do better to end HIV.

The Ryan White HIV/AIDS Program is a model program that—working with existing health coverage programs such as private insurance, Medicaid, and Medicare—provides care, medications, and support services that address the social determinants of health, and helps improve drug adherence and health outcomes. Sixty-one percent of their clients have a poverty level of 100% or below, nearly 74% of their clients represent communities of color, and the viral suppression rate for Black and Hispanic/Latino clients is 84.1% and 89.1%, respectively, just slightly lower than the viral suppression rate for White clients of 91%.15 The Ryan White Program’s success is key to ending HIV.

Almost all Ryan White Program funding by law is distributed based on the number of people living with HIV in a particular jurisdiction, which means that underserved areas, such as those in the South, where many people of color reside, receive the same amount of funding as high-resourced areas. These communities are already dealing with limited Medicaid programs, and unfortunately state leaders have chosen not to expand Medicaid. Although I hope that will change, they are still underserved and deserve more resources from the Ryan White Program as well as HIV prevention and community health center funding, particularly because that is where the funding for PrEP resides.

The Ending the HIV Epidemic initiative got it right by first dedicating new resources to where more than 50% of HIV diagnoses occur (https://bit.ly/3ect4Sa). To lay the groundwork, funding was distributed based on case counts. However, because the initiative is not tied to funding formulas, the Biden administration should evaluate how future funding is distributed to better address the needs of underserved communities. Because all these jurisdictions already receive funding from the various historic domestic HIV programs, in the future the Ending the HIV Epidemic program should consider those resources as they carry out their programs. At the same time, we need to examine existing programs to determine how their funding is being used and distributed. No matter the program, all need to be held accountable for their spending and results. If certain areas need more funding and technical assistance, they should receive it. The funding must follow the data.

New medications, such as long-acting treatment and PrEP, will help achieve the goal of ending HIV easier. Hopefully, the new technologies developed to deliver vaccines for COVID-19 can be used to develop an HIV vaccine. Companies and research institutions are also working on cure research.

COVID-19 has shed a light on the weak public health infrastructure of the United States and demonstrated the value of having a robust health care system. Hopefully, the federal government will invest the resources needed to build it up. This will benefit our response to not only HIV but other infectious diseases, such as hepatitis and diseases that we do not even know about today. Our government and communities cannot tackle these epidemics in silos but must approach them comprehensively as a syndemic. Funding streams make that difficult, but accommodations must be made.

We can end HIV, but it will take the right leadership, and sufficient resources, prioritized for those who need them most.

CORRESPONDENCE
Correspondence should be sent to Carl Schmid, Executive Director, HIV+Hepatitis Policy Institute, 1602B Belmont St NW, Washington, DC 20009 (e-mail: cschmid@hivhep.org). Reprints can be ordered
at http://www.ajph.org by clicking the “Reprints” link.

PUBLICATION INFORMATION
Full Citation: Schmid C. Ending HIV in the United States is possible with the proper leadership and sufficient and targeted resources.. Am J Public Health. 2021;111(7):e1–e3.
Acceptance Date: April 15, 2021
DOI: https://doi.org/10.2105/AJPH.2021.306349

CONFLICTS OF INTEREST
The author has no conflicts of interest to declare.

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https://ajph.aphapublications.org/doi/10.2105/AJPH.2021.306349