Despite being the biggest funder of HIV programs worldwide, the United States has a proven “inability to control its own epidemic,” at least so far, according to a series of reports published in The Lancet.

But the series, a kind of state of the HIV union by some luminaries in HIV research and policy, does lay out a road map for reaching the Ending the HIV Epidemic goal by 2030: “a unified, national approach that includes universal access to health care; reduces geographic, racial and ethnic disparities in HIV services; and addresses discrimination and racism in health care,” according to a press release about the series.

The series comprises six reports and two invited commentaries on the following topics:

  • Epidemiology: The epidemic has moved to the South and into rural areas, where Black people have the least access to pre-exposure prophylaxis (PrEP) programs and must drive the farthest to access them. These are also areas that disproportionately have not expanded Medicaid.
  • Race, gender and HIV: Racial disparities are stark among trans and cisgender women too, with Black women accounting for 58% of new diagnoses among cisgender women in 2018. Trans women, particularly trans women of color, have an HIV prevalence of 14%, compared with 1% of cisgender women, yet only 49% of trans women with HIV have been diagnosed, signaling a lack of access to testing.
  • Sexual minority status and race: Black same-gender-loving men made up 38% of all new HIV diagnoses among men who have sex with men (MSM), and the HIV diagnosis rate has increased 20% among Latino gay and bisexual men from 2009 to 2018. This led researcher Kenneth Mayer, MD, of Fenway Health in Boston, to write, “As MSM living with HIV are more likely to be Black or Hispanic and live outside of urban centers, we must find culturally appropriate and nuanced solutions that will reach these populations, no matter where they live.”
  • HIV and opioids: The face of the HIV and opioid epidemic is shifting too, with the number of white people who inject drugs increasing 16%. Again, the people most affected lived in rural areas, where opioid outbreaks led to outbreaks of HIV.
  • Patchy insurance coverage: While Ryan White programs continue to provide care for people living with HIV, the insurance landscape continues to be complex for this population: 40% receive care through Medicaid, 35% through private insurance, 8% through Medicare, 7% through other sources and 11% remain uninsured. The authors call out the incomplete implementation of the Affordable Care Act’s Medicaid expansion as a barrier to ending HIV.

The final report, which details the unified approach outlined above, lays out a path forward.

“Policy, public health, clinician and community stakeholders must prioritize strategies that attend to the social inequities at the intersection of race, gender, class, age, and sexuality that compound the impacts of HIV and COVID-19 in Black communities,” wrote Errol Fields, MD, of Johns Hopkins University School of Medicine, in an invited commentary. “The racial disparities that so rapidly emerged with COVID-19 are a reminder that until these inequities are addressed, disparities in HIV and COVID-19 outcomes will persist and ending the HIV epidemic will remain elusive.”

Click here to read the press release.

Click here to read the full series.