Promising to take "aggressive action" to end HIV in the U.S., President Joe Biden on Worlds Aids Day on Wednesday announced a 3-year roadmap to help reduce new HIV transmissions in the U.S. by 90% by 2030. And he did so by being the first U.S. president to link systemic racism and other discrimination directly to the prolonged HIV epidemic.
"We are going to finish this fight," he said during an address in honor of World AIDS Day. "It shouldn't matter where you live in the country, or how much money you make. We have to respond across the board to the HIV epidemic everywhere and support all people living with HIV."
In 2019, 36,801 Americans were diagnosed with HIV, even though effective treatment and prevention pills can eliminate HIV transmission. The National HIV/AIDS Strategy will expand HIV testing, care, and prevention services, but it doesn't stop there.
This is a first, says Gregorio Millett, vice president of the American Foundation for AIDS Research (amfAR).
"This a fundamentally different strategy," says Millett, who helped draft the first National HIV/AIDS Strategy in 2010. "In some ways, it goes a bit further than other strategies were able to do."
The plan calls racism a "public health threat" regarding HIV, and at Wednesday's event, Biden called out racial and gender disparities that continue to drive the epidemic. More than half of new HIV diagnoses in 2018 came from just 57 jurisdictions, including seven rural states and San Juan, Puerto Rico. Four of those seven states didn't expand Medicaid under the Affordable Care Act, according to data from amfAR.
All seven of the rural states have specific laws on the books that criminalize nondisclosure of HIV status, whether there's been actual HIV transmission or not. In 2018, for instance, a consortium of the most notable HIV scientists declared HIV nondisclosure laws unsupported by current HIV science. Other data shows that lack of access to stable housing can also influence HIV risk behaviors and the ability of people to attend doctor visits and take medication as prescribed. And experiences of racism, homophobia, and transphobia within the health care setting is linked to less likelihood of taking HIV medication or of getting general health care.
And that doesn't even address the racial disparities in HIV that appear to be widening.
Despite the fact that Black Americans make up 13% of the U.S. population, they accounted for 46% of new HIV acquisitions in 2019. And while the longtime image of a person affected by HIV has been a gay white man, new data released by the CDC this week showed that HIV rates are really only dropping among gay white men; rates remain high among gay Black and Latino Americans.
Meanwhile, countries like the U.K. and the Netherlands have already managed to reach international goals for ending the HIV epidemic, according to the Joint United Nations Programme on HIV/AIDS (UNAIDS).
"The U.S. has been behind its peer countries for a while," says Jennifer Kates, PhD, senior vice president and director of Global Health and HIV Policy at the Kaiser Family Foundation. "When you look at the U.S. compared to its peers, we perform much worse in terms of viral suppression and all the major markers that you'd want to see."
Kates, Millett, and others co-authored a 2020 paper detailing all the nonmedical issues that worsen the HIV epidemic. To put the strategy into place in 2022, the Biden administration has asked Congress to allocate $670 million. (For comparison, the Trump administration requested $1 billion in the first 2 years of the Ending the Epidemic plan, according to the Kaiser Family Foundation.)
The plan is massive, spanning 98 pages and addressing everything from expansion of syringe services to keeping better data on how HIV affects transgender women. Other topics include expanding care for Native Americans and HIV care outside of traditional clinical services. It also adds sections on addressing HIV across the lifespan and quality-of-life measures. It was largely welcomed by HIV experts and advocates.
And while some parts of the plan will need congressional support, other parts can be addressed at a departmental level, says a senior White House official, who calls it "a whole-of-government approach."
That means it won't just be carried out by the Department of Health and Human Services and its partners, like the CDC and the National Institutes of Health. And departments like Agriculture, Labor, Justice, Education, Interior, Veteran Affairs, and Housing and Urban Development will be required to fold the HIV strategy's goals into their work, too.
For instance, because housing has been found to be a major factor in people getting HIV and having worse outcomes, the Office of AIDS Policy will work not just with HUD's Housing Opportunities for Persons With AIDS (HOPWA) program, but also with other departments within HUD to fold in this new HIV strategy, the White House official says.
"Now having other parts of HUD at the table, they are thinking about what could be the role of public housing or Section 8 programming as part of the HIV response," the official says, referring to two housing assistance programs that right now don't include HIV as an eligibility requirement.
The same goes for working more closely with states, the Department of Justice, and people living with HIV to eliminate HIV nondisclosure laws, the official says.
More Than Just 'Viral Load'
In 2019, the Trump administration created the ambitious goal to reduce new HIV transmissions by 90% by 2030. But it also repealed Obama-era policies that protected transgender people's access to health care and challenged health care expansion under the Affordable Care Act, among other policies impacting civil rights.
In 2019, those policies led Naina Khanna, co-executive director of the Positive Women's Network-USA (PWN-USA), to join dozens of other people living with HIV to crowd Robert Redfield, then the CDC director, off a stage at a gathering of people living with HIV to promote the new plan to end the HIV epidemic.
"The only thing that mattered about us in those documents was our viral load," says Khanna, who, along with a network of people living with HIV, drafted their own plan to end the HIV epidemic this year called "Demanding Better." It pushed for some items that did eventually show up in the plan, such as the emphasis on quality of life, the inclusion of immigrants and sex workers as important populations to address in the strategy, and the emphasis on aging with HIV.
"So to have this strategy that really affirmatively names accountability on quality of life, on mental health for people living with HIV, addressing comorbidities, addressing housing instability for people living with HIV — these are all major steps forward."
Ruffling Feathers and Making Changes
From where she sits in a small house in Huntsville, AL, Morgan Farrington calls the new strategy something "you could actually, conceivably, create a toolkit from."
Farrington sits on the implementation board for Alabama's own Ending the HIV Epidemic plan. How this strategy will play in the state — which didn't expand Medicaid, has HIV criminalization laws, and has no legal syringe services programs — she's unsure. She's suggested specifically calling out racism as a public health threat to ending the epidemic but was shot down.
"They didn't want to put any more hot-button issues in front of anybody with this," she says. "Nobody got where they are with the Department of Public Health in this state by ruffling feathers."
YouTube: "President Biden Delivers Remarks on World AIDS Day," The White House.
HIV.gov: "National HIV/AIDS Strategy for the United States 2022-2025," "What Is Ending the HIV Epidemic in the United States?"
Gregorio Millett, vice president, American Foundation for AIDS Research.
amfAR: "Ending the HIV Epidemic Database."
The Lancet, Public Health: "Homelessness, unstable housing, and risk of HIV and hepatitis C virus acquisition among people who inject drugs: a systematic review and meta-analysis."
AIDS and Behavior: "Patient and Provider Perspectives on HIV Stigma in Healthcare Settings in Underserved Areas of the US South: A Mixed Methods Study."
CDC: "HIV and African American People," "2021 HIV Vital Signs," "Ending the HIV Epidemic: Jurisdictions."
The Lancet: "The UK reaches UNAIDS 90-90-90 targets."
UNAIDS: UNAIDS warns that progress is slowing and time is running out to reach the 2020 HIV targets."
American Journal of Public Health: "The Broader Context of 'Ending the HIV Epidemic: A Plan for America' Initiative."
Kff.org: "Ending the HIV Epidemic (EHE) Funding Tracker."
Media briefing, White House, Nov. 30, 2021.
Naina Khanna, co-executive director, Positive Women's Network-USA.
PWN-usa.org: "Demanding Better, An HIV Federal Policy Agenda by People Living with HIV."
Morgan Farrington, member, implementation board, Alabama's Ending the HIV Epidemic plan.