It has been nearly 4 decades since the Centers for Disease Control and Prevention reported a rare lung infection among 5 previously healthy young men in Los Angeles—what would be the first recorded cases of Pneumocystis carinii pneumonia in men who were discovered to have human immunodeficiency virus (HIV) infection. Since the first cases of AIDS were identified in the United States, the number of people with HIV in the United States has reached an estimated 1.2 million, with nearly 40 000 people receiving a new diagnosis in 2017 alone.1This infection, which was initially nearly uniformly fatal, has become a chronic disease largely because of the scientific breakthrough of a new group of medications, known as highly active antiretroviral therapy (HAART), which has helped to control the epidemic in the United States and globally. Despite this pivotal advancement, only 60% of the people living with HIV in the United States have achieved viral suppression.1 Additionally, the financial costs of HIV are substantial, especially for the federal government, which spent an estimated $20 billion on HIV care and treatment in fiscal year 2016 alone.2 Even though the human and financial burdens of HIV remain substantial, it is now possible to end transmission of the virus and control the epidemic in the United States within the next 10 years.
In the State of the Union address on February 5, 2019, President Donald Trump announced a national commitment to end the spread of HIV in the United States by the year 2030.3 This announcement reflects extensive work by officials in the Department of Health and Human Services and the National Institutes of Health and is focused on targeting resources to the 48 counties in the United States with the highest burden of HIV to ensure a 90% reduction of new infections in the next 10 years.4 Prevention and treatment tools widely available today make this target achievable.5 To make this vision a reality, the administration will have to overcome substantial challenges in 3 main areas: preventing HIV in high-risk communities, ensuring that individuals receiving treatment have undetectable viral loads, and addressing the large socioeconomic, racial, and geographic health disparities associated with this disease.
First, prevention is the first step toward halting transmission. A key element of prevention is preexposure prophylaxis (PrEP), which is highly effective in preventing HIV if taken daily. However, many people at risk of HIV encounter challenges in consistently taking daily PrEP. The development of long-acting PrEP, which may be taken monthly or yearly instead, could be revolutionary in promoting adherence to the medication. In addition to finding longer-acting medicines, the administration will need to address the costs of PrEP therapy, which can be as much as $2000 a month.6 Even though the medication is covered by most insurance plans, co-payments can still be exorbitant, and for those without insurance, PrEP can be prohibitively expensive. Although some state programs offer assistance to cover the costs of these medicines, high-risk populations report financial factors as a major barrier to PrEP.7 Beyond cost, PrEP needs to be far more easily accessible. For example, PrEP currently requires a prescription to obtain, which can be a barrier because many physicians require patients to make clinical visits before they will dispense a prescription. The US Food and Drug Administration should consider and test the efficacy and safety of allowing PrEP to be made available over the counter. Beyond PrEP, ongoing efforts to promote effective, evidence-based prevention tools should include condoms, male circumcision, and making postexposure prophylaxis widely available to individuals who are unintentionally exposed to HIV.
Second, while PrEP and other forms of prevention should be a cornerstone in a national strategy to prevent HIV, it will not be enough to curb the epidemic. Beyond prevention, an effective national strategy will need to ensure that those living with HIV maintain long-term viral suppression. Clear scientific evidence indicates that those whose viral loads are undetectable rarely transmit the virus to others.8 Despite evidence that viral suppression leads to substantially healthier lives and low risk of transmission, challenges across the care continuum have prevented achieving widespread viral suppression. One factor is consistent attrition in care: an estimated 85% of individuals with HIV have received the diagnosis, 73% of whom have received some HIV care and only 60% of whom have achieved viral suppression.1 The result is that among all US residents who likely have HIV, only half are achieving true viral suppression.1 In this regard, management of long-term HIV is similar to the challenges of diagnosing and treating other chronic conditions, like diabetes and hypertension, for which nonadherence is high even among individuals who regularly interact with the health system.
In addition to these general challenges, HIV-specific barriers to adherence, including stigma and discrimination, pose substantial obstacles to accessing and staying in care. A concerted effort to address adherence will require a multifaceted approach. This includes eliminating all co-payments for HIV medications, funding research on how to improve adherence, and making medicines more readily available to vulnerable populations. Adherence to long-term medications is a challenge that affects the entire health care system, but without seriously addressing this issue for people living with HIV, the national goal of zero new cases will not be achieved.
Third, efforts to increase prevention and undetectability will not sufficiently drive down the epidemic if they fail to focus on the significant racial, socioeconomic, and geographic disparities that continue to define the HIV epidemic in the United States. African Americans, who make up 13% of the US population, accounted for 43% of new HIV diagnoses in 2017; Latinos, who make up 18% of the US population, accounted for 26% of new HIV diagnoses in 2017.1 Many social factors contribute to these disparities, including economic instability, institutionalized discrimination, and mass incarceration.9 For example, one study found a dose-response relationship between the level of housing instability and achievement of viral suppression among people living with HIV.10 Removing social safety programs will undermine the administration’s strategy and will reduce the likelihood of achieving the goal of the newly announced initiative. Similarly, any policy that substantially increases the number of uninsured persons would lead to more difficulty accessing care and make achieving zero new cases nearly impossible.
The ambitious goal to end the HIV epidemic, like any large-scale initiative, needs to engage leaders across political parties, building on the legacy of President George W. Bush’s program, the President’s Emergency Plan for AIDS Relief (PEPFAR), which has saved more than 16 million lives worldwide by providing treatment for individuals living in Africa. The current effort will require federal agencies to eliminate silos of funding, forgo the proposed cuts in spending for HIV drugs, and promote access in communities most severely affected by the virus. It will be essential to have a permanent director of the Office of National AIDS Policy, a long-standing vacancy that must be filled to move this plan forward. In addition, the administration will need to more aggressively engage with the community of people living with HIV and those who directly care for them.
If the goal of getting to zero transmissions in the United States is to be achieved, effective interventions for HIV prevention and for enhancing treatment adherence to achieve and maintain viral suppression, as well as approaches to address disparities in HIV care, must be used properly. By doing so, it is possible that the 40-year-old HIV epidemic in the United States can be brought to a close.
Published Online: March 8, 2019. doi:10.1001/jama.2019.1817
Conflict of Interest Disclosures: None reported.
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