New HIV infections continue to decline only modestly in the United States, while many other wealthy Western nations have seen steep declines, thanks to more successful efforts abroad to promptly diagnose and treat the virus and promote the HIV prevention pill. HIV, PrEP.
in a new HIV surveillance report released Tuesday, the Centers for Disease Control and Prevention estimated that new HIV transmissions decreased by 12% nationally between 2017 and 2021, from 36,500 to 32,100 cases.
In comparison, according to Dear All According to the Joint United Nations Program on HIV/AIDS, between 2015 and 2021, the annual rate of infection fell by more than 70% in the Netherlands, 68% in Italy and 44% in Australia. UK health authorities Recorded around 2,700 diagnoses in England in 2021, a drop of about a third from 2017 and half from 2015.
Experts told NBC News that the US remains far behind in the fight against HIV due to the lack of a national health care system and a network of sexual health clinics; fragmented and underfunded public health systems; and worse synchronization between government, academia, health care, and community organizations.
These experts also pointed to factors such as racism, inadequate adoption of evidence-based treatment for opioid use disorder, state laws criminalizing HIV exposure, and medical mistrust of people of color.
“HIV in the United States is very much a disease of those who are most disenfranchised in society,” said Dr. Boghuma Titanji, an infectious disease specialist at Emory University.
The power of pills
The 2010s heralded the era of so-called biomedical HIV prevention. A series of landmark studies established two critical facts: one, that completely suppressing the virus with antiretroviral treatment eliminate sexual transmission risk in addition to lengthening life expectancy almost back to normaland two, that when HIV-negative people take the antiretrovirals Truvada or discover daily as pre-exposure prophylaxis, or PrEP, reduce your risk of contracting the virus by 99% or more.
Consequently, nations that have managed to far outpace the US in reducing new infections have gotten more people with HIV diagnosed and treated, and have done so earlier in the course of infection. These countries have also often seen a higher proportion of people at higher risk of HIV, ie gay men, receiving PrEP.
An estimated 1.2 million Americans have HIV. According to the CDC, only 87% of them are diagnosed and only 58% are on treatment and have a completely suppressed viral load. This latter figure compares with robust national rates of viral suppression, estimated by health authoritiesof 82% in Australia, 83% in the Netherlands, 89% in the United Kingdom and 74% in Italy. The rate is above 70% in at least 16 other European nations.
In the US, the virus has maintained its vastly disproportionate impact on gay and bisexual men, who, according to the new CDC report, account for about 70% of new cases despite accounting for only about 2%. of the adult population.
First approved in 2012, PrEP has skyrocketed in popularity among white gay men in the US, while failing to gain a significant foothold among their black and Latino peers.
The CDC has My dear that about 814,000 gay and bisexual men are good candidates for PrEP. Recent data suggested that the number of people, mostly from this population, ever using PrEP each year more than doubled between 2017 and 2022, to at least 318,400. However, a recent CDC study suggested that only about half of that group took PrEP during any given month in the past year, suggesting that many people take it only temporarily.
The most recent four-year national decline was driven by an estimated one-third reduction in cases among youth ages 13 to 24, which Dr. Robyn Neblett Fanfair, acting director of CDC’s Division of HIV Prevention, he characterized as «very encouraging» in a media call on Tuesday. The CDC attributes this success to progress in expanding testing, treatment, and PrEP among gay and bisexual men, who account for 80% of cases in that age group.
But infection rates among the older counterparts of these men have remained statistically stable.
In England, biomedical prevention among gay and bisexual men was vastly improved drastically reduced their HIV diagnosis rate so drastically, by roughly three-quarters in a decade, that by 2022, fewer of them have tested positive for the virus than heterosexuals. In the US, transmissions by gay and bisexual men outnumber heterosexuals by more than three to one.
Dr. Chris Beyrer, director of the Duke University Institute for Global Health, commented that many of the nations that have seen such precipitous declines «don’t have to deal with the really sharp health disparities and lack of access» that have dyed usa hiv fight.
persistent divisions
HIV has exposed racial and socioeconomic flaws in the US for decades, and the virus disproportionately affects people of color and the poor.
Blacks and Latinos respectively comprised 40% and 29% of the most recent transmissions, despite the fact that these racial groups represent only 12% and 19% of the US population. About one in five new infections are among women, more than half of them among black women.
The new CDC report reveals that such racial disparities have decreased only slightly in recent years. Breaking down the transmission trajectory by race and sex showed that black men were the only group that experienced a statistically significant reduction.
Estimated new infections among gay and bisexual men decreased between 2017 and 2021 from 9,300 to 8,100 among blacks and from 7,800 to 7,200 among Latinos. However, these changes were not statistically significant, in contrast to the significant decrease among whites, from 5,800 to 4,800 cases.
Politics and public health
The recent fervent use by conservative politicians of anti-LGBTQ legislation and rhetoric to appeal to the Republican base threatens to further undermine efforts to combat HIV, public health experts have warned.
“All this simple hate towards the LGBTQ community is not good for ending the epidemic,” said Kathie Hiers, executive director of AIDS Alabama.
Hiers also denounced what he characterized as inadequate and poorly coordinated national support for housing among people living with and at risk of HIV. He pointed to New York’s strong support for HIV-positive homeless people as a cornerstone of that state’s success in fighting the virus.
About half of HIV transmissions occur in the South, which has an infection rate about 50% higher than the West and Northeast, and twice that of the Midwest. Southern, Republican-dominated states have tended to devote fewer resources to fighting the virus compared with liberal states and cities elsewhere, such as San Francisco and New York, which have a history of fighting substantial HIV epidemics.
Pundits have long cited the refusal of most Southern legislatures to expand Medicaid under the Affordable Care Act as one of the main drivers of regional disparities in HIV treatment and prevention.
“The Medicaid expansion is a massive structural intervention to support the most vulnerable in our communities,” said Dr. Hyman Scott, an HIV prevention expert with the San Francisco Department of Public Health.
silver linings
There is hope that the South may be turning around, given the CDC’s finding that it was the only region to see a statistically significant decline, 12%, in estimated new HIV infections between 2017 and 2021.
Furthermore, the decline of HIV appears to be accelerating, albeit marginally. The CDC previously reported the new infection rate was essentially stable in the mid-2010s and then inches 8% lower between 2015 and 2019.
And while the most recent data is somewhat mixed due to a drop in HIV testing following the onset of COVID-19, an apparent sustained decline in transmissions in 2020 and 2021 represents a victory for the prevention and treatment workforce. of HIV. Infectious disease clinics, for example, often proved agile in the face of disruptions from the new pandemic by pivoting towards telehealth and supply patients with months of drugs at a time.
The CDC is not satisfied.
«In prevention, patience is not a virtue,» said Dr. Jonathan Mermin, director of the CDC’s National Center for the Prevention of HIV, Viral Hepatitis, STDs and Tuberculosis, during Tuesday’s press conference. . “We can end HIV in America. We know the way, but does our nation have the will?
Fighting for the future of HIV
The federal government hopes that an increase in spending will be the linchpin that will finally cause the HIV epidemic to recede rapidly.
In 2019, Donald Trump endorsed a plan to increase federal outlays on HIV. Between fiscal years 2020 and 2023, this infusion of new annual funding, much of it funneled into the 48 counties where roughly half of broadcasting occurs, has it shot itself from $267 million to $573 million. Mermin asked Congress to approve President Biden’s budget request for $850 million for fiscal year 2024.
The stated purpose of spending is to cause the 2017 HIV transmission rate to collapse by 75% by 2025 and 90% by 2030. But, as CDC surveillance clearly shows, the current trajectory of the epidemic is a long way from reaching targets so high.
Emory’s Boghuma Titanji said that to succeed in defeating HIV, the nation must address the myriad of intractable social inequities that drive transmission, including poverty, racism, stigma, homophobia, homelessness and poor access. to medical care.
Absent such progress, Titanji said, she anticipates that by the end of the decade, HIV in the US will be «more or less the same: a disease that will continue to disproportionately impact the most vulnerable communities.»