Preventive HIV Care Needs to Be a Priority

As the HIV/AIDs epidemic in the United States continues to ravage through lower income communities and disproportionately affect Black and Latinx men, Chris Beyrer, MD, MPH, discusses why preventive care is key.  

Chris Beyrer, MD, MPH, is an infectious disease epidemiologist by training and the Desmond Tutu Professor of Public Health and Human Rights at the Johns Hopkins Bloomberg School of Public Health.

Dr Beyrer has worked on a range of infectious diseases but has primarily focused on HIV/AIDS, viral hepatitis, tuberculosis, and now, for the past year, has been one of the members of the COVID-19 Vaccine Prevention Network and working on the COVID-19 vaccine trials.

In this interview, Dr Beyrer expands on his contributions to an article published in The Lancet titled “Call to Action: How Can the US Ending the HIV Epidemic Initiative Succeed?” shedding light on current statistics and what work needs to be done to bring an end to the rising number of cases.  

Can you talk about HIV rates in the United States? How have these rates changed over the past few years, and what are some of the challenges with controlling this epidemic?

The United States is really alone among the advanced, developed countries, industrialized countries, in being one of the top 10 most affected by HIV/AIDS. We have always had quite a severe epidemic because we had an early outbreak here which for many years, was
under-addressed.

We now find ourselves with about 1.2 million estimated people living with HIV in the United States. The epidemic has changed pretty substantially in demography. It began as a bicoastal epidemic, affecting cities like Los Angeles, San Francisco, New York, Boston, and Washington DC. However, it now much more concentrated in the South and Southeast areas of the country—a broad swath that basically goes from Texas across the deep South, Florida, Georgia, the Carolinas, and all the way up to Baltimore, MD. To give you a feel of how concentrated this epidemic is, there are approximately 7100 counties in the United States but 48 of them account for 50% of all new infections.

Most of them are in the South and Southeast. That unfortunately includes Baltimore, MD, where I am based. It also has changed in race and ethnicity, with an increasing concentration of HIV cases among Black and Latinx communities and populations—particularly concentrated in Black women, who are hugely disproportionately affected by HIV. Then, among Black and Latinx men, cases are concentrated in men who have sex with men. 

What we have been seeing now for the last 5 years with the Centers for Disease Control and Prevention (CDC) data is that the epidemic among White gay and bisexual men has been coming under control with a reduction of overall
cases.

The epidemic in Black men who have sex with men has been essentially flat, unfortunately, remaining stable and hard to contain. The epidemic among Latinx gay and bisexual men is increasing and increasing the fastest in the United States.

This is the real challenge, addressing the inequities and disproportionately affected populations. In addition to the challenges with racial, ethnic, sexual orientation, gender identity, higher rates in trans women—particularly trans women of color, we also see a concentration of HIV in those states—particularly in rural areas—where there has been an expansion of Medicaid through the Affordable Care Act.

What is comes down to, unfortunately, is an old issue for the United States, which is unequal access to health care and health insurance.

What are some fundamental barriers and challenges that need to be addressed within HIV care?

Well, there are a number. Certainly, one of the issues has been access. The big challenge is the access issues not for the lowest income Americans, many of whom qualify for Medicaid, but really, that large swath of the population who work in job sectors that do not provide health insurance, or only provide minimum catastrophic coverage, remains an issue. 

We are also extremely concerned about the persistence of stigma. Stigma in health care settings, particularly in the South, remains an issue. It has multiple components. It is what social scientists refer to as intersectional stigma, which means there is both stigma and discrimination against people living with HIV, first and foremost.

Secondly, there is anti-Black racism, which is a very real issue in this country, as we all know. 

Thirdly, there is still a lot of homophobia. There is discrimination against LGBT people and trans people, who are among the most affected populations in this country, and unfortunately, the most likely to be mistreated in health care settings.

We are working on our next big project, which will include an intersectional stigma reduction program for health care workers in the South to try and improve outcomes for Black gay and bisexual men. We think that is important. 

Historically, this has not been done so much in the HIV area, but there have been anti-stigma and anti-racism efforts and programs to deal with cancer disparities, which it turns out are also a function of discrimination in health care.

Does a fragmented health care system impact care for this patient population, and how can the US health system better address the HIV epidemic?

Yes, there’s no question that the fragmentation of health care is a big problem. As I said, we see, particularly in the states that have not expanded Medicaid, a different pattern emerging, which is higher rates in rural populations.

That is concerning and it is unique to the southeastern part of the country. It is also challenging for a particular population who is very much at risk—adolescents and young adults. On average, most people become sexually active starting at age 15 or 16 years. At that time, they are often covered by their parents’ health insurance. 

It is always challenging for adolescents to access sexual health services, and the United States does not offer services in schools, as so many industrialized countries do. Now, what we are seeing is that the highest rates of new infection are really in the 15- to 24-year old sexual and gender minority youth—gay, bi, and trans youth.

Those folks are markedly underserved in many health care settings. There are challenges with, for example, being on your parents’ insurance if you might be a candidate for preventive HIV care like pre-exposure prophylaxis (PrEP). That opens up a cascade of questions about why you are at risk and why you need this medication. Some families are supportive and others are not, presenting increased access challenges.

What should the payer population know about ending or even addressing the HIV epidemic? How can they better tailor their health care plans to help combat the growing number of patients?

One challenging aspect in this country in terms of reducing new infections and addressing the problem of incidence of infections has been the low access to, uptake, and use of PrEP thus far. If taken as prescribed, PrEP is remarkably effective for HIV prevention, and it could help us bend the curve and end the epidemic, if only we could reduce the number of new infections.

The ending the HIV epidemic initiative that the previous administration put forward had a very ambitious goal of a reduction of 75% in new infections in 5 years, and 90% in 10 years. The most recent CDC data suggest that our epidemic is declining at about 2% a year. That is nowhere near enough of a decline to achieve epidemic control.

That means that payers and providers need to boost efforts helping people access PrEP, including ensuring they are remaining adherent. It is absolutely critical, and many of us would argue that, at this point, it is the backbone of treatment programs, and payers are paying too much for it.

Is there anything else you would like to add to this conversation?

I would say that what is frustrating is that we have a very powerful set of tools. We have tremendous advances in treatment and in prevention, but we are not getting them to the people who need them most. The unequal access to and uptake in use of these technologies is really limiting our ability to control HIV.

We are not on a trajectory to get control of this epidemic in this country if we continue this rate that we’re going at. We really need to ramp up prevention. We need to help people living with the virus get virally suppressed and stay virally suppressed.

That is for their own health, but also to prevent onward transmission to more sexual partners. We need to get HIV back on the national agenda. That is going to be a challenge. 

Reference:
Beyrer C, Adimora A, Hodder S, et al. Call to action: how can the US Ending the HIV Epidemic initiative succeed?. The Lancet. 2021;397(10279):1151-1156. doi:10.1016/s0140-6736(21)00390-1