A World AIDS Day Reminder: No One Should Be Left Behind

As a nurse who has for decades provided clinical care and conducted research on the challenges faced by individuals at risk for and living with HIV, I believe the steady progress our nation has made in combatting HIV/AIDS is truly remarkable.

That is why, on this World AIDS Day, I’m feeling especially hopeful.

Thanks to groundbreaking research, innovative treatment, targeted prevention, and a coordinated national strategy, we again showed what’s possible. Statistics on progress, such as a 12% reduction in estimated new HIV infections and 7% decline in confirmed diagnoses from 2017 through 2021, make me optimistic that we can continue to build on decades of incremental advances.

However, we are at a critical juncture in our national response to HIV/AIDS — and time is running out to achieve the Biden administration’s goal of ending the HIV epidemic in the U.S. by 2030. To do so, we must confront the single biggest barrier to accomplishing this objective: our nation’s persistent inability to address HIV’s inequitable impact on specific populations.

In the U.S., an estimated 69% of HIV cases were among Black/African American (40%) and Hispanic/Latino (29%) people in 2021; Black/African American and Latino/Hispanic men who have sex with men (MSM) and Black women who have sex with men (WSM) have some of the highest levels of risk for receiving a new HIV diagnosis. Transgender women are also particularly affected. And more than half of new diagnoses are among people ages 13-to-34. More specifically, 21% of new diagnoses among men and 13% among women are in young people ages 13 through 24 years.

These inequities did not appear out of thin air. As the CDC acknowledges, HIV incidence and exposure are worsened by underlying systemic issues — including racism, discrimination, homophobia, poverty, and stigma — that prevent too many people from receiving effective and sorely needed HIV services. Our healthcare institutions must move beyond anti-bias training and adopt and support a whole-person sexual health framework — which means shifting our current practices from sick care to addressing the many social and economic factors that impact sexual health outcomes.

Here’s what that should look like in practice:

Ensure equitable use of effective existing solutions. Universal HIV testing, pre-exposure prophylaxis (PrEP), and antiretroviral treatment are an incredibly effective combination at reducing incidence of HIV/AIDS. In one community-engaged public health initiative in Atlanta designed to support Latino MSM, 92% of people connected to five clusters of HIV transmission achieved viral suppression within a year of HIV diagnosis; 85% maintained an undetectable viral load at their last test. Federal funds should support and scale up focused interventions specifically tailored to communities furthest from achieving the national goal.

Reduce barriers to care. Income and health insurance status should never determine who receives access to HIV care and who doesn’t. Programs like One Tent Health pop-up HIV screen and PrEP initiation program — which provide free, fast HIV screening regardless of insurance status and offer education about PrEP and other helpful prescriptions to those eligible — reduce the risk of illness and encourage prevention among people who couldn’t otherwise afford testing or care. We need more of these initiatives.

Earn back lost trust. Years of abuse, racism, and exclusion have eroded trust in our health institutions and keep many from seeking care. Currently, our national focus has been centered on understanding the root causes of medical mistrust. We need to shift our focus to understanding the factors associated with trustworthiness in order to design healthcare strategies to bolster trust and engagement in care.

Decriminalize HIV and sexual health. Discriminatory and ineffective HIV criminalization laws enacted in the early days of the AIDS epidemic remain on the books in many states. More than just relics of a time when little was known about HIV or AIDS, these laws continue driving stigma, deepening disparities and discouraging testing. Recent judicial decisions capping PrEP payment options are sadly in line with this outdated and ineffective model. The Department of Justice recommends repealing these unfair and outdated laws and court rulings; states and courts should do so.

Activate all available clinical and non-clinical providers. The current crop of HIV specialists can’t meet demand. Granting full-practice authority enables advanced practice registered nurses, pharmacists, and physician assistants to expand access to HIV prevention and treatment without reducing quality of care. Allowing trusted health professionals to practice at the top of their licensure and funding research focused on new models of HIV service delivery enhances our collective ability to bring more people into the HIV care continuum.

Invest in implementation research and treatment and outreach pilots. Federal, state, and local agencies must increase investments to incentivize innovation and speed the adoption of evidence-based interventions. We need more programs like the CDC’s Closing the Gap with Social Determinants of Health Accelerator, which funds state and local initiatives to improve health outcomes among people experiencing health disparities, and the CMS 1115 demonstrations, which fund state-based pilot or experimental projects designed to better serve Medicaid participants.

While we redouble efforts to end HIV at home, we must also not turn our back on the rest of the world. Over the past 20 years, the U.S. has invested more than $100 billion in the global HIV response via PEPFAR. The results are astounding: 25 million lives saved and millions of infections prevented across dozens of countries. Yet the program now faces an existential crisis, with some in Congress threatening to eliminate funding for political purposes. A program this effective needs to be strengthened, not disbanded.

Having spent my career working towards an HIV-free future for our country and world, I’ve never been more confident that this day is coming. Everyone — whether in government, healthcare, or the community — can make a difference. If we take this walk together, we will reach the finish line.

Vincent Guilamo-Ramos, PhD, MPH, MSW, RN, ANP, PMHNP, is a nurse and the Bessie Baker Distinguished Professor and founder of the Center for Latino Adolescent and Family Health at the Duke University School of Nursing. He is co-chair of the HHS Presidential Advisory Council on HIV/AIDS and an Aspen Institute Health Innovators Fellow. He also is a member of the CDC/HRSA Advisory Committee on HIV, Viral Hepatitis, and STD Prevention and Treatment; a member of the HHS Panel on Antiretroviral Guidelines for Adults and Adolescents; and the vice chair of the Board of the Latino Commission on AIDS.