Ending HIV as an epidemic in the U.S. by 2030: What reforms are needed now?

John Heys

9/7/2022 Facebook Twitter LinkedIn Email

In 2019, the U.S. government announced the Ending the HIV Epidemic initiative, a plan to end the epidemic in the U.S. by reducing new HIV infections by 90% by 2030. While there are significant barriers to achieving this ambitious goal, a new IDSA and HIVMA policy paper published in Clinical Infectious Diseases outlines policy reforms that would make ending the epidemic possible. Two of the paper’s authors, Judith Feinberg, MD, FIDSA, of the West Virginia University School of Medicine, and Anna K. Person, MD, FIDSA, of Vanderbilt University Medical Center, recently spoke with Science Speaks about the paper, its recommendations and what reforms are needed now.

Why is now a critical time to examine obstacles preventing the U.S. from reaching its goals for reducing new HIV infections?

Dr. Judith Feinberg: The federal government’s plan aims to end the U.S. epidemic by 2030. It’s really timely now to think about whether it is possible to do this in seven and a half years. That’s the first thing. Second, HIV, sadly, is increasing in areas that have not experienced HIV before. That’s an enormous challenge for those affected individuals, but also for the health care system, because a lot of these people are located in places where there’s no HIV expertise.

The circumstances are pretty compelling. Now is a very good time to be asking, how are we going to build that HIV and infectious diseases workforce? How are we going to reach people who need treatment? And how are we going to pivot to the fact that we have two streams of what seem to be uncontrolled infection? One is in Black and Latino/Hispanic men who have sex with men, especially in the South. The second is in people who inject drugs.

The paper discusses policies at federal, state and local levels. Why are such broad-based reforms needed?

Dr. Anna Person: There is the expression “all politics are local politics.” This rings true now more than ever. The challenges facing Dr. Feinberg in West Virginia are different than those we are facing in Tennessee, which in turn are different in California or in New York City, in rural vs. urban areas, blue states vs. red states, etc. What matters to our patients are changes they can see in their day-to-day lives. They want policies and changes that they can see in their everyday existence, that affect them and their families. While national policies get a lot of attention, folks living with HIV in crisis often can’t wait for these national policies to “trickle down” to them.

At the same time, we rely on individuals with lived experience to tell us what policy changes are needed. It is our job to help use our platform to push those changes up to the local, state and federal policymakers. And then we must hold those policymakers accountable to science- and evidence-based approaches to making people’s lives better.

One of the paper’s principles addresses the ID and HIV clinical and research workforce. What’s needed in this area to reach the nation’s HIV reduction goals?

Dr. Feinberg: We really need an enhanced workforce. We don’t have enough people. I’m 76, and people like me, who were residents and fellows and assistant professors when HIV started, who really saw how terrible AIDS was and made a lifetime commitment to it, are aging out and retiring. We simply do not have enough health care providers to diagnose and manage HIV, especially in rural communities where HIV is exploding due to the injection drug epidemic that are situated far from Ryan White clinics.

Plus, HIV is concentrated among racial, ethnic and sexual minority populations and we need both more researchers and more health care professionals from these groups to build trust and lasting engagement in care. We need more and more people in the workforce who look like our patients. And it’s not just for HIV. These are also the doctors and other clinicians who are going to take care of monkeypox, polio, endocarditis caused by injection drug use, and all these other things. It’s really important, and it will strengthen us. There’s no downside to it.

One of the paper’s principles calls for addressing social determinants of health. What role do these play in the response to HIV and other infections like COVID-19 and monkeypox?

Dr. Person: Once again, we are in a crisis where equity is playing a front and center role in response to a pandemic. We have folks living with HIV who don’t have transportation to get 5 miles down the road to attend their doctor’s appointments. They may not be able to take the time off work, have bus fare or gas money, or have childcare to be able to go get vaccinated against COVID-19 or monkeypox virus, or have the ability to isolate if they become infected. They may not have broadband internet to access the websites to sign up for monkeypox vaccinations. Or they may be unhoused, dealing with mental health struggles or substance use disorder, or be unable to prioritize preventive health or access medical care in a traditional setting.

Until we address social determinants of health, all epidemics will hit the most vulnerable the hardest. “Housing is health care,” for example, is not just a catchy phrase. It’s the literal truth.

Based on where we are today, how optimistic are you that the U.S. will reach its goal of reducing new HIV infections in this country by 90% by 2030?

Dr. Person: I want to remain optimistic this can happen because we have all the tools we need. But, at the same time, we need to hold our policymakers accountable. We need to help them make evidence-based, scientifically accurate policies that address all aspects of health, and then work hard to make sure those policies help the most vulnerable in our population. I am optimistic, but I am also motivated, and I know it will take a lot of work to get where we need to be. But the HIV community is known for their passion and hard work, so that’s good news.

Dr. Feinberg: We can prevent HIV, we can manage it, and we can keep people healthy. And once people have undetectable viral loads, we can prevent them from transmitting HIV to someone else. So, technically speaking, we have all the tools. The issue is: Do we have the political and social commitment to use the tools that we have?

Read the full paper, “Principles for Ending HIV as an Epidemic in the United States: A Policy Paper of IDSA and HIVMA,” on the CID website.