Lancet: Minorities continue to be most impacted by US HIV epidemic

Last week medical journal The Lancet published a series of six articles in which the authorised discussed the issue of the continuing HIV epidemic in the United States. The US is the largest sponsor of global AIDS programs but remains ahead of other G7 countries in the number of new cases and the severity of their ongoing epidemic.

The articles note that the biggest challenges facing the US are rooted in racial and gender disparities, gaps in domestic funding for programs, and lack of access to HIV treatment and prevention services due to geographic location and fragmented healthcare systems.

Although the total number of new HIV infections in the United States has decreased by 16% over the past decade people from racial, gender and sexuality minorities are still at a significantly increased risk of HIV – something only amplified by the COVID-19 pandemic. The risk of contracting HIV has only increased for people of colour and men who have sex with men (MSM). These disparities are even high for people living in southern states and rural areas.

Geography and HIV

The geography of the US HIV epidemic has changed dramatically in the past decade and is currently most intense in the South, which accounts for 51% of all people living with HIV and 47% of new HIV diagnoses in 2018. The South’s geography means most people live in rural areas making it difficult to access healthcare. The authors note that the epidemic is also being influenced by HIV-related stigma and low levels of health literacy.

A disproportionately heavy burden falls upon black men and women in the South. In 2018 38% of all diagnoses amongst MSM were in black men, with 63% of these men living in the South. Similarly, 58% of women diagnosed with HIV were black and 65% of them reside in the South.

Although HIV diagnoses amongst all MSM remained relatively stable from 2009 to 2018, inequality changed what those diagnoses looked like. While the number of diagnoses among white MSM decreased by 25% over the decade there was an increase of 20% amongst Hispanic MSM.

Intertwined epidemics

The continuing opioid epidemic in rural areas such as the Appalachians is closely linked to the HIV epidemic amongst people who inject drugs (PWID). Rural communities are particularly vulnerable to co-epidemics of opioids and HIV due to limited access to healthcare, support services and limited harm reduction programs.

Disparities are also seen at the gender level. Women who inject drugs are 1.2 times more likely to acquire HIV than their male peers – often second to use a needle after their male partner. In 2017, women accounted for 28% of all new HIV diagnoses amongst PWID.

The rising cost of healthcare

People living with, or at risk of acquiring, HIV have to seek healthcare through a fragmented and complex network of financial systems. Of those accessing healthcare:

• 40% receive Medicaid (public insurance)
• 35% have private insurance
• 8% access medicare
• 7% other sources
• 11% remain uninsured in any way.

Conclusion

This series of articles concludes the ending the United States’ HIV epidemic will require a unified national approach that includes universal access to healthcare; reduces geographic, racial and ethnic disparities in HIV services; and fights discrimination, stigma and racism in healthcare.

“The United States has shown tremendous leadership in the fight against the AIDS epidemic on a global scale, and now we must show the same leadership here at home. We have the innovation and expertise to make this possible, we just need the political will to do it.” concluded Dr Chris Beirer, Professor of Public Health and Human Rights at the Johns Hopkins Bloomberg School of Public Health.

2020 turned out to be one of the deadliest years on record in US history. COVID-19 is one of the top three causes of death for Americans, the last time such a number of deaths was recorded was during the First World War.