Healio Special Report: Health Care and Politics

Healio Special Report: Health Care and Politics

Issue: May 2021
Disclosures: Gandhi reports no relevant financial disclosures.
April 18, 2021
4 min read

Biden plan seeks to bolster HIV response, opening door to stronger post-pandemic US

Issue: May 2021
Disclosures: Gandhi reports no relevant financial disclosures.
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With increased funding for measures to end HIV as an epidemic in the United States, the Biden budget plan takes an important step toward addressing the challenge of ongoing and future pandemics.

The Ending the HIV Epidemic (EHE) initiative, launched by the previous administration, commits the nation to the achievable, ambitious and essential goal of reducing HIV transmissions in the U.S. by 90% within the next decade. It is achievable because we have the tools through treatment, technology and biomedical prevention to accomplish it. It is ambitious because it requires a unified will and an investment of resources.


The EHE initiative directs much-needed funding and technical assistance to 48 jurisdictions plus Washington, D.C., and San Juan, Puerto Rico, that accounted for 50% of new HIV diagnoses in 2016 and 2017, and to seven additional states with a high proportion of HIV diagnoses in rural areas.

And although the last year has seen the initiative slip from public and political prominence, it also has demonstrated that ending HIV as a public health threat is essential.

The last year has highlighted the importance of structural barriers to medical services, as well as deeply rooted systemic inequities and racism that fueled America’s HIV epidemic and now greatly exacerbate the COVID-19 pandemic. If we don’t address these barriers now, we leave ourselves vulnerable to the next public health threat. The current, and still new, pandemic has shown us that if we want to stem the spread of preventable infectious diseases, we need to ensure access to affordable, comprehensive health coverage for all of us.

What must be done to end the ongoing HIV epidemic? We need enhanced surveillance that includes data encompassing disparities based on ethnicity, race, sexual orientation and gender identity. We need to address social determinants of health that include starkly inequitable access to housing and education. We need to examine the ways that health services are accessed, and make sure they are available to people in remote and rural communities, indigenous communities and communities that remain largely invisible because of discriminatory laws and policies against marginalized populations. This includes people whose sexual or gender identities are stigmatized and targeted, people who earn income from sex work, people who have been incarcerated and people who have come to this country in pursuit of the same dream that has brought so many here.

We need to ensure that integrated health services, including those that reduce harm, such as syringe services and overdose prevention, are accessible to people with substance use disorders. We need to ensure that individuals are not forced to choose between meeting their basic living needs and accessing the medications that can keep them healthy by preventing or treating HIV and other chronic conditions. And we need to make community engagement a standard and funded component of public health.

Before the pandemic, according to the CDC, just 56% of people with HIV in the U.S. were virally suppressed. Just 18% of the approximately one million individuals who could benefit from PrEP were accessing and using the preventive measure. And among PrEP users, there are massive disparities: only 5.9% of Black/African Americans and 10.9% of Hispanic/Latino individuals who could benefit from this proven prevention measure were receiving it.

During the last year, ground has been lost. An evaluation by the CDC of commercial laboratory data found that the 7-day average of HIV tests performed dropped dramatically after March 13, 2020, and had not recovered by Sept. 30, 2020. An analysis of PrEP prescriptions from a national database found a 15.5% reduction in prescriptions for individuals on PrEP and a 31% reduction in new PrEP users. Although we do not yet have national data or estimates on the impact on viral suppression, an urban clinic in San Francisco reported that the odds of patients not being virally suppressed in their clinic is now 31% higher than before the pandemic.

In addition, according to a survey of clinics funded by the Ryan White HIV/AIDS Program conducted by the Kaiser Family Foundation, 30% had experienced an increase in new clients and nearly 40% reported a change in payer status, resulting primarily in an increase in clients who were uninsured.

All of these data make accelerated efforts imperative now, if the U.S. is not to squander the investments it has made in putting evidence-based measures to work across all of our communities.

But they also show the need for a strengthened public health infrastructure and for services that are adaptable, diverse and reach everyone who needs services the most. That is why, in addition to the investment in the EHE initiative, we need more funding for the federal Ryan White program — initiated in the name of a teenager with HIV whose rights to the most basic services were questioned — and for state and federal efforts to address needs for services to diagnose, treat and prevent STDs, viral hepatitis and substance use disorders, and to address reproductive health needs.

In addition, the search for improved treatment and better biomedical preventive tools must continue. The quest for an HIV vaccine informed and furthered the search for a COVID-19 vaccine. Now we must apply the lessons of COVID-19 vaccine research and development to the development of an HIV vaccine and other biomedical approaches to preventing HIV. We also need research that is informed by all the people who will benefit from our advances, by extending clinical trial infrastructure and access to reach populations disproportionately impacted by HIV, including in rural and resource-limited areas. This, too, requires funding to support expanded efforts, communication and outreach.

The answers to the COVID-19 pandemic, as well as to our longest and most-entrenched epidemic — HIV — continue to lie not only in dollars but in political will. The initial numbers in the president’s budget proposal — $670 million for HIV in 2022, an increase of $267 million over 2021 — are encouraging but more will be needed. The full plan will tell us more, and it will be up to Congress to appropriate the funding necessary to end HIV as an epidemic.

What our elected officials do now will determine whether we as a nation effectively address the HIV epidemic and may as well decide the outcome of pandemics to come.

For more information:

Rajesh T. Gandhi, MD, FIDSA, is chair of the HIV Medicine Association, professor of medicine at Harvard Medical School and director of HIV clinical services and education in the division of infectious diseases at Massachusetts General Hospital in Boston.