In this issue of AJPH, Giroir (p. 22) describes the current administration’s proposed Ending the HIV Epidemic (EHE) plan. The plan outlines an ambitious start to ending the epidemic of HIV in the United States. Because the success of any EHE initiative relies on multisectoral stakeholders, we have invited scientists and public health professionals to comment on the proposed plan to describe both the strengths and the deficits that may inhibit fulfilling immediate goals and sustaining these goals over the long term.

The first and most crucial step in any effort to eliminate HIV is to ensure accessibility of HIV testing for anyone at heightened HIV vulnerability. This step is the one on which all other HIV prevention and care strategies hinge and is the hardest one to accomplish. The science is clear and consistent: early testing is key to early entry into care and better HIV-related outcomes. Although there are overall increases in HIV testing in the United States, these population-level increases mask a lack of testing as well as late testing in key groups most vulnerable to HIV: adolescents, homeless individuals, African American women, Latino/a individuals (Guilamo-Ramos et al., p. 27), and Asian/Pacific Islanders.

Disparities in HIV testing continue to be driven by lack of knowledge of testing availability, lack of access to testing, and stigma, fear, and discrimination associated with testing. Andrasik et al. (p. 67) provide a reminder of how implicit bias perpetuates disparities in testing and access to quality HIV-related care among HIV vulnerable groups. Most importantly, testing once is not sufficient—repeat testing at regular intervals is necessary and requires the availability of and engagement in culturally competent and informed health care. Finally, for those most vulnerable to HIV today, concerns about employment, affordable housing, and affordable health care outweigh the potential fears of an HIV diagnosis. Thus, HIV testing that is nested within a medical home that connects to HIV-related care and includes comprehensive physical and mental health care enables timely and regular HIV testing with a greater emphasis on prevention.

Although preexposure prophylaxis (PrEP)—the latest biomedical addition to the HIV prevention arsenal—has demonstrated high efficacy in several large-scale trials, low population-level effectiveness persists. In the United States, the high cost of PrEP, lack of PrEP knowledge, and clinician reluctance to prescribing PrEP fuel unequal access and uptake of PrEP, thereby minimizing its potential protective impact. Efforts to reduce structural barriers are unevenly distributed across the United States. In California, Colorado, the District of Columbia, Florida, Illinois, Massachusetts, New York, Ohio, Virginia, and Washington State, PrEP assistance programs cover PrEP copay costs or provide medication assistance for individuals at or below 500% to 350% of the federal poverty level who are uninsured or underinsured and prescribed PrEP. Similar PrEP assistance programs are nonexistent in the Southeast even though the Southeast now accounts for the most new cases of HIV and HIV-related deaths compared with any other US region.

As described by Hiers (p. 32), factors fueling HIV-related health care disparities in the Southeast include high rates of unemployment, poverty, and lack of insurance coverage. Although Medicaid is the most likely source of health care coverage among residents in the Southeast, Medicaid expansion was not taken up uniformly across these states; this is a missed opportunity to increase PrEP accessibility, as discussed by Chan et al. (p. 65). Although the EHE plan seeks to increase funding for HIV prevention for local and state health departments across the Southeast, the structural barriers affecting the social determinants of health will hamper the long-term success of HIV prevention efforts in this region.

Furthermore, current HIV prevention campaigns promoting PrEP focus on men who have sex with men, given the persistently high HIV vulnerability in this group. However, African American women and adolescents are at heightened HIV vulnerability yet are less likely to be considered PrEP eligible. In a move to level the playing field of PrEP accessibility, in October 2019, California became the first state to allow pharmacists to dispense 60-day prescriptions of PrEP to any individual who could provide proof of a recent (past seven days) HIV-negative test result. Such measures will immensely increase the reach of PrEP, reduce disparities in uptake, and help sustain its use over the long term. An additional benefit of widespread PrEP availability may include increased HIV and sexually transmitted disease testing, when an effective treatment plan is available regardless of the test result.

As with previous disease eradication programs, success lies in the availability of an HIV vaccine and other long-acting HIV prevention tools (https://bit.ly/2O1lR8r). The MOSAICO Study (ClinicalTrials.gov: NCT03964415), currently under way in the Americas and Europe, will enroll thousands of men who have sex with men and transgender individuals to test HIV vaccine efficacy. But results are not expected until 2023, and concerns persist about whether the vaccine can sustain protection against a rapidly mutating virus. Nonetheless, a vaccine that would require shots every few years rather than a pill a day regimen, as with PrEP, would be a game changer in the HIV elimination campaign.

As a primary prevention tool, an efficacious HIV vaccine could eliminate disparities in access, uptake, and adherence that inhibit the population-level effectiveness of current primary prevention methods such as PrEP. An effective HIV vaccine could also turn the tide against the growing HIV epidemic in the Southeast, as well as among vulnerable groups: men who have sex with men, transgender individuals, adolescents, African American women, and Asian/Pacific Islanders. In short, an effective HIV vaccine is the missing tool in the HIV elimination arsenal that can overcome the socioeconomic and political concerns that inhibit current HIV prevention efforts, ensure a decline in new cases, and sustain this decline for generations to come.

Finally, disease elimination efforts are not new in the United States or the global community. Important to remember is that early campaigns were not one-shot deals that yielded complete eradication of any of their target diseases. In fact, these programs continue to depend on vigilant monitoring and surveillance to rapidly identify and intervene in isolated outbreaks. Similar to how recent outbreaks of polio and measles were identified and addressed, the ability to monitor, identify, and intervene in isolated outbreaks is essential to sustaining EHE goals.

As seen with a recent HIV outbreak among people who inject drugs in Massachusetts, Alpren et al. (p. 37) report that the availability of systems to monitor new HIV cases in real time was essential to controlling this outbreak. New York and other states have implemented dashboards providing detailed data on HIV testing, incidence, and treatment outcomes. Similar systems are required in the Southeast and Midwest. In his article describing the New York City dashboard, Nash (p. 53) provides evidence of the importance of such systems both for monitoring HIV and HIV-related outcomes and for ensuring that measurement of HIV-related markers is consistent across place and time.

We are now in an era when the elimination of HIV is a real possibility. But attaining this goal rests not only on science—the presence of biomedical prevention tools or a vaccine—but also on tackling the pervasive and harmful political, social, cultural, and economic barriers that inhibit the success of these prevention tools and the ability to sustain these efforts over time. Taking innovative steps to confront these barriers is needed to make the possibility of ending the HIV epidemic a reality and to ensure the health and well-being of generations to come.

See also the AJPH Ending the HIV Epidemic section, pp. 2268.

CONFLICTS OF INTEREST

The authors have no conflicts of interest to disclose.

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Farzana Kapadia, PhD, MPH, and Stewart Landers, JD, MCPFarzana Kapadia is with the College of Global Public Health and the Department of Population Health, New York University, New York, NY and is the deputy editor of AJPH. Stewart Landers is with US Health Services, Boston Office, John Snow, Inc., Boston, MA, and is an associate editor of AJPH. “Ending the HIV Epidemic: Getting to Zero AND Staying at Zero”, American Journal of Public Health 110, no. 1 (January 1, 2020): pp. 15-16.

https://doi.org/10.2105/AJPH.2019.305462

PMID: 31800280

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