HIV incidence down 73% since 1980s, but racial, ethnic disparities remain
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The annual incidence of HIV in the United States declined 73% from a peak of 130,400 infections in 1984 and 1985 to 34,800 infections in 2019, according to estimates published today in MMWR.
However, the proportion of infections that occur among Black and Hispanic/Latino people has increased since 1981 — the year the first reported cases of AIDS were published in MMWR. The 40-year anniversary of that report is Saturday.
“Ending the HIV epidemic requires addressing health disparities,” CDC epidemiologist Karin Bosh, PhD, and colleagues wrote in the new report. “Equitable implementation of prevention tools to diagnose HIV infection early, treat persons with HIV to rapidly achieve viral suppression, and link persons to preventive services to reduce new transmissions will hasten the decrease in HIV incidence.”
Bosh and colleagues compared data reported to the National HIV Surveillance system from three eras to estimate annual HIV incidence among people aged 13 years or older. They examined data from 1981 to 2019 and compared the distributions of HIV incidence by sex at birth, race and ethnicity and the transmission category, peak of infections and the final year of the study period.
In addition to the overall decline, Bosh and colleagues noted that a greater proportion of infections occurred among women in 2019 (18%) than in 1981 (8%) or in 1984 to 1985 (12%). The proportion of infections that occurred among white people decreased from 56% in 1981 to 25% in 2019.
In contrast, HIV incidence among Black people surpassed the rate seen among white people in 1988 and remained higher than in any other ethnic and racial group through 2019. Black people accounted for 29% of infections in 1981, 30% between 1984 and 1985 and 41% of infections in 2019. Additionally, Latino/Hispanic people accounted for 16% of infections in 1981, 14% of infections between 1984 and 1985 and 29% of infections in 2019.
According to Bosh and colleagues, the largest reduction in HIV incidence since 1981 has occurred among people who inject drugs, following the introduction of syringe services programs. The incidence in this population plummeted 93% from a peak in 1988-1990 to 2019, although none of those gains occurred in the last decade — likely because of the opioid epidemic.
The United Nations General Assembly will hold a high-level meeting next week to discuss ending HIV/AIDS as a global public health threat by 2030. The U.S. has already announced its own federal plan to end HIV by 2030, which focuses on increasing the use of PrEP and leveraging public money to increase the level of viral suppression in the country.
“The prevention tools available today, including HIV testing, prompt and sustained treatment, pre-exposure prophylaxis, and comprehensive syringe service programs, as well as new technologies being developed, such as long-acting antiretroviral agents, self-testing, and telemedicine, provide an opportunity to substantially decrease new HIV infections,” the authors wrote. “Ongoing priorities should include maximizing critical partnerships, implementing treatment and prevention services at scale, and ensuring a focus on decreasing disparities.”
Perspective
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At the 40-year anniversary of the first published description of AIDS, we have remarkable progress to celebrate but also have the sad realization that we have far to go to end the HIV pandemic. This report calls out the disproportionate impact of HIV on Black and brown people; gay, bisexual and trans individuals; and people who inject drugs. It rightly reminds us that the disparities that drive the HIV epidemic go deep and compel us to uproot systemic and structural racism and its downstream effects on access to health care, income inequality, lack of affordable housing, lack of transportation and the like. Add to that the homophobia and transphobia that keep people living in the shadows and you have the secret sauce of the ongoing HIV epidemic in America.
What the article does not mention is the way that HIV has disproportionately made its home in the South, including rural areas. We have truly become two countries because some states look forward to realistically ending the epidemic by 2030 or even 2025 and the rest of us are left behind. The rate of new HIV diagnoses in my state, Georgia, is the highest in the nation among states. Ours is twice the rate of California and nearly twice that of New York. The South is the epidemic cauldron where politicians rejected Medicaid expansion in spite of the fact that maps of poverty, diabetes, hypertension and deaths from heart disease all look like the map of HIV. In the South, educational attainment is low and incarceration is high, and maternal mortality rivals that of low-income countries. In many of these states, public health has been underfunded for decades, and we have seen the dramatic consequences of that with the onslaught of COVID-19. The other important issue not mentioned in the MMWR is that we simply cannot do the work that needs to be done with our dwindling HIV workforce, especially in the South.
I remain optimistic about our ability to end the domestic HIV epidemic, but it will require fundamentally rethinking our approaches. The easy part has been done. Although much has been said about the response to COVID-19 drawing on our infrastructure and knowledge from the HIV response, now it’s time for the HIV response to get renewed attention. The HIV pandemic will still be here when the COVID-19 pandemic has been vaccinated away — and so will its disparities.
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