Ending the HIV Epidemic: 40 Years of Progress

June 29, 2021 | Anna Bartels, Tequam Worku

This June marked the 40-year anniversary of the first five cases of what later became known as AIDS reported in CDC’s Morbidity and Mortality Weekly Report. Since then, more than 32 million people have died from the disease worldwide and nearly 38 million currently live with HIV (including 1.2 million people in the United States). Over that period, tremendous strides have been made in HIV testing, prevention strategies, and treatment of individuals living with the virus to ensure that they can lead healthier and longer lives. Prevention strategies include the development of pre-exposure prophylaxis (PrEP), an anti-retroviral drug that prevents HIV infection among people at risk of exposure. Biomedical advancements also led to the development of treatment drugs, such as antiretroviral therapy, which helps reduce the viral load among those living with the virus.

While these advancements have led to significant progress in reducing HIV/AIDS-related deaths and new infection rates, HIV/AIDS continues to be a persistent problem in the United States—with significant disparities across ethnic and racial lines. For example, in 2018 nearly 42% of new diagnoses in the United States were among African American men. Studies show that significant barriers to care include lack of access to health services, including testing and treatment, as well as stigma and discrimination towards people with HIV/AIDS.

The federal government is making significant investments in ending the HIV epidemic. On May 28, President Biden released his FY 2022 budget request to Congress, including $6.73 billion—an increase of $330.8 million from the FY 2021 enacted budget—for the Ending the HIV Epidemic in the U.S. (EHE) initiative. The EHE initiative aims to reduce new infections in the United States by 90% by 2030, targeting programs, resources, and infrastructure to the jurisdictions most heavily burdened by the disease. The initiatives would direct funding across CDC, HRSA, National Institutes of Health, the Department of Housing and Urban Development’s Housing Opportunities for People with AIDS program, and the Indian Health Service.

State legislatures are also taking significant steps towards reducing stigma and advancing access to HIV care and prevention—read more on that below.

Decriminalizing HIV Exposure and Transmission

More than half of jurisdictions across the U.S. have laws that criminalize HIV exposure. These laws may affect EHE efforts since it could reinforce HIV stigma and disincentivize high-risk populations from being tested. In the current legislative sessions, several states enacted or are considering legislation to modify or repeal criminal sanctions related to HIV exposure and transmission. Illinois passed HB 1036 that repeals the state’s HIV criminalization statues, including a law that allowed felony charges against HIV-positive individuals for failing to disclose their health status with partners before unprotected sex. In addition, Nevada passed SB 275 that repeals the felony penalty, but leaves the misdemeanor penalty, for intentionally, knowingly, or willfully engaging in conduct that is intended or likely to transmit the disease. The Virginia legislature passed SB 1138, which repealed the law that made the failure to disclose one’s positive HIV status before sex a misdemeanor. Under the Virginia law, the intentional transmission of HIV remained a felony.

Expanding Access to HIV Testing in Various Settings

Early HIV diagnosis is integral to reducing new infections. Significant improvements in HIV diagnostic technologies over the past couple of decades have helped scale up HIV prevention efforts towards ending the epidemic. California introduced AB 835, which would require emergency departments to offer HIV testing to patients who have blood drawn and attempt to give the patient the test results before they left the facility. In addition, the California State Department of Public Health would be required to give emergency departments information on financial support for HIV testing and linkages to care for HIV positive patients. New Jersey introduced A 971, which would require hospitals and clinical laboratories to provide information on and offer HIV screening to patients living in areas with high rates of transmission. The bill also states that the hospital or laboratory may not bill the patient beyond any applicable copayments, co-insurance, or deductibles regardless of whether the laboratory is in-network. The New Jersey health commissioner would be required to generate and update quarterly a list of locations with a high prevalence of HIV infection and make available through the New Jersey Department of Health’s website. Finally, Washington, D.C introduced the HIV In-Home Test Tax Exemption Amendment Act of 2021 to exempt sales of HIV in-home tests from taxation. The bill sponsors noted that, at $40 per test on average, at-home tests are a significant amount of money for consumers, so the tax exemption could reduce the financial burden on those who need testing.

Access to PrEP and PEP

Arizona introduced HB 2695, which would prevent health plans from prior authorization requirements or any other protocol that could restrict or delay dispensing the medication. Pennsylvania introduced HB 617, a bill that would require all health insurance policies to cover PrEP, and prohibits them from moving the drug to a specialty tier for monetary gains or impose patient counseling in order to receive PrEP. Minnesota introduced HF 855, authorizing pharmacists to dispense PrEP without a prescription to individuals with a recent (i.e., within the past seven days) negative HIV test, as well as postexposure prophylaxis (PEP) for individuals with HIV exposure in the previous 72 hours. The bill also enhances access to PrEP through health insurance plans, requiring health plans to cover all prescriptions as if they were dispensed by a prescription order. It would also prohibit plans from working with pharmacy benefit managers that prohibit PrEP dispensing as a condition of their pharmacy contract. Pharmacists would be required to attend a training program that includes information on the use of PrEP/PEP and financial assistance programs for these drugs before being allowed to dispense them.

Building on the progresses made over the past 40 years, states are working to end the HIV epidemic with equitable and accessible HIV testing, preventive services, and care to populations most at risk of transmission and with the highest burden of disease. ASTHO will continue to highlight new policies and innovative strategies that can help move towards ending the HIV epidemic.