ENDING AIDS IN AMERICA

meeting the challenge

Once an unimaginable goal, we now have the knowledge and tools to end AIDS in America. New and improved medications, expanded health coverage options, and an updated understanding of the relationship between treatment, care and prevention have created a new paradigm for the HIV/AIDS epidemic in the United Statesand offer the promise of ending new infections. In fact, the Centers for Disease Control and Prevention has stated that achieving an AIDS-free generation is within our grasp.1 Fulfilling this promise, however, will require commitment, perseverance and leadership. Now is the time to make this unprecedented opportunity a reality by ensuring solutions based on science and human rights, by reducing barriers to access and by creating effective public-private partnerships.

A CONFLUENCE OF DEVELOPMENTS OVER THE PAST SEVERAL YEARS HAS PRESENTED AN OPPORTUNITY TO FINALLY END AIDS IN AMERICA.

HIV in the United States Today

An estimated 1.1 million people currently are living with HIV in the United States, with nearly one in six unaware they are HIV positive.2 Although the total number of people living with HIV has increased, largely due to better treatment options, the number of people becoming newly infected has held steady at approximately 50,000 annually since the late 1990s.2 More than 15,000 people with AIDS die each year in the United States; and since the start of the epidemic, more than 650,000 people overall have died.2,3 HIV disproportionately affects many of the most marginalized communities in our country: These groups include communities of color; gay, bisexual and other men who have sex with men (MSM); those who struggle with substance abuse; those who have faced domestic violence; those who are living in poverty; and transgender individuals. While African-Americans comprise 14% of the U.S. population, they represent 44% of both new HIV infections and people living with HIV.2 Latinos make up 16% of the overall population, but account for 21% of new infections and 19% of people living with HIV.2 MSM experience 63% of all new HIV infections, with new diagnoses increasing fastest among the youngest MSM (ages 1324).2 While new infections have decreased among all women in recent years, African-American and transgender women remain disproportionately affected. For example, the HIV incidence rate among African-American women is 20 times that of white women.4 Geographically, the South has both the highest number and rate of AIDS diagnoses, followed by the Northeast, West and Midwest.2

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white msm black msm hispanic/latino msm black heterosexual women black heterosexual men white heterosexual women hispanic/latina heterosexual women black male IDUs black female IDUs
1,300 1,200 1,100 850 2,700 5,300 6,700

aidswatch: ending aids in america

11,200 10,600

CDC, ESTIMATED NEW HIV INFECTIONS

United States, 2010
Subpopulations representing 2% or less of the overall US epidemic are not reflected in this chart.

0 2,000 4,000 6,000 8,000 10,000 12,000

number of new hiv infections

Costs of HIV Care and Treatment

Ending AIDS in America will improve individual and public health, and it will result in significant long-term cost savings. In the era of antiretroviral treatment, the average annual cost of care for a person living with HIV is $23,000; the estimated lifetime cost of treating one HIV infection is $379,668.5 Eliminating just one years worth of the 50,000 new HIV infections that occur annually would save nearly $19 billion in lifetime treatment costs. Because HIV disproportionately affects the poor and low-income communities that are less likely to have private health insurance, government programs such as Medicaid, Medicare and the Ryan White Program are critical to addressing care and treatment needs. In fiscal year 2012, total federal spending for HIV care was approximately $14.8 billion, with the largest amounts going to Medicare ($5.8B), Medicaid ($5.3B) and Ryan White ($2.4B).6 States also share the costs of treating HIV, with the highest financial burden occurring in states with the most new diagnoses. According to the CDC, the 10 states with the highest cost burden for HIV care (highest to lowest) are Florida, California, New York, Texas, Georgia, Pennsylvania, North Carolina, Illinois, Maryland and New Jersey.5

The New Paradigm

A confluence of developments over the past several years has presented an opportunity to finally end AIDS in America. These developments include: Treatment as Prevention: A landmark 2011 clinical trial found that individuals who had HIV in their bodies reduced to undetectable levels by antiretroviral medications (viral suppression) were 96% less likely to transmit the virus.7 The study showed convincingly that HIV medications not only can treat existing HIV infection, but also can prevent future transmissions.8 In addition, in 2014 the PARTNER Study, a two-year study looking at 1,110 couples having condomless sex at least some of the time, reported no incidence of HIV transmission by partners with an undetectable viral load.9 Pre-Exposure Prophylaxis (PrEP): PrEP is a biomedical prevention strategy in which people who do not have HIV (but who are at risk because of sexual behaviors or injection drug use) take a daily dose of medication to reduce their risk of becoming infected. When used consistently, PrEP is shown to significantly decrease infection risk.10

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THANK YOU TO OUR SPONSORS: amfAR + AIDS Project Los Angeles + Bristol-Myers Squibb + Campaign to End AIDS + CommunityEducationGroup.org + fhi360 + Human Rights Campaign Foundation + International Association of Providers of AIDS Care + Legacy Community Health Services + National Minority AIDS Council + Pozitively Healthy

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100

CDC, PERCENT ENGAGED IN STAGES OF CARE

82% 66%
United States, 2010

percent of all people with hiv

80 60 40 20 0

37%

33%

25%

diagnosed

linked to care

retained in care

prescribed art

virally suppressed

HIV Care Continuum (Treatment Cascade): The HIV treatment cascade shows, in graphic form, how many people living with HIV are involved with the spectrum of care. The cascade begins with testing and diagnosis of HIV, and moves through linkage to care, retention in care, receiving antiretroviral therapy (ART) and maintaining an undetectable viral load. The treatment cascade helps identify when people fall out of care and can be used to target resources to close any gaps in care.11 Health Reform: Implementation of the Affordable Care Act (ACA) offers unprecedented opportunities to improve access to health insurance for people living with HIV, nearly 30% of whom have historically been uninsured.12 The end of pre-existing condition exclusions, the availability of subsidies for marketplace policies and the expansion of Medicaid (in some states) all increase the availability of coverage. For this coverage to be effective for people living with HIV, however, it must include the range of treatments needed by people living with HIV, and it must be affordable. National HIV/AIDS Strategy (NHAS): Released in 2010, the first-ever U.S. national strategy includes three main goals: 1) reduce new HIV infections, 2) increase access to care and improve health outcomes for people living with

HIV, and 3) reduce HIV-related health disparities.13 Since then, many federal agencies have incorporated NHAS goals into their program priorities, and there has been an emphasis on increased coordination among federal agencies to support achieving those goals. Ongoing implementation of the NHAS includes a priority for addressing gaps in the HIV care continuum.

Challenges
Despite significant advances, a number of equally significant challenges remain as we work to end AIDS in America. As indicated in the HIV treatment cascade (see chart, Percent Engaged in Stages of Care), an estimated 18% of people living with HIV do not know that they are HIV positive. Of those who are aware that they are living with HIV, 66% are initially linked to care, but only 37% stay engaged in regular care. Despite the efficacy of recent HIV medications, three out of four people are not currently virally suppressed, an important factor in both preserving individual health and preventing new infections. Clearly, we must do more to close the gaps identified in the care continuum. Other challenges arise from persistent HIV-related stigma and HIVs disproportionate impact on low-income and historically underserved communities. There is a shortage of

APRIL 2829, 2014

THANK YOU TO OUR SPONSORS: amfAR + AIDS Project Los Angeles + Bristol-Myers Squibb + Campaign to End AIDS + CommunityEducationGroup.org + fhi360 + Human Rights Campaign Foundation + International Association of Providers of AIDS Care + Legacy Community Health Services + National Minority AIDS Council + Pozitively Healthy

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affordable, safe housinga critical factor in adhering to treatment and preserving health for people living with HIV and preventing further transmissions. People living with HIV experience much higher levels of unemployment than the general population, leading to more poverty and lack of access to other resources and services. Even for HIV-positive individuals in good health, HIV-related discrimination and stigma pose barriers to obtaining employment and accessing care. Stigma also underlies the many criminal laws targeting HIV-positive individuals. Currently, 33 states have HIV-specific criminal laws.14 These laws criminalize exposure to HIV (often regardless of intent or actual transmission), include behaviors not known to transmit HIV (such as spitting or biting), and provide for heightened penalties if an individual is HIV positive. These laws ignore scientific knowledge about HIV and actually undermine public health by discouraging people from learning their HIV status (knowledge of status is typically required as an element of the crime). They single out people based on HIV status, which further perpetuates stigma.15 HIV-specific criminal laws also are superfluous, as every state has general criminal laws under which the behavior targeted by HIV-specific laws could be prosecuted.14

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recent years,3 in large part due to harm reduction intervention models, substance use remains problematic and can increase sexual risk-taking behaviors. In addition to direct physical and emotional harm, people experiencing intimate partner violence may be at heightened risk of contracting HIV, as they may not be able to take steps to protect themselves (for example, by using condoms) without prompting further abuse.

Conclusion
We have reached an unprecedented crossroads in the HIV epidemic in the United States where the possibility of ending AIDS is in sight. While significant challenges remain, they are surmountable with a coordinated, thoughtful and dedicated responseone that is grounded in science and human rights. More than three decades into the epidemic, it is time to summon the resources and political will to create an AIDSfree nation.

1 Centers for Disease Control and Prevention (CDC). CDC features: world AIDS day. November 27, 2013.

www.cdc.gov/features/worldaidsday/

Addressing the Roots of the HIV Epidemic

We have long known that while HIV is an individual and public health issue, the HIV epidemic in the United States is also driven by deeply entrenched and interwoven social and economic inequities. Any response to HIV that hopes to end the epidemic must address these inequities. One major factor is poverty, as research indicates people living below the federal poverty level are twice as likely to be HIV positive.2 Living in poverty limits access to a range of resources needed to maintain health (such as safe housing, healthy food, medications and medical care) and may drive people to behaviors that increase risk of HIV infection (for example, trading sex for food or money). Racial, ethnic and sexual identity minorities continue to experience the discrimination and stigma that can deter people from engaging with HIV testing, treatment and prevention efforts. High incarceration rates for racial and ethnic minority men, particularly African-Americans, can destabilize communities and perpetuate cycles of poverty and violence. While new HIV infections in injecting drug users have decreased in

2 CDC. Todays HIV/AIDS epidemic. December 2013.

www.cdc.gov/nchhstp/newsroom/docs/HIVFactSheets/TodaysEpidemic-508.pdf
3 Kaiser Family Foundation (KFF). Fact Sheet: The HIV/AIDS epidemic in the United States. March 2013.

http://kff.org/hivaids/fact-sheet/the-hivaids-epidemic-in-the-united-states/
4 KFF. Fact sheet: black Americans and HIV/AIDS. March 2013,

http://kff.org/hivaids/fact-sheet/black-americans-and-hiv-aids/

5 CDC. HIV cost-effectiveness. April 2013. www.cdc.gov/hiv/prevention/ongoing/costeffectiveness/ 6 KFF. Fact sheet: Medicaid and HIV/AIDS. March 2013. http://kff.org/hivaids/fact-sheet/medicaid-and-hivaids/ 7 Cohen MS, et al. Prevention of HIV-1 infection with early antiretroviral therapy. N Engl J Med. August 11,

2011. www.nejm.org/doi/full/10.1056/NEJMoa1105243

8 National Institutes of Health (NIH). HIV study named 2011 breakthrough of the year by Science. December

22, 2011. www.nih.gov/news/health/dec2011/niaid-22.htm

9 Rodger A, et al. HIV transmission risk through condomless sex if HIV+ partner on suppressive ART: PARTNER

study. 21st Conference on Retroviruses and Opportunistic Infections, Boston, 2014. Abstract 153LB.

10 CDC. Pre-exposure prophylaxis: questions and answers. www.cdc.gov/hiv/prevention/research/prep/ 11 CDC. Fact sheet: HIV in the United States: the stages of care. July 2012.

www.cdc.gov/nchhstp/newsroom/docs/HIV-Stages-of-Care-Factsheet-508.pdf
12 CDC. The affordable care act helps people living with HIV/AIDS. April 2013.

www.cdc.gov/hiv/policies/aca.html

13 Office of National AIDS Policy. National HIV/AIDS Strategy. July 2010.

www.whitehouse.gov/administration/eop/onap/nhas

14 CDC. HIV-specific criminal laws. July 2013. www.cdc.gov/hiv/policies/law/states/exposure.html 15 The Center for HIV Law and Policy. Positive justice project: HIV criminalization fact sheet. (n.d.)

www.hivlawandpolicy.org/resources/positive-justice-project-hiv-criminalization-fact-sheet

APRIL 2829, 2014

THANK YOU TO OUR SPONSORS: amfAR + AIDS Project Los Angeles + Bristol-Myers Squibb + Campaign to End AIDS + CommunityEducationGroup.org + fhi360 + Human Rights Campaign Foundation + International Association of Providers of AIDS Care + Legacy Community Health Services + National Minority AIDS Council + Pozitively Healthy