Opinion

VIEWPOINT
HIV in the United States
Getting to Zero Transmissions by 2030
Ingrid Katz, MD, MHS It has been nearly 4 decades since the Centers for Dis- First, prevention is the first step toward halting
Harvard Global Health ease Control and Prevention reported a rare lung infec- transmission. A key element of prevention is preexpo-
Institute, Cambridge, tion among 5 previously healthy young men in sure prophylaxis (PrEP), which is highly effective in pre-
Massachusetts; and
Los Angeles—what would be the first recorded cases of venting HIV if taken daily. However, many people at risk
Harvard Medical
School, Cambridge, Pneumocystis carinii pneumonia in men who were dis- of HIV encounter challenges in consistently taking daily
Massachusetts. covered to have human immunodeficiency virus (HIV) PrEP. The development of long-acting PrEP, which may
be taken monthly or yearly instead, could be revolu-
infection. Since the first cases of AIDS were identified in
Ashish K. Jha, MD, the United States, the number of people with HIV in the tionary in promoting adherence to the medication.
MPH
United States has reached an estimated 1.2 million, with In addition to finding longer-acting medicines, the
Harvard Global Health
Institute, Cambridge, nearly 40 000 people receiving a new diagnosis in 2017 administration will need to address the costs of PrEP
Massachusetts; and alone.1 This infection, which was initially nearly uni- therapy, which can be as much as $2000 a month.6
Harvard School of formly fatal, has become a chronic disease largely be- Even though the medication is covered by most insur-
Public Health,
Cambridge, cause of the scientific breakthrough of a new group of ance plans, co-payments can still be exorbitant, and for
Massachusetts. medications, known as highly active antiretroviral those without insurance, PrEP can be prohibitively
therapy (HAART), which has helped to control the epi- expensive. Although some state programs offer assis-
demic in the United States and globally. Despite this piv-
tance to cover the costs of these medicines, high-risk
otal advancement, only 60% of the people living with populations report financial factors as a major barrier to
HIV in the United States have achieved viral suppression.1
PrEP.7 Beyond cost, PrEP needs to be far more easily
accessible. For example, PrEP currently requires a pre-
Additionally, the financial costs of HIV are substantial, es-
pecially for the federal government, which spent an es- scription to obtain, which can be a barrier because
timated $20 billion on HIV care and treatment in fiscal many physicians require patients to make clinical visits
year 2016 alone.2 Even though the human and financial before they will dispense a prescription. The US Food
and Drug Administration should con-
sider and test the efficacy and safety of
allowing PrEP to be made available over
Even though the burdens of HIV remain
the counter. Beyond PrEP, ongoing
substantial, it is now possible to end efforts to promote effective, evidence-
transmission of the virus and control based prevention tools should include
condoms, male circumcision, and mak-
the epidemic in the United States ing postexposure prophylaxis widely
within the next 10 years. available to individuals who are unin-
tentionally exposed to HIV.
burdens of HIV remain substantial, it is now possible to Second, while PrEP and other forms of preven-
end transmission of the virus and control the epidemic tion should be a cornerstone in a national strategy to
in the United States within the next 10 years. prevent HIV, it will not be enough to curb the epi-
In the State of the Union address on February 5, demic. Beyond prevention, an effective national strat-
2019, President Donald Trump announced a national egy will need to ensure that those living with HIV
commitment to end the spread of HIV in the United maintain long-term viral suppression. Clear scientific
States by the year 2030.3 This announcement reflects evidence indicates that those whose viral loads are
extensive work by officials in the Department of undetectable rarely transmit the virus to others. 8
Health and Human Services and the National Insti- Despite evidence that viral suppression leads to sub-
tutes of Health and is focused on targeting resources stantially healthier lives and low risk of transmission,
to the 48 counties in the United States with the high- challenges across the care continuum have prevented
est burden of HIV to ensure a 90% reduction of new achieving widespread viral suppression. One factor is
infections in the next 10 years.4 Prevention and treat- consistent attrition in care: an estimated 85% of indi-
ment tools widely available today make this target viduals with HIV have received the diagnosis, 73% of
achievable.5 To make this vision a reality, the adminis- whom have received some HIV care and only 60% of
Corresponding
Author: Ashish K.
tration will have to overcome substantial challenges in whom have achieved viral suppression.1 The result is
Jha, MD, MPH, 3 main areas: preventing HIV in high-risk communi- that among all US residents who likely have HIV, only
Harvard Global Health ties, ensuring that individuals receiving treatment half are achieving true viral suppression. 1 In this
Institute, 42 Church St,
have undetectable viral loads, and addressing the regard, management of long-term HIV is similar to the
Cambridge, MA 02138
(ajha@hsph.harvard. large socioeconomic, racial, and geographic health challenges of diagnosing and treating other chronic
edu). disparities associated with this disease. conditions, like diabetes and hypertension, for which

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 Opinion Viewpoint

nonadherence is high even among individuals who regularly inter-
act with the health system.
In addition to these general challenges, HIV-specific barriers to
adherence, including stigma and discrimination, pose substantial ob-
stacles to accessing and staying in care. A concerted effort to ad-
dress adherence will require a multifaceted approach. This in-
cludes eliminating all co-payments for HIV medications, funding
research on how to improve adherence, and making medicines more
readily available to vulnerable populations. Adherence to long-
term medications is a challenge that affects the entire health care
system, but without seriously addressing this issue for people liv-
ing with HIV, the national goal of zero new cases will not be achieved.
Third, efforts to increase prevention and undetectability will
not sufficiently drive down the epidemic if they fail to focus on
the significant racial, socioeconomic, and geographic disparities
that continue to define the HIV epidemic in the United States.
African Americans, who make up 13% of the US population,
accounted for 43% of new HIV diagnoses in 2017; Latinos, who
make up 18% of the US population, accounted for 26% of new
HIV diagnoses in 2017.1 Many social factors contribute to these
disparities, including economic instability, institutionalized dis-
crimination, and mass incarceration.9 For example, one study
found a dose-response relationship between the level of housing
instability and achievement of viral suppression among people liv-
ing with HIV.10 Removing social safety programs will undermine
the administration’s strategy and will reduce the likelihood of
achieving the goal of the newly announced initiative. Similarly,
any policy that substantially increases the number of uninsured
persons would lead to more difficulty accessing care and make
achieving zero new cases nearly impossible.
The ambitious goal to end the HIV epidemic, like any large-
scale initiative, needs to engage leaders across political parties,
building on the legacy of President George W. Bush’s program, the
President’s Emergency Plan for AIDS Relief (PEPFAR), which has
saved more than 16 million lives worldwide by providing treatment
for individuals living in Africa. The current effort will require federal
agencies to eliminate silos of funding, forgo the proposed cuts in
spending for HIV drugs, and promote access in communities most
severely affected by the virus. It will be essential to have a perma-
nent director of the Office of National AIDS Policy, a long-standing
vacancy that must be filled to move this plan forward. In addition,
the administration will need to more aggressively engage with the
community of people living with HIV and those who directly care
for them.
If the goal of getting to zero transmissions in the United States
is to be achieved, effective interventions for HIV prevention and for
enhancing treatment adherence to achieve and maintain viral sup-
pression, as well as approaches to address disparities in HIV care,
must be used properly. By doing so, it is possible that the 40-year-
old HIV epidemic in the United States can be brought to a close.

ARTICLE INFORMATION
Published Online: March 8, 2019.
doi:10.1001/jama.2019.1817
Conflict of Interest Disclosures: None reported.
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2018;5(3):ofy035. doi:10.1093/ofid/ofy035

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