Editor’s Note: Vincent Guilamo-Ramos is dean of the Duke University School of Nursing. As a nurse practitioner, she specializes in preventing HIV/AIDS and sexually transmitted infections and improving the lives of sexual minorities and other youth receiving HIV prevention and treatment. He is a member of the HIV/AIDS President’s Advisory Council of the Department of Health and Human Services. The views expressed in this comment are his own. View more opinions on CNN.
The long fight to end HIV/AIDS has seen real progress fueled by innovative research, prevention, treatment and education. But our country’s ambitious goal of ending the HIV epidemic by 2030 is still at stake.
This World AIDS Day, we must be honest with ourselves: We are not moving fast enough and we will fall short if we do not make significant changes in the way we deal with the epidemic.
Our slow progress is not because we don’t have the tools. This is because we haven’t used the tools to reach the people who need them most.
Take, for example, my 25-year-old patient, Manny, who immigrated from the Dominican Republic and lives in a neighborhood with high HIV rates and low access to prevention and treatment. As a man who has sex with men (MSM), Manny should have been offered PrEP, a breakthrough drug that effectively prevents HIV infections and was released in 2012. He has no insurance and felt an internalized shame about being gay. Manny only visited the health department when he developed a high fever and rash that covered most of his body. HIV test was positive.
Manny’s story is not out of the ordinary and highlights the health care access, policy and environmental challenges that threaten our ability to end HIV/AIDS and create a system that leaves many people behind.
Data from the U.S. Centers for Disease Control and Prevention estimate that 34,800 Americans contracted HIV in 2019. That’s a cumulative decline of just 12% over the previous nine years. And it’s far below the pace needed to reach the goal of ending the epidemic by 2030.
The same data reveal an opportunity to change our strategy for greater impact. Between 2010 and 2019, annual new HIV infections among Black MSMs decreased by 1% and White MSM by 32%. But over the same period, new cases increased by 16% among Latino ECEs. This fact reflects a stark disparity: Many people still get HIV and do not have to.
Tools and resources are available to address this disparity. We must use them differently. Here’s how:
In neighborhoods like Manny’s, the virus can spread at a much higher rate than in communities with adequate access to prevention and treatment services. Many states now have regulatory restrictions that prevent key members of the HIV care team (such as general nurses, physician assistants, and pharmacists) from independently providing full-scale prevention and treatment, consistent with their education and licensing. For example, nurse practitioners in Maryland may prescribe PrEP independently, while nurse practitioners just across the border in Pennsylvania need a joint practice agreement designed to formalize oversight by a physician to provide the same service.
This creates unnecessary barriers to optimally scaling care for millions of Americans, including the 1.2 million people living with HIV. But, for example, if GPs were allowed to practice at the highest level of their education and license, independently of doctors in all states, including HIV care teams, we could reduce the number of people living in counties with primary health care shortages by 70 percent. % according to 2018 UnitedHealth report. We must encourage state legislatures to remove such harmful state-level regulatory restrictions.
Access to PrEP is not universal, as Manny’s case shows. For many, PrEP may not be available in their community, there may be few healthcare providers experienced in managing PrEP, and government-sponsored pay programs may not be available to cover PrEP costs.
For example, while free PrEP coverage is mandated by the Affordable Care Act, a federal court in Texas ruled in favor of a business called Braidwood Management, which refused to offer PrEP coverage, leaving employees at risk and underinsured.
HIV risk is influenced by the social context in which a person lives, has sex, and engages in relationships. To this end, at the Duke University School of Nursing, we use a research-based tool to help providers, educators, researchers, and policymakers refocus on the social determinants of health that affect HIV exposure and susceptibility.
Our framework allows them to consider the unjust social processes and strength-based resilience factors that prepare people and communities to thrive despite structural challenges. This makes it easier for practitioners to think about the dynamic, multi-level mechanisms involved so they can design more effective programs with faster results. We should use tools like this around the country to tailor our interventions to root causes and make sense of people’s daily lives.
Manny’s case illustrates how deep and complex feelings about homosexuality and HIV are, preventing many people from seeking the help they need to stay HIV negative or live a healthy and safe life with the disease. Our society continues to marginalize MSM and people who inject drugs, are at financial risk, or live with HIV.
Braidwood Management declined to offer PrEP coverage because it “facilitates and encourages homosexual behavior, prostitution, promiscuity, and intravenous drug use.” We must confront deeply rooted beliefs like these that affect decision making and care patterns.
The high and stagnant number of new infections should not be our reality during the decades of the HIV epidemic. And it doesn’t have to be. We can double over 40 years of tackling HIV and continue to take decisive and sustained action, driven by data and science, to expand HIV prevention, treatment and the reach of professionals. we have the information. We have vehicles. We have the resources. Now the question is, do we have the will?