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