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Who in America continues to acquire HIV? While medication plays a crucial role, addressing disparities is essential to ensuring that care reaches those who require it the most.

As the world observes another World AIDS Day on December 1, it is crucial to recognize the substantial progress achieved in the global fight against HIV and acknowledge the ongoing challenges. While the United States has witnessed a gradual decrease in overall new HIV infections from 2017 to 2021, a closer examination of the data reveals persistent disparities primarily affecting LGBTQ individuals and communities of color.

As a social epidemiologist and a proud gay Latino, I am personally and professionally invested in understanding and addressing the HIV disparities faced by my communities. It is disheartening to realize that, despite the availability of medical advancements capable of ending the AIDS epidemic, these resources are not reaching those who need them the most.

The HIV prevention arsenal has evolved over the years. Initially, in the 1980s, condoms and behavioral changes were the primary prevention strategies. However, the development of effective medications has allowed individuals to live with HIV. The concept of “treatment as prevention” emerged in the 1990s, emphasizing that individuals with a reduced viral load from antiviral therapy are less likely to transmit the virus. In recent years, the message has shifted to “undetectable = untransmittable” (U=U) after a landmark study concluded that virally suppressed individuals are unable to transmit the virus to their sexual partners.

In 2005, non-occupational postexposure prophylaxis (nPEP) was introduced to prevent infection in those exposed to HIV. The approval of preexposure prophylaxis (PrEP) in 2012 provided a daily antiviral therapy for individuals not yet exposed to HIV. In 2021, the FDA approved a long-acting, injectable form of PrEP as an alternative to daily pills.

Despite these advancements, many preventive options are not reaching their intended recipients. In the U.S., of the estimated 1.2 million people eligible for PrEP, only 30% received a prescription in 2021.

Racial disparities persist, with gay and bisexual men representing two-thirds of new HIV infections. White men exhibit higher rates of condomless anal sex compared to Black and Latino men. Between 2015 and 2019, white gay and bisexual men experienced a 17% decrease in HIV cases, while Black and Latino counterparts saw no significant reductions, likely attributed to disparities in access to HIV prevention medication. Only a little over 40% of those HIV negative had used PrEP in the past 12 months, with white men reporting higher usage than Black and Latino men. Among HIV-positive individuals, 95% were actively using antiviral therapy, showing little variation by race.

Factors such as stigma, limited healthcare access, mistrust in the healthcare system, socioeconomic status, and cultural nuances restricting PrEP access likely contribute to the enduring HIV burden faced by Black and Latino men, transgender individuals, and those experiencing homelessness.

Closing the gap in PrEP access necessitates addressing these challenges. A recent systematic review of 42 interventions aimed at promoting PrEP among gay and bisexual men in the U.S. identified the most promising strategies as those targeting social and environmental factors hindering access and adherence.

Effectively addressing access barriers at both community and healthcare levels can bolster public health initiatives, facilitating the expansion of PrEP access. This involves confronting issues like stigma and medical mistrust, particularly among Black and Latino gay and bisexual men, thereby diminishing racial disparities in HIV infections.

It’s crucial to recognize that, while HIV disproportionately affects specific groups, individuals engaging in heterosexual activities are still at risk and must be included in the broader HIV prevention efforts.

World AIDS Day serves as a poignant reminder that the battle against HIV is a global undertaking requiring a nuanced understanding of the distinct challenges faced by various communities. By addressing disparities and tailoring interventions, we can move closer to a world where HIV is no longer a pervasive threat.

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