On National HIV Testing Day 2018, we must acknowledge that we are far from ending the U.S. HIV epidemic and that our progress is uneven and fragile at best. HIV testing is the gateway to both prevention and care, and we continue to fail at providing this essential service to those most in need.
This is outrageous because we finally know how to prevent HIV infections. For those who test negative, pre-exposure prophylaxis with a daily drug offers highly effective prevention. For those diagnosed with HIV, linkage to care and continuous access to HIV medications can lead to a near normal lifespan, eliminate progression to AIDS, and suppress the virus to “undetectable” levels thus eliminating HIV transmission to others.
Last week, Centers for Disease Control and Prevention released data showing no improvement over a decade in the proportion of people ever tested for HIV or the frequency of testing for those with highest risk of HIV exposure. Less than 40 percent of “non-institutionalized” adults had ever received an HIV test.
Fewer than 62 percent of those with higher likelihood of HIV exposure had ever been tested, and in this population the interval between tests did not meet the annual screening goal, with little improvement in frequency of screening throughout the decade.
Nearly 30 percent of men with a male sex partner had never been tested for HIV. Never! How will we end an epidemic that disproportionately affects this population if we are unable even to successfully implement testing?
As an HIV physician, I see the results of delayed testing daily in Atlanta, where too many individuals learn they have HIV only after developing AIDS, sometimes after they become sick enough to be hospitalized.
The South is now the epicenter of the American HIV epidemic, and home to the top ten cities with the highest proportion of people who are diagnosed with HIV only after progressing to the advanced, and avoidable, stage of AIDS.
It is no coincidence that we also have the poorest access to healthcare and the highest rates of uninsured persons in the nation, in addition to a big Southern helping of homo- and transphobia, racism, stigma and discrimination.
While we must improve delivery of testing targeted to our most affected populations, we also must implement routine voluntary HIV testing in healthcare settings.
In 2006, CDC called for all sexually active adults to be offered HIV testing at least once as part of routine care, and for people at higher risk to be offered testing at least yearly. Routine screening requires access to routine medical care. Access to medical care must be expanded if we are to end AIDS, yet it is increasingly under attack.
The Patient Protection and Affordable Care Act, which has provided more than 20 million Americans access to health coverage, is again threatened with repeal and obstructed by rising insurance rates due to repeal of the individual mandate and the introduction of unregulated health plans.
The Centers for Medicare and Medicaid Services encourages work requirements and other eligibility restrictions for those who rely on Medicaid for health coverage. A House funding bill proposes elimination of the Health Resources and Services Administration Family Planning program that provides more than four million individuals with preventive services, including HIV and STI testing and treatment, cancer screenings and well-women exams.
The bill also proposes a $100 million cut to federally qualified health centers (FQHCs) serving low income Americans. Aside from decimating care, these cuts would decrease access to HIV testing and prevention services for millions, fueling a rise in new HIV infections.
Thankfully, the bill rejects the White House proposal to cut funding to the Ryan White HIV/AIDS Program but flat funding ignores the reality that a steadily increasing number of people living with HIV need reliable care to stay healthy and stop transmission of the virus, all the more so in states that did not expand Medicaid. Cuts to Medicare, Medicaid, FQHCs, or the ACA, will further strain clinics already bulging at the seams.
Again in 2016, nearly 40,000 people were newly diagnosed with HIV in the US, with over half occurring in the South, disproportionately among gay and bisexual men of color and transwomen.
Amidst rosy talk about “ending AIDS” and “ending the epidemic,” we cannot allow health systems to be dismantled. We must demand that Congress increase funding and commitments to health at all levels if we truly want to end AIDS.
Melanie Thompson, M.D., is chair of the HIV Medicine Association, and founder and principal investigator of the AIDS Research Consortium of Atlanta (ARCA), a non-profit community-based HIV/AIDS research center. Dr. Thompson is also a private practitioner in Atlanta. ARCA has received research funding from Bristol Myers Squibb, CytoDyn, Gilead Sciences, GlaxoSmithKline, Merck, Sharp & Dohme, Roche Molecular Systems, Taimed and ViiV Hea