The Broader Context of “Ending the HIV Epidemic: A Plan for America” Initiative

Despite tremendous progress in addressing HIV, the epidemic remains stubbornly persistent in the United States, which lags behind its peers on key HIV-related measures (https://bit.ly/30LiQOP). The “Ending the HIV Epidemic: A Plan for America” (EHE) initiative is the Trump administration’s response to this situation (https://bit.ly/2DW9Deb). In launching the EHE in 2019, federal officials identified the hardest-hit areas, as measured by new HIV diagnoses, for a targeted effort in 50 local jurisdictions as well as seven states with substantial rural HIV burden. To assess progress, the government will use standard HIV-specific indicators, including HIV incidence, viral suppression, and preexposure prophylaxis (PrEP) coverage. Integral to the success of the EHE, however, are numerous other contextual and structural factors that could facilitate or mitigate progress.

We identify key additional factors, categorized in the following areas: policy and legal, socioeconomic, service availability, and overlapping epidemics (Table 1). Such factors are important for assessing the initial environment from which the EHE will operate, informing its implementation, and monitoring progress over time.

TABLE 1—

Contextual and Structural Factors Affecting the Implementation and Reach of the “Ending the HIV Epidemic: A Plan for America” (EHE) Initiative

Additional EHE Indicators	National	EHE Local Jurisdictions (50)	EHE States (7)
Policy and legal factors, no. of states/jurisdictions with the following policies
Medicaid expansion (2019)	38	32	2
Medicaid work requirements: pending and approved (2019)	13	7	4a
HIV criminalization laws in place (2019)	39	42	7
State health insurance protections by
Gender identity and sexual orientation (2018)	14	17	0
Gender identity only (2018)	2	2	0
Syringe exchange not permitted by state law (2019)	12	5b	6
Socioeconomic factors, %
Poverty rate (2017)	14.6	16.4	17.3
No. above national average	NA	33	6
Range	NA	7.0–42.0	14.6–21.5
Unemployment rate (2018)	3.9	3.8	4.0
No. above national average	NA	26	3
Range	NA	2.4–6.2	3.2–4.8
Share uninsured, aged < 65 y (2017)	12.2	14.4	13.2
No. above national average	NA	30	1
Range	NA	4.5–24.3	9.2–17.3
Service availability, no. of sites
Ryan White clinics (2018)	1 037	447	112
Community health centers (2018)	11 566	2 853	1 421
Total substance abuse facilities (2019)	12 987	2 875	1 200
Licensed buprenorphine providers (2019)	72 445	22 085	5 858
Total syringe services programs (2019)	334	73	19
Title X family planning clinics (2019)	3 997	751	649
Overlapping epidemics
HCV prevalence per 100 000 (2016)	930	NA	1 077
Sexually transmitted infections
Gonorrhea rates per 100 000 (2017)	171	247	231
Congenital syphilis rates per 100 000 (2017)	23	39	12
Chlamydia rates per 100 000 (2017)	525	675	574
Counties at risk for HIV or HCV outbreak among people who inject drugs (2018)	220	0	76

Note. NA = not applicable. EHE local jurisdictions include 48 counties, the District of Columbia, and San Juan, Puerto Rico.

Source. amfAR. “Ending the HIV Epidemic” database. Available at: http://ehe.amfar.org. Accessed August 29, 2019; Frederiksen et al.¹; Kaiser Family Foundation. State Health Facts database. Available at: https://www.kff.org/statedata. Accessed August 29, 2019; US Census Bureau. American Fact Finder. 2017. Available at: https://factfinder.census.gov. Accessed August 29, 2019.

^aAdditionally, in March 2019, a federal judge struck down work or blocked requirements in two other EHE states.

^bEHE jurisdictions in Arizona and Pennsylvania are located in areas with locally permissible syringe programs and are not included in this tally.

POLICY AND LEGAL FACTORS

Policy and legal factors directly affect the availability and accessibility of health services, including those for HIV treatment and prevention. For example, in states that have expanded their Medicaid programs under The Patient Protection and Affordable Care Act (Pub L No. 111-148, 124 Stat. 855 [March 2010]; ACA), people with and at risk for HIV will be more likely to have insurance coverage and therefore access to needed interventions.² Similarly, those at risk for HIV in states that have legalized syringe services programs will have a greater opportunity to prevent HIV acquisition compared with those in states that have not legalized syringe services programs (https://bit.ly/2OkEmaH). As shown in Table 1, 32 of the 50 local EHE jurisdictions are in states that have expanded Medicaid, and two of the seven states with rural HIV epidemics also have expanded Medicaid. (All data presented herein are based on our analysis of data from the Kaiser Family Foundation’s State Health Facts database [available at: https://www.kff.org/statedata] and amfAR’s, The Foundation for AIDS Research, “Ending the HIV Epidemic” database [available at: http://ehe.amfar.org], unless otherwise noted.) In addition, although almost all (45 of 50) EHE local jurisdictions are in states that have legalized syringe exchange, only one of the seven EHE states has legalized syringe exchange.

Other policy and legal factors that are important to consider include whether a state has instituted Medicaid work requirements; has criminalized HIV; or provides legal nondiscrimination protections based on sexual orientation and gender identity in health insurance beyond those provided by the ACA.

SOCIOECONOMIC FACTORS

Socioeconomic factors, such as poverty, unemployment, and uninsurance rates, affect an individual’s ability to access needed services and complicate their risk for HIV. Studies have found, for example, that such factors were associated with increased sexual risk taking,³ suboptimal engagement in HIV care,⁴ and increased HIV incidence.⁵ Conversely, having health insurance is associated with greater access to PrEP among those at risk for HIV⁶ and higher rates of durable viral suppression among those with HIV.⁴ As such, these factors provide critical information for implementation of the EHE initiative. Jurisdictions with similar HIV rates but different levels of poverty or uninsurance may require different levels of investment or different types of intervention.

As shown in Table 1, 30 EHE local jurisdictions had uninsurance rates greater than the national average (12.2%), ranging from a low of 4.5% to a high of 24.3%. Similarly, 33 local jurisdictions had poverty rates greater than the national average (14.6%), ranging from a low of 7.0% to a high of 42.0%.

SERVICE AVAILABILITY

Service availability is key to supporting and increasing uptake of HIV treatment and prevention services, as planned under EHE. Ryan White clinics and health centers, in particular, are central to the administration’s plans to retain patients on treatment and deliver PrEP. Other service sites are also important, including HIV testing, Title X–supported family planning, substance use treatment, and syringe services sites.

Just under half of the nation’s Ryan White clinics (447 of 1037) are located in EHE local jurisdictions, and 112 are in the 7 EHE states. About a quarter of community health center sites (2853 of 11 566) are in EHE local jurisdictions, and 1421 are in the seven states. Of the 3997 Title X–funded family planning clinics, 751 are located in EHE local jurisdictions, and 649 are in the seven EHE states.¹ However, the number of Title X sites is expected to shrink significantly, with more than 900 withdrawing from the program because of new federal rules concerning abortion, including 225 in EHE states or jurisdictions.¹

OVERLAPPING EPIDEMICS

Addressing the domestic HIV epidemic requires grappling with multiple overlapping epidemics of other sexually transmitted infections, HCV, and opioid use. Without doing so, progress in addressing HIV could be stalled at best. The EHE jurisdictions, on average, have high rates of these other epidemics. As shown in Table 1, for example, the rate of confirmed gonorrhea diagnoses in the 50 EHE local jurisdictions is 247 per 100 000 compared with a national rate of 171. Of the 220 counties identified by the Centers for Disease Control and Prevention as most at risk for an HCV or HIV outbreak in the context of the opioid epidemic, none are EHE local jurisdictions, but 76 are in the seven EHE states.

CONCLUSIONS

The EHE-targeted areas represent a diverse set of geographies that, in addition to being hard hit by HIV, face other barriers and challenges that could affect the implementation and reach of the initiative. These go beyond the standard HIV-specific measures the government will use to assess the EHE yet are integral to its success. In addition to the factors discussed here, broader issues that are not easily measurable at the state and local levels stand to affect efforts to curtail the HIV epidemic. These issues range from uncertainty about the future of the ACA (and implications for insurance coverage and access), to pressures affecting drug pricing, to the ongoing challenges of deeply ingrained stigma and discrimination. Understanding this additional context will be important for policymakers and others to consider as the EHE is implemented and assessed over the coming years.