Ending the HIV Epidemic in the United States

In 2013, the number of new, annual U.S. HIV cases—which had been decreasing steadily—began to level off, bringing to a halt years of progress in eliminating the disease.¹ Moreover, an estimated 15% of Americans currently living with HIV are unaware of their status,² and thus don’t receive the care and treatment they need. In response, the U.S. Department of Health and Human Services (HHS) has proposed an initiative—Ending the HIV Epidemic: A Plan for America—to end HIV in the United States by 2030. Its goal is to reduce new infections by 75% within five years and by 90% within 10 years.³ It combines the successful programs, resources, and infrastructure of multiple HHS agencies, including the Centers for Disease Control and Prevention (CDC).³

The HHS initiative will initially focus on regions where the majority of new HIV diagnoses have been reported (48 U.S. counties; Washington, DC; and San Juan, Puerto Rico) and the seven U.S. states (Alabama, Arkansas, Kentucky, Mississippi, Missouri, Oklahoma, South Carolina) with substantial rural HIV burden (see Figure 1).⁴ The CDC will coordinate efforts to expand key HIV prevention strategies in these geographic areas. While specific action plans will vary based on each community’s needs, the CDC will focus on the initiative’s four key strategies: diagnose, treat, prevent, and respond (see Figure 2).

Figure 1.

A map of the U.S. regions where half of new HIV cases were diagnosed in 2016-17, plus the seven states that had substantial rural HIV burden in that same period. Images courtesy of the Centers for Disease Control and Prevention.

Figure 2.

The HHS’s Ending the HIV Epidemic initiative includes four key strategies—diagnose, treat, prevent, and respond.

Because 40% of new HIV infections are transmitted by people who don’t know their status, expanding testing is a crucial step in reducing HIV⁵ The CDC recommends that everyone 13 to 64 years of age be tested for HIV at least once, and those at high risk be tested at least yearly. People likely to be at high risk include injection drug users and their sex partners, sex workers, sex partners of HIV-infected persons, and men who have sex with men or heterosexual men or women who have had (or whose sex partners have had) more than one sex partner since their last HIV test.⁶ People with or without HIV who have ulcerative sexually transmitted infections are also at increased risk for acquiring or transmitting HIV infection.⁷

In March 2019, the CDC released two reports— “Vital Signs: Ending the HIV Epidemic” and “Vital Signs: HIV Transmission Along the Continuum of Care–United States, 2016”—highlighting what health care providers, people with HIV, and communities can do to prevent new HIV infections and end the epidemic.^{2, 4} Both reports emphasize that immediate and effective treatment with antiretroviral therapy (ART) is key to ending HIV. Recommended for all people with HIV, ART has transformed a disease once associated with early death into a chronic condition.⁸ It also prevents HIV transmission.⁸ Taking ART as prescribed can lower a person’s viral load, which is referred to as viral suppression or having an undetectable viral load (less than 200 copies/mL).⁸ People with HIV whose viral load remains low or undetectable live longer and healthier lives, yet only half of people with HIV maintain viral suppression.⁴ The CDC estimates that 43% of new HIV infections are transmitted by people who know they have HIV but are not receiving care, and another 20% are transmitted by people who are in care but are not virally suppressed.²

For people who are HIV negative, strategies such as practicing sexual abstinence, limiting the number of sex partners, never sharing needles, and correct and consistent condom use will help prevent acquisition of HIV. People who are at high risk can take pre-exposure prophylaxis (PrEP), a daily pill that reduces their chances of acquiring HIV, and people who have been exposed to HIV can take postexposure prophylaxis (PEP), which consists of 28 days of ART and reduces the risk of infection if started no more than three days after exposure.⁹ Having an undetectable viral load is now a proven prevention strategy. People who are treated with ART and maintain viral suppression have no risk of transmitting HIV to others.¹⁰

Nurses are in a prime position to improve HIV patients’ engagement with care. Nurses should advocate for the initiation of treatment without delay in those who are newly diagnosed and provide resources and support to help them remain in care. Nurses are also invaluable in helping to counteract the stigma associated with HIV, and in creating environments in which all people, no matter their cultural background or risk profile, feel welcome to take advantage of prevention and treatment services.

The CDC’s HIV prevention web page (www.cdc.gov/hiv) provides a variety of resources to assist nurses and other providers in educating patients on HIV, as well as guidelines and recommendations for prevention, testing, clinical care, treatment, and counseling services. The CDC also provides HIV training courses, either online or in person, to aid clinicians in gaining a better understanding of holistic care and the treatment of people with HIV. Additionally, the CDC offers a free web content syndication service (www.cdc.gov/hiv/library/syndicated/index.html) that gives HIV care providers and public health partners (state and local organizations that work in HIV prevention) shareable content in real time. This allows partners to add cdc.gov content directly to their own websites.

HIV care providers at all levels need to be ready to respond to the demands created during this initial phase of the HHS Ending the HIV Epidemic initiative. Calling the CDC’s hotline at (800) CDC-INFO or (800) 232-4636 (or [888] 232-6348 TTY) are reliable ways for nurses and others to obtain answers about HIV-related clinical practice and treatment guidelines.