Ending HIV in the USA: integrating social determinants of health – Authors' reply

In their response to our call to action¹ in the Lancet Series on HIV in the USA, Courtenay Sprague and Sara E Simon argue that biomedical solutions alone have failed, and will continue to fail, to control the HIV epidemic in the USA and that policy must include efforts to address the social determinants of health. We concur, and believe that the Series on HIV in the USA highlights these important concerns.² Sprague and Simon note that the health disparities and structural barriers that have characterised the US health-care system since its inception, which we reviewed in the Series as correlates of HIV prevalence and incidence,¹ have also been drivers of poor outcomes in the COVID-19 response. We would add that although the COVID-19 vaccines represent remarkable achievements in biomedical sciences, the uneven roll-out via the patchwork of US public-health systems swiftly revealed that unaddressed social determinants can undermine even the most efficacious interventions,³ as is true with high-efficacy HIV preventive tools like antiretroviral pre-exposure prophylaxis (PrEP). These drugs offer virtually complete protection if taken as prescribed for men who have sex with men (MSM) and other populations at risk, yet PrEP uptake, adherence, and use are lower among US MSM and women in minority racial and ethnic groups, in south USA, among people with lower-level incomes, and in circumstances in which social determinants (eg, poverty, unstable housing, anti-gay stigma, anti-Black racism, and policies limiting health insurance coverage) undermine the effectiveness of this intervention.⁴

How likely is it that social determinants of health will be addressed by the Biden–Harris administration? There are reasons for optimism. The administration has committed to expanding the Affordable Care Act to increase health insurance coverage for currently uninsured and underinsured Americans.⁵ Although health insurance alone will not solve the social determinants of health, in our current system, it is an essential step in accessing health-care services and in addressing Sustainable Development Goal 3: to ensure healthy lives and promote wellbeing for all at all ages. Addressing HIV in the USA will require addressing one key social determinant of health: racism within our health-care systems and, more broadly, within our society. The USA is undergoing a historic and long overdue reckoning with the structural realities of anti-Black racism that maintain poverty, segregation, and injustice. Our Lancet Series showed that the increasing burden in HIV among Black and Latinx Americans in southern USA was substantially driven by persistent social and structural determinants that must be addressed to improve health outcomes and the broader goal of human wellbeing and flourishing.

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We declare no competing interests. Support for this Correspondence and the Lancet Series on HIV in the USA was provided in part by the Foundation for AIDS Research, the US National Institute on Drug Abuse, the Center for AIDS Research (grant number P30AI094189) at Johns Hopkins University, Emory University, Harvard University, and the University of North Carolina, and the Desmond M Tutu Professorship in Public Health and Human Rights at Johns Hopkins University.