HIV & AIDS in America

In 1981, the United States of America became the first country to identify AIDS as a distinct condition. Since then many thousands have become infected, and more than half a million people have died of AIDS in America¹ – the equivalent of the entire population of Las Vegas. There are currently more than one million people living with HIV in America² and around a quarter of these are unaware of their infection,³ posing a high risk of onward transmission.

Yet the USA has no formal AIDS strategy, and thousands of uninsured Americans struggle to access good HIV care and antiretroviral therapy. The world’s biggest donor of AIDS-related funding is itself facing an major, ongoing AIDS epidemic, and the situation grows worse each year.

America’s unequal AIDS epidemic

HIV and AIDS affect all sectors of American society – men and women, young and old, black and white, gay and straight, rich and poor. The impact of AIDS has nevertheless been more serious among some groups than others. In the early years of the epidemic, the most commonly identified ‘vulnerable groups’ in America were men who have sex with men, injecting drug users, haemophiliacs and Haitians.

Today, AIDS continues to infect thousands of gay and bisexual men and injecting drugs users every year, but it has also become a serious problem among heterosexual African Americans, and the Latino population is increasingly affected too. The table below shows how the burden of AIDS among various ethnic groups compares to the percentage of the population that each ethnic group represents. Further statistics can be found on our African American HIV and AIDS statistics page.

Race	% of AIDS diagnoses in 2005	% of population in 2005
White, non-Hispanic	29%	67%
African American	50%	12%
Latino(-a)	19%	14%
Asian/Pacific Islander	1%	4%
American Indian/Alaska Native	1%	1%

Estimated AIDS Diagnoses & U.S. Population by Race/Ethnicity, 2005⁴

New AIDS cases across the US, 2005 (brown = highest concentration, light yellow = lowest)⁵

Discussion of the current epidemic in the black community can be found on our HIV/AIDS and African Americans page.

There are also variations in the geographical distribution of AIDS cases across the USA. Once an epidemic that was concentrated mainly in the gay populations on the East and West coasts, AIDS has also now taken hold within Black and Latino communities in many Southern states. The map on the right shows how AIDS cases were distributed across the US in 2005.

More AIDS statistics for the USA are available in our HIV statistics section.

HIV & AIDS Prevention in America

On a national scale, the main HIV prevention strategy in America is to introduce widespread HIV testing to identify HIV positive people. The Advancing HIV Prevention (AHP) initiative for example advocated voluntary testing in all healthcare facilities, as well as improved ‘partner notification’ services to ensure partners of HIV positive people were made aware of the risk they were at. More recently, the USA has also implemented new testing guidelines that state that all adolescents and adults aged 15 – 64 should be routinely tested for HIV whenever they visit a healthcare facility.⁶

Beyond AHP, the USA has no other national prevention strategy or prevention targets. Prevention initiatives that actively work to prevent people becoming infected tend to be carried out on a state- or city-wide level, either by local authorities, or by HIV support organisations. Such prevention initiatives may concentrate on particular communities or groups of people, or they may be more general in their focus. Independent organisations play a particularly big role in preventing HIV amongst injecting drug users, as it is illegal for federal money (and occasionally state or city money) to be used for needle exchange programmes.

One area where prevention efforts have been successful in the US is the prevention of mother-to-child transmission (PMTCT). Routine HIV testing for pregnant women in many states, and good treatment and care, means that diagnoses of HIV in babies have dropped dramatically since HIV was first discovered in the US.

AIDS cases in the USA, 1981-2005⁷

In other areas, prevention efforts have had less of an effect however, and while combination antiretroviral treatment has helped to dramatically reduce the number of people developing and dying of AIDS in America, overall, around 40,000 continue to be diagnosed with AIDS every year (see the graph). This suggests that HIV infection levels are not declining.

In September 2007, over 100 AIDS organisations joined together to call for the introduction of a National AIDS Strategy that would set out a clear national prevention plan and bring an end to the 40,000 new infections that occur each year.⁸. The campaign targets the candidates for the 2008 presidential election, a number of whom have a particular interest in HIV and AIDS.

“The wealthiest nation in the world is failing its own people in responding to the AIDS epidemic at home. Our country must develop what it asks of other nations it supports in combating AIDS: a comprehensive national strategy to achieve improved and more equitable results." - Rebecca Haag, Executive Director of AIDS Action.⁹

AIDS and sex education in America

The level and type of sex and HIV/AIDS education received by school children and students tends to vary depending on state regulations and the type of school or college a child is attending. In some areas, sex education that incorporates information on HIV is comprehensive and compulsory. In others, it is not, and children may leave school knowing virtually nothing about HIV and AIDS.

In recent years, abstinence-only education, which is backed by President George Bush and teaches children to wait until marriage before having sex, has become particularly popular. However, this form of sex education has proved controversial, as many say it is ineffective and does not adequately teach about sexually transmitted infections and other related issues.¹⁰ Many AIDS and sexual health organisations therefore advocate a more comprehensive approach that includes information about condoms and general discussion of teenage sexual relationships.

AIDS education amongst adults is also used as a prevention tool, particularly in communities where HIV levels are high. Discussion of AIDS in the workplace, or at community meetings and religious gatherings can provide essential information to adults whom might otherwise be unaware they are at risk.

AIDS treatment and care in America

Antiretroviral treatment is available to anyone with good medical insurance in the USA. For those without insurance, or who are underinsured for their condition, there are a number of options available to help them fund treatment, including Medicaid, Medicare, and funding provided by the Ryan White Comprehensive AIDS Resource Emergency (CARE) act¹¹. AVERT has more about AIDS treatment and care in America.

Unfortunately, levels of funding are not always sufficient to provide adequate treatment and care services for an ever-growing HIV positive population. The US AIDS Drug Assistance Programme (ADAP), which aims to provide treatment for the very poorest through Ryan White CARE act funding, is frequently oversubscribed and in some states there have been considerable waiting lists for access to drugs in the past.¹² Those with advanced HIV infection who need newer, more expensive AIDS drugs to keep their condition under control may also face problems with obtaining funding from their insurance company.

This said, ‘expanded access’ trials of new antiretroviral drugs for people who have exhausted their treatment options are regularly held across the USA, extending the lives of many who might otherwise die of AIDS.¹³ This is a legacy of strong activism in the early days of the epidemic that encouraged better and more rapid access to new drugs.

Knowledge, attitudes, stigma and discrimination

While HIV and AIDS today affect more people than ever before, the general attitude towards AIDS has changed markedly. Once a subject that caused considerable panic and hysteria in the media, AIDS in America is comparatively overlooked by the press today. This is in part due to the fact that AIDS never became the generalised epidemic once feared, and also because the introduction of antiretroviral therapy in the mid-1990s signalled the end of AIDS as a condition that was always considered fatal. Better knowledge of transmission routes and risk factors has also helped to calm fears.

The availability of treatment means most Americans are more willing to be tested for HIV than they once were, as there is now a reason for knowing one’s HIV status early. Around 48% of the population now say they have been tested for HIV at least once in their lives.¹⁴

Legislation has also helped to improve life for people living with HIV and AIDS. In 1986, the government made clear to employers that they would be prosecuted if they discriminated against HIV positive people. The Americans with Disabilities Act now makes it illegal to discriminate against someone on the basis of their HIV status.¹⁵

In a 2006 survey, 26% of respondents thought HIV could be caught by kissing, 16% thought sharing a drinking glass was a risk and 10% thought that touching a toilet seat might pass on HIV

Myths, stigma and discrimination do persist however. In a 2006 survey¹⁶, 26% of respondents thought HIV could be caught by kissing, 16% thought sharing a drinking glass was a risk and 10% thought that touching a toilet seat might pass on HIV. Many HIV positive people also find that they are still discriminated against on a day-to-day basis. In 2007, a woman from New York state filed a lawsuit against a summer holiday camp after her 10-year-old son was turned away for having HIV.¹⁷ The case has yet to be resolved.

Discrimination also persists on a national level. Any man that has ever had sex with another man is still banned for life from donating blood for example, despite the fact that modern screening methods can detect HIV with blood within a few days of infection. Protests against this restriction have so far proven unsuccessful, with the US Food and Drug Administration claiming it is still a necessary public health measure.¹⁸

The US also still has a restriction on HIV positive people entering the United States, whether they are on holiday or visiting on a more long-term basis. Those who do not hold an approved medical waiver form (which can be difficult to acquire) risk being barred entry or deported if they test HIV positive, or are found to be carrying AIDS medication. For this reason, major international conferences on HIV and AIDS are virtually never held in the USA, both as a symbol of international protest against the ban, and more practically, because many HIV positive delegates could be refused entry.

Spending on AIDS in the USA and overseas

In the 2007 financial year, US federal funding for HIV and AIDS was estimated to total $23.4 billion. Of this, 56% was for care, 11% for research, 9% for cash and housing assistance, 4% for prevention, and 19% for combating the international epidemic.¹⁹

Though spending on the domestic HIV and AIDS has risen in recent years, many AIDS organisations say it remains inadequate. Cash shortages are particularly severe in Southern states, where the epidemic is newer, and funding has not yet been allocated to reflect the increase in cases. Recent changes to the Ryan White CARE act were designed to address this problem, but have met with strong opposition from those in areas where AIDS is more established, who have suffered cuts in federal funding to pay for improved services in the South.

International spending on AIDS-related projects has increased substantially in recent years. The President’s Emergency Fund for AIDS Relief (PEPFAR), which was set up in 2003, aimed to spend $15 billion over 5 years. By the end of 2008 it will have exceeded this aim. PEPFAR was recently renewed for another 5 years, during which time the US government hopes to spend $30 billion.

AIDS in America: where are we today?

In the early 1980s, AIDS was seen as a disease of gay men and drug users, and as such was often overlooked or marginalised by both politicians and the media, whose prejudicial views sometimes coloured their response to the illness. Very vocal activism by groups such as ACT UP, and the discovery that AIDS could essentially affect anyone helped to change this, bringing greater aid and concern for those living with the virus. Activism also improved research into the illness, and resulted in a significant lowering of costs for many of the earliest HIV and AIDS drugs.

The activism of the 1980s and early 1990s is harder to find in modern-day America. With the introduction of combination therapy in the mid-1990s, HIV very quickly moved from being a fatal to a chronic, controllable condition. As the drugs have improved, so has the outlook for people living with HIV. The general reduction in levels of hysteria and fear surrounding the illness has also meant less prejudice and ignorance for those living with the condition to fight against. In many respects AIDS has once more returned to being an comparatively overlooked illness.

This is not to say that it is no longer a problem. Tens of thousands of people are newly infected with HIV in America every year, and AIDS is now the leading cause of death amongst African American women. Gay men and injecting drug users too are still infected at a very high rate. Over 17,000 people died of AIDS in 2005 alone, yet increasingly AIDS is seen as an ‘overseas’ or an ‘African’ problem, rather than something that directly affects US citizens. The PEPFAR programme tends to receive greater attention and attract considerably more comment in the press than the work taking place within the US to fight AIDS.

When AIDS is mentioned on a national level, it is often in relation to the chronic funding shortages for AIDS services, the epidemic among African Americans or the fact that the US has still not lifted the ban on HIV positive people entering the country. With the exception of the reduction in mother-to-child transmission in recent years, the news is rarely good. AIDS continues to affect marginalised groups, and continues to receive nowhere near the attention or funding that is required to effectively tackle the problem. AIDS organisations are now demanding a national strategy on AIDS, but until their calls are heard, AIDS will remain a very real problem with no real solution.