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HIV and AIDS in the United States of America (USA)

The United States of America (USA) currently has around 1.2 million people living with HIV.  Nearly one in eight of these people are unaware they have HIV.1 The size of the epidemic is relatively small compared to the country’s population, but is heavily concentrated among several key affected populations. Most new HIV infections occur among men who have sex with men (sometimes referred to as MSM), with African American/black men who have sex with men most affected. African American/black heterosexual women are also disproportionately affected.2

HIV rates are higher in southern states, which account for around 44% of all people living with HIV, despite making up roughly one-third (37%) of the population.3

Since the beginning of the HIV epidemic, 675,000 people have died of AIDS-related illnesses in the USA.4

Although the USA is the greatest national funder of the HIV epidemic globally, it is still facing a major ongoing HIV epidemic itself, with around 40,000 new infections a year.5 Stigma and discrimination continue to hamper people's access to HIV prevention, testing and treatment services, fuelling the cycle of new infections.

Although the USA is the greatest national funder of the HIV epidemic globally, it is still facing a major ongoing HIV epidemic itself.

The USA lacked a comprehensive plan on HIV until President Obama created a National HIV/AIDS Strategy in 2010.

The latest strategy, released in 2015, is structured around four core aims: reducing new HIV infections, increasing access to care and improving health outcomes for people living with HIV, reducing HIV-related disparities and health inequities and achieving a co-ordinated national response to the epidemic.6

Key affected populations in the USA

The impact of the HIV epidemic in the USA is more serious among some groups than others. These key affected populations can be grouped by transmission category (for example, men who have sex with men) but also by race, with people of colour having significantly higher rates of HIV infection over white Americans.7

A complex set of economic and socioeconomic factors drive risk to these populations, including discrimination, stigma, poverty and a lack of access to care.8 Sexual networks is also a major determining factor, with populations at a high risk to HIV tending to have sex with people in their own communities.

Men who have sex with men in the USA

Men who have sex with men (MSM) are most affected by HIV in the USA, accounting for more than two-thirds of all new HIV diagnoses in the country.9New infections are on the increase, increasing by 9% between 2010 and 2014.10

If current diagnosis rates continue, one in six men American men who have sex with men will be diagnosed with HIV in their lifetime. There are significant disparities by race as this equates to one in two African American/black men who have sex with men, one in four Hispanic/Latino men who have sex with men and one in 11 white men who have sex with men.11

At the end of 2013, 687,800 American men who have sex with men were living with HIV and an estimated 15% were unaware of their infection.12 This is echoed by a 2014 survey by the Centres for Disease Control (CDC) of men who have sex with men, which found 75% of those surveyed who were living with HIV were aware of their status, compared with 71% of HIV-negative respondents.13

Every three years, the CDC studies sexual risk behaviours among men who have sex with men in selected cities. The latest data from this survey suggests the number of men who have sex with men having anal sex without a condom is increasing, with 15.7% reporting this in 2014 compared to 13.7% in 2008.14

The survey found around one-third (35.2%) of young male high school students who had sex with men had also engaged in condom-less anal sex and other higher risk behaviours – a higher proportion than in earlier surveys.15

African Americans/black people in the USA

African American/black people are most affected by HIV in the USA. This group accounted for 4% of all new HIV infections in 2014 and 41% of the total number of people living with HIV in the USA, despite only making up 12% of the population.16Among all African American/black people diagnosed with HIV in 2014, an estimated 57% (11,201) were men who have sex with men. Of these, 39% (4,321) were young men (aged 13 to 24).17

From 2005 to 2014, the number of new HIV diagnoses among African American/black women fell 42%, although it is still high compared to women from other racial or ethnic groups. In 2014, an estimated 1,350 Hispanic/Latino women and 1,483 white women were diagnosed with HIV, compared to 5,128 African American/black women.18

African American/black men and women are most likely to be infected through unprotected sex with a man or by injecting drugs. Other factors such as heightened levels of poverty, lack of access to adequate healthcare and stigma surrounding men who have sex with men also increase this group's risk of HIV infection.19

Young African American/black men who have sex with men (aged 13 to 24) are most affected.20 In 2014, 55% of young men who have sex with men newly diagnosed with HIV were African American/black.21

High HIV prevalence within the African American/black community and the increased likelihood of individuals within this community only having sex with others in the community heightens their risk of HIV.22

PLHIV in USA

Hispanic/Latino people in the USA

HIV continues to be a serious threat to the health of the Hispanic/Latino community. In 2014, Hispanic/Latino people accounted for almost a quarter of all estimated new diagnoses of HIV in the USA, despite representing about 17% of the total US population.23

Men accounted for 86% of all new infections among this community, and the large majority of infections resulted from sex between men.24The Hispanic/Latino community faces a number of challenges to accessing HIV prevention and treatment services. Language, cultural factors and fear of being deported are all key barriers.25

Prisoners in the USA

The USA has the largest incarcerated population in the world, with 2.2 million people in prison or other closed settings.26 The country incarcerates a larger percentage of its population than any country in the world except the Seychelles, with 698 prisoners per 100,000 people.27

HIV prevalence is estimated to be 1.5% among prisoners, compared to 0.5% among the general population. Most prisoners are infected with HIV before they are incarcerated with one study estimating that one in seven people living with HIV in the USA go through the prison system every year. The majority of these belong to other key populations for HIV such as African Americans/black people or men who have sex with men.28

Others become infected while they are in prison – for example, via unprotected sex. A study in the New York area found 13% of incarcerated men and women reported being sexually active in the previous six months.29

“In almost any jurisdiction in the US, there’s a concentration of the epidemic in the correctional population.”

- Anne Spaulding, infectious disease specialist, Emory University 30

People who inject drugs in the USA

Heroin use is increasing in the USA among men and women in most age groups and across all income levels, rising by 63% between 2002 and 2013. This trend coincides with an increase in hepatitis C virus infections and new outbreaks of HIV associated with injecting drug use. 31 However, despite this, between 2010 and 2014 the overall annual number of new HIV diagnoses among people who inject drugs (sometimes referred to as PWID) in the USA decreased by 26%.32

An estimated 7% of new HIV infections in 2013 in the USA were among people who inject drugs.33 Of those living with HIV, around 18% are injecting drug users.34 The majority of people who are living with HIV who inject drugs are African Americans/black people (46%).35 Harm reduction programmes such as needle and syringe programmes, opioid substitution therapy and treatment for overdose need to be scaled up to accommodate the needs of this fast-growing population.

Young people in the USA

Young people (aged 13-24) accounted for 22%, or more than one in five, new HIV infections in 2014.3681% of these infections occurred among 20 to 24 year olds.37At the end of 2012, an estimated 57,200 youths (between 18 and 24) were living with HIV in the USA. Of these, 25,300 were unaware they had HIV – the highest rate of undiagnosed HIV in any age group.38 This age group is also the least likely to be receiving treatment for HIV.39

Results from CDC’s 2015 Youth Risk Behavior Surveillance System (YRBS)40,which monitors health risk behaviours among high school students, found:

  • Low rates of testing: Only 10% of sexually active high school students had been tested for HIV.
  • Low rates of condom use: 43% of sexually active high school students did not use a condom the last time they had sexual intercourse.
  • Substance use: 21% of sexually active high school students had drunk alcohol or used drugs before their most recent sexual intercourse.

HIV prevention programmes in the USA

American health authorities are placing increased emphasis on the role that 'social determinants of health', such as a person's age, class, race, living environment and poor access to healthcare, have on their risk of becoming infected with HIV. 41

To address these issues, the USA has adopted a High-Impact Prevention (HIP) approach. Funded by CDC, this approach combines behavioural, medical and structural interventions targeted towards most at-risk populations in specific geographical areas.42

One such behavioural intervention is the ‘Peers Reaching Out and Modelling Intervention Strategy’ (PROMISE). This is a community-led programme that has been successful in reducing HIV risk in groups such as people who inject drugs. People from these communities are recruited as role models to disseminate information and materials to their peers to help them move towards safer practices.43

Another HIP strategy is Data to Care, which began in 2013. This public health intervention aims to produce data to identify people who have been diagnosed with HIV but are not in care, in order to link them to treatment.44e

HIV prevention campaigns

The CDC leads on campaigns that aim to take the taboo out of HIV. Specifically, the 'Act Against AIDS' campaign has many strands that target different population groups. The most recent include:

  • Doing It

A national campaign in English and Spanish designed to motivate all adults to get tested for HIV and know their status. The campaign’s overriding message is that HIV testing should be a part of everyone’s regular health routine. It uses the hashtag #DoingIt and phrasing such as “He’s doing it. She’s doing it. We’re doing it. YOU should be doing it, too” and “Look who’s #DoingIt”.45

  • Know the Facts First

This campaign provides teenage girls (ages 13-19) with accurate information about sexually transmitted diseases including HIV and how to prevent them, helping them to make informed decisions. The US Department of Health and Human Services’ Office on Women’s Health (OWH) sponsors this campaign.46

  • HIV Treatment Works

This campaign encourages people living with HIV to get in care, start taking HIV medications, remain in care and stay on treatment as directed.47

  • We Can Stop HIV One Conversation at a Time

This campaign encourages Hispanics/Latino men and women to talk openly about HIV and AIDS with their families, friends, partners, and communities. Resources are available in English and Spanish.48

HIV and sex education

The status of sexual health education varies substantially throughout the USA and is insufficient in many areas.49

President Obama eliminated three quarters of the budget for abstinence-only education in 2009, which had previously received the majority of funding, turning instead towards more comprehensive approaches.50 51 Despite this, in 2014, 26 states stated that abstinence needed to be ‘stressed’ in HIV education in school, and only 22 states made comprehensive sex education in schools mandatory.52

Treatment as prevention

In December 2014, the USA released guidelines recognising the benefits of early treatment for a person living with HIV and in prevention. 53 This is because a suppressed viral load (lower levels of HIV in the body) decreases the likelihood of transmitting HIV to others. When people are engaged in care, healthcare providers can also offer advice on measures to further reduce the risk of transmitting HIV to others.

Pre-exposure prophylaxis (PrEP), where HIV-negative people can take treatment before exposure to HIV to prevent infection, has been recommended in America since 2012 for people at ongoing substantial risk of HIV infection. This includes HIV-negative people in a sexual relationship with a person living with HIV, people who inject drugs and men who have sex with men who do not consistently use condoms.54

Of the 1.2 million people who were eligible for PrEP in the USA in 2015, only an estimated 30 000 were prescribed it.55 It is estimated that increasing PrEP coverage in the USA could prevent around 48 000 new infections within five years ,and up to 185,000 new infections in the same period if increased coverage were combined with expanded testing and treatment.56

However, 34% of primary care doctors and nurses in the USA do not know about PrEP and are therefore not offering it to people at risk of HIV.57

HIV testing and counselling in the USA

With 13% of the population unaware that they are living with HIV, increasing access to testing and counselling is a fundamental priority of America’s National HIV/AIDS Strategy.58 The number of Americans testing for HIV has increased in recent years, but it is thought that only 54% have ever tested for HIV.59

A 2012 study into HIV testing history among people with Medicaid and commercial insurance found testing to be very low (4.3% among Medicaid patients and 2.8% among commercial insurance patients). 80% of these tests took place alongside STI screening or Hepatitis testing, suggesting that routine HIV testing is not widespread and that people mostly test for HIV as a result of actively testing for other illnesses.60

Testing rates remain far too low even among groups at high risk for HIV infection, including men who have sex with men, African Americans/black people and young people.61. In a study of men who have sex with men based in 20 American cities published in 2013, 34% who had HIV were unaware of their positive status. Of these, more than one-third (35%) had not been tested in the past 12 months.62

Although African Americans/black people are more likely to get tested for HIV than Hispanic/Latino people or white people, more than a third have never been tested.63.

Antiretroviral treatment in the USA

More than half (61%) of President Obama’s 2017 federal budget request for HIV spending was for care and treatment programmes. In comparision, just 3% of the budget request was for HIV prevention and 8% was for HIV research.64

The USA launched the HIV Care Continuum Initiative in 2013 to improve the capacity of all states to systematically identify and re-engage people living with HIV in treatment. This has expanded the number of people working in the HIV response by engaging and training non-traditional care providers such as community based organisations.65

At the same time, thousands of additional people living with HIV in the USA have been enrolled in comprehensive health insurance through the implementation of the Affordable Care Act.66 Early studies of the Affordable Care Act’s effect on the healthcare of people living with HIV in America, such as a 2014 study of five states by the Kaiser Family Foundation, suggest that many people have used the systems established under the Act to find more affordable and comprehensive health insurance coverage.67

According to the Kaiser Family Foundation, Medicaid was the largest source of insurance coverage for people with HIV in 2014, estimated to cover more than 40% of people with HIV in care.68

As a result of these interventions, about three in four (74.5%) of people newly diagnosed with HIV were linked to HIV medical care within one month of diagnosis in 2014 (the most recent data available). This result exceeded the USA’s annual target of 73.9%. However, only 56.5% of newly diagnosed people were retained in care – below the 60% target.69

Barriers to HIV prevention in the USA

As someone involved with the HIV response for over 30 years, I have witnessed terrific progress in the areas of HIV education, prevention, treatment, and social protections; however, stigma and discrimination against people living with HIV remains the single largest component of the HIV response where we continuously fail to reach real significant progress.

- Eric Sawyer, Civil Society Partnership Advisor at UNAIDS

Social barriers

70Addressing stigma and discrimination around HIV is a major challenge for the USA, including misconceptions about how HIV is transmitted. For example, a 2015 survey of people in Georgia, the state with the fifth-highest number of HIV diagnoses in the country, found 75% of those questioned reporting that people living with HIV experience stigma and discrimination. While most said they would feel “comfortable” working with someone living with HIV, 44% felt “very” or “somewhat” uncomfortable with having a person living with HIV as a roommate. The vast majority (90%) said they would be uncomfortable having an intimate relationship with a person with HIV. 71

In 2013, GNP+ launched the USA Stigma Index as a way for people living with HIV to document experiences of stigma and discrimination and mobilise communities to act to tackle the issue. As of 2016, its findings are yet to be published.72

Uneven healthcare provision is also a major barrier to effective services, with the quality of HIV prevention and care received varying greatly across the country depending on location and socio-economic group. Non-white people in the South experience the worst clinical outcomes after being diagnosed with HIV. Factors that contribute towards this include: poverty and poor access to healthcare relative to the rest of the country.73

Economic barriers

The federal budget request for 2016 included a total of $34.0 billion for domestic HIV and AIDS.74 It has been acknowledged that this is a restricted amount of money, however commitments to increase funding towards prevention have not been made.

The funding of prevention efforts for people who inject drugs have been particularly controversial. Federal funding for needle exchanges, which are globally recognised as an effective way to reduce HIV transmission, was banned until 2009. However, Congress failed to allocate any funding for this intervention until January 2016.75

Legal barriers

Legislation has contributed to the improvement of the lives of those living with HIV and AIDS in the USA. This culminated in 2010 when President Obama lifted the ban on entry into the country for all HIV-positive people.

An analysis by CDC and Department of Justice researchers found that, by 2011, a total of 67 laws explicitly focused on persons living with HIV had been enacted in 33 states.76 Many of these convictions have occurred against people for spitting or biting, despite these not being routes of HIV transmission.77 Convictions under these laws, when combined with Canadian convictions, total more than the entire number of convictions made in the rest of the world.

The future of HIV and AIDS in the USA

“The United States will become a place where new HIV infections are rare, and when they do occur, every person, regardless of age, gender, race/ethnicity, sexual orientation, gender identity, or socio-economic circumstance, will have unfettered access to high quality, life-extending care, free from stigma and discrimination.”

- The US National HIV/AIDS Strategy’s mission statement78

In 2016, the American government updated its National HIV/AIDS Strategy. Its four key focus areas (as outlined in the introductory section of this page) remain unchanged. It will also begin to monitor HIV stigma, HIV among people who are transgender and the effectiveness of PrEP as a prevention strategy.79 White House Office of National AIDS Policy (2015) ‘The National HIV/AIDS Strategy: Updated to 2020’

In order to break the cycle of transmission among key affected populations in the USA, increasing the impact of targeted campaigns towards people in these groups is vital. Expanding access and uptake to HIV testing, and increasing the number of people who are aware of their status, will also go a long way to controlling the epidemic in this country.

Last full review: 
01 May 2015

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Last updated:
29 November 2016
Last full review:
01 May 2015