The United States of America (USA) currently has around 1.2 million people living with HIV, with one in seven people unaware that they have HIV.1 The size of the epidemic is relatively small compared to the total population, however it is heavily concentrated among several key affected populations and geographically in the southern states – where 49% of all HIV new infections occur. Since the beginning of the HIV and AIDS epidemic, 659,000 people have died of AIDS-related illnesses in the USA.2
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 50,000 new infections per year. Stigma and discrimination continue to hamper people's access to HIV prevention, testing and treatment services, fuelling the cycle of new infections.
The USA lacked a comprehensive plan on HIV until 2010 when President Obama created a National HIV/AIDS Strategy. 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 coordinated national response to the epidemic.3
Key affected populations in the USA
The impact of the HIV epidemic in the USA is more seriously among some groups than others. These key affected populations can be grouped by transmission category i.e. men who have sex with men (MSM), but also by race, with people of colour having significantly higher rates of HIV infection over white Americans.4
A complex set of economic and socioeconomic factors drive risk to these populations, including a lack of access to care, discrimination, homophobia, stigma and poverty.5 Sexual networks is also a major determining factor for HIV risk in the USA, with populations at a high risk to HIV tending to have sexual relations with people in their own communities.
Men who have sex with men in the USA
Only 66% of MSM living with HIV in 2011 were aware of their infection, and young MSM aged 18-24 were even less likely to know (49%). There are significant disparities by race as well. 86% of white MSM were aware of their status, compared to only 63% of Hispanic/Latino MSM and 54% of black/African American MSM.8
Higher numbers of sexual partners, greater numbers of sexually transmitted infections (STIs) and having unprotected anal sex are some of the reasons why HIV transmission is more common among MSM.9
Black/African Americans in the USA
Black/African Americans accounted for 46% of all new HIV infections in 2013, and make up 43% of the total number of people living with HIV in the USA, despite only making up 13% of the population.10
Between 2009-2013, black/African Americans accounted for:
- 63% of all HIV infections among women
- 67% of all HIV infections among children below 13 years old
- 42% of all HIV infections among males.11
Black/African American 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 MSM also increase this group's risk of HIV infection.
High HIV prevalence within this community, and the increased likelihood of black/African Americans to only have sexual relations with others in their community, heightens their risk of HIV.14
Hispanics/Latinos in the USA
Hispanics/Latinos accounted for 23% of new HIV infections in the USA in 2013. This is relatively proportionate to their share of 17% of the USA population, but they are still more than three times as likely to be infected with HIV as white people.15
Men accounted for 86% of all new infections among the Hispanic/Latino population, the large majority of infections resulting from sex between men.
The Hispanic/Latino communnity face a number of challenges to accessing HIV prevention and treatment services. Language barriers, cultural factors and fear of being deported if asked about their immigration status, are all key barriers to reaching this community.16
Prisoners in the USA
The USA has the largest incarcerated population in the world with 2.2 million people in prisons or other closed settings.17 The country incarcerates a larger percentage of its population than any country in the world except the Seycelles, with 698 prisoners per 100,000 people.18
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 black African Americans or men who have sex with men.19
Others become infected while they are in prison, for example, via unprotected sex. A study in the New York area found that 13% of incarcerated men and women reported being sexually active in the previous six months.20
“In almost any jurisdiction in the US, there’s a concentration of the epidemic in the correctional population” - Anne Spaulding, an infectious disease specialist, Emory University 21
People who inject drugs in the USA
People who inject drugs (PWID) accounted for 7% of new HIV infections in 2013.22 Among people living with HIV in the USA, around 18% are people who inject drugs (PWID).23 The majority of PWID who are living with HIV are African Americans (46%).24
In 2014, a shocking 47,055 people died of a drug overdose in the USA. This is a huge increase of 137% since 2000.25 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
It is thought that 50% of young people living with HIV are not aware of their infection.28 A sense of complacency, or an attitude of 'it doesn't affect me' has prevented young people from testing for HIV and subsequently accessing antiretroviral treatment (ART).
HIV prevention programmes in the USA
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.29
HIV prevention efforts are supported and funded largely by the US Centre for Diseases Control and Prevention (CDC).
The CDC provides funding and support for states to target high-risk groups through its ‘High-Impact Prevention’ approach. This approach uses a mix of interventions that are scientifically proven, cost-effective, measurable and targeted toward populations most at-risk in specific geographical areas.30
One such behavioural intervention is the ‘Peers Reaching Out and Modelling Intervention Strategy’ (PROMISE). PROMISE is a community-led programme that has been successful in reducing HIV risk in key affected populations, such as PWID and MSM. People belonging to these groups are recruited as role models to disseminate information and materials to their peers to help them move towards safer practices.31
HIV prevention campaigns
The CDC leads on multiple campaigns that aim to take the taboo out of HIV. Specifically, the 'Act Against AIDS' campaign has many strands that target different population groups, for example:
- ‘Let's Stop HIV Together'
A campaign that focuses on the fact that HIV does not discriminate, we are all at risk, and everyone should be talking about HIV. Uses large-scale advertising and social media to spread its message.32
- 'Start Talking. Stop HIV'
A campaign that targets MSM and encourages them to talk about HIV with their partners, whatever their relationship status.33
- 'Testing Makes Us Stronger' & 'Take Charge. Take the Test'
Two campaigns targeting African Americans, especially men who have sex with men, and women to get an HIV test.34
HIV and sex education
The prevalence of having been taught about HIV in school in the USA has declined from 92% in 1997, to 85% in 2013.35
The level and type of HIV education given varies from state-to-state. In some areas, sex education with information about HIV is comprehensive and compulsory. In others, young people may leave school knowing virtually nothing about HIV and AIDS.36
In 2014, 26 states stated that abstinence needed to be ‘stressed’ in HIV education in school, and only 22 states mandated there to be sex education in schools.37 This is despite the fact that a 2013 CDC survey showed that 47% of high school students have had sex, 34% had sex in the past three months, and of these, 41% had not used a condom during sex.38 To date, the government has channelled over $1.5 billion into abstinence-only education programmes – a large bulk of this between 1996 and 2009.39
In his 2009 budget, Obama made a pledge to replace abstinence-only education with funds for more comprehensive sex education.40 Three-quarters of the budget on abstinence-only education was eliminated, with $190 million being made available for comprehensive approaches to sex education.41
Treatment as prevention
A study by the CDC showed that 91.5% of all new HIV infections in the USA in 2009 were transmitted from people who were not in medical care, including those who did not know they were infected.42 In response, in December 2014, the USA released ‘Recommendations for HIV Prevention with Adults and Adolescents with HIV in the United States’.43
These guidelines recognise the benefits of early treatment for a person living with HIV, but also for prevention. A suppressed viral load decreases the likelihood of onward transmission. Additionally, when people are engaged in care, healthcare providers can offer advice on interventions to further reduce the risk of transmitting HIV to others.44
Pre-exposure prophylaxis (PrEP), where HIV-negative people can take treatment before exposure to HIV to prevent infection, has been approved in the USA and France. It can now be prescribed to some members of high-risk groups, such as serodiscordant couples, MSM and PWID.45 Up to 30,000 people in the USA are thought to be using PrEP to prevent HIV.46
However, in the USA, 34% of primary care doctors and nurses do not know about PrEP and are therefore not offering it to people at risk of HIV. If more people who can benefit from PrEP took it, new infections would reduce.47
HIV testing and counselling in the USA
With 14% of the population unaware that they are living with HIV, increasing access to testing and counselling is a fundamental priority of the National HIV/AIDS Strategy. The number of Americans testing for HIV has increased in recent years, however it is thought that only 54% have ever tested for HIV.48
In 2006, the CDC published new guidelines which called for automatic, routine HIV testing of all adults and adolescents attending a healthcare setting. The policy allows patients to opt out if they do not wish to take a test, but removes the need for written consent and pre-test prevention counselling, which acted as barriers to HIV testing.49
As a result of this new strategy and a marketing campaign, Washington D.C. reported a 26% increase in the number of people testing for HIV in 2010 on the previous year.50
However, a more recent study looked at HIV testing history among people with Medicaid and commercial insurance and found that testing during 2012 was 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.51
Antiretroviral treatment in the USA
57% of the annual federal HIV/AIDS budget is spent on antiretroviral treatment, reflecting the growing number of people living with HIV as treatment continues to extend life expectancies.52
Antiretroviral treatment in the USA is available to anyone with good medical insurance. For those who are without insurance or underinsured, Medicaid, Medicare, and funding provided by the Ryan White Comprehensive AIDS Resource Emergency (CARE) Act are available to help with treatment costs.53
The National HIV/AIDS Strategy admits "large numbers of uninsured and underinsured people with HIV mean that not everyone has sufficient access to HIV therapy.54 In 2009, an estimated 70,000 people living with HIV were uninsured.55 The Strategy places a strong emphasis on the impact of the 2014 Affordable Care Act on the future provision of HIV treatment, such as expanded Medicaid eligibility; protection for people with pre-existing conditions that will allow them to access health insurance; and increased access to tax credits.56
However, a considerable proportion of those who are able to access treatment are not being retained in care. A 2001-2009 study found that only 20% of HIV-positive participants were considered 'highly engaged with specialist outpatient care'.57 The most recent data from the CDC from 2011 shows that of the 1.2 million people living with HIV, only 37% were receiving treatment, and just 30% of this number had a suppressed viral load.58
Barriers to HIV prevention in the USA
Addressing stigma and discrimination around HIV is a major challenge for the USA, including misconceptions about how HIV is transmitted.59 For example, in a 2011 survey, 45% of people stated that they would feel uncomfortable if someone living with HIV prepared their food.60
Uneven healthcare provision is also a major barrier, 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 which contribute towards this include: poverty, poor access to healthcare relative to the rest of the country, a focus on abstinence based education and laws that criminalise HIV transmission and restrict harm reduction programmes for PWID.61
The federal budget request for 2015 included a total of $30.4 billion for domestic HIV and AIDS. Of this, 57% is for care and treatment, 9% for research, 10% for cash and housing assistance, and 3% for prevention.62 It has been acknowledged that this is a restricted amount of money, however commitments to increase funding towards prevention have not been made.
Prevention efforts for PWID have been controversial. Needle exchange services were not permitted any federal funding, even though in some areas of the USA these programmes were successful in reducing the rate of HIV transmission.63 64
The ban on federal funding for needle exchanges was lifted in 2009. However, Congress has since failed to allocate funding for needle exchanges.65
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.
Nevertheless, 300 people have been convicted for exposing others to HIV in the USA. Combining the convictions in the USA and Canada equals more than all other countries in the world put together. Many of these convictions have occurred against people for spitting or biting, despite these not being routes of HIV transmission.66
The future of HIV and AIDS in the USA
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.
In addition, ensuring that people who are already living with HIV are accessing HIV treatment and care services, and most importantly, staying in care, will help to reduce AIDS-related mortality and onward transmission of HIV. Access to healthcare also needs to be more uniform across all of the states.
Up-scaling the treatment as prevention (TasP) approach has the potential to considerably reduce new infections. If all HIV-positive people were on antiretroviral treatment, specifically those belonging to key affected groups, then many new transmissions could be averted.
Considering the increase in new infections among young people, a combination approach to HIV prevention education needs to be adopted and heightened, away from the historical abstinence-only approach.
- 1. CDC (March, 2015) ‘Today’s HIV/AIDS Epidemic’
- 2. CDC (2015, February) 'HIV Surveillance Report, 2013'
- 3. The White House (2015, July) 'The National HIV/AIDS Strategy: Updated to 2020'
- 4. CDC (March, 2015) 'Today’s HIV/AIDS Epidemic'
- 5. CDC (March, 2015) 'Today’s HIV/AIDS Epidemic'
- 6. CDC (March, 2015) HIV Among Gay and Bisexual Men
- 7. CDC (Feb 2015) HIV Surveillance Report, 2013; vol. 25 Accessed [11/05/2015]
- 8. CDC (March, 2015) 'HIV Among Gay and Bisexual Men'
- 9. CDC (March, 2015) 'HIV Among Gay and Bisexual Men'
- 10. CDC (Feb 2015) HIV Surveillance Report, 2013; vol. 25 Accessed [11/05/2015]
- 11. CDC (April, 2015) 'HIV Surveillance by Race/Ethnicity (through 2013)'
- 12. CDC (2014, February) 'HIV Among African Americans'
- 13. CDC (April, 2015) HIV Among African American Gay and Bisexual Men
- 14. CDC (2013, March) ' HIV and AIDS among Gay and Bisexual Men' Factsheet
- 15. CDC (March, 2015) HIV Among Latinos Factsheet
- 16. CDC (2013, November) ' HIV among Hispanic/Latinos in the United States and Dependent Areas'
- 17. Walmsley, R. (2015) ‘World Prison Population List’ International Centre for Prison Studies
- 18. Rubin, R. (2016) ‘US prisons missing opportunities to tackle HIV in inmates’ The Lancet S0140-6736(16)31078-31079
- 19. Rubin, R. (2016) ‘US prisons missing opportunities to tackle HIV in inmates’ The Lancet S0140-6736(16)31078-31079
- 20. Tawandra, L. et al (2016) ‘Predictors of sexual behaviour among men and women in New York City area prisons’ Culture, Health & Sexuality 8:1-14
- 21. Rubin, R. (2016) ‘US prisons missing opportunities to tackle HIV in inmates’ The Lancet S0140-6736(16)31078-31079
- 22. CDC (April, 2015) HIV and Injecting Drug Use
- 23. CDC Epidemiology of HIV Infection through to 2013
- 24. CDC (April, 2015) HIV and Injecting Drug Use
- 25. CDC (2016) ‘Morbidity and Mortality Weekly Report: Increases in Drug and Opioid Overdose Deaths – United States, 2000-2014’
- 26. CDC (April, 2015) HIV Among Youth
- 27. CDC (April, 2015) HIV Among Youth
- 28. CDC (April, 2015) HIV Among Youth
- 29. CDC (2010) ' Establishing a Holistic Framework to reduce inequities in HIV, Viral Hepatitis, STDs and Tuberculosis in the United States'
- 30. CDC (2015) ‘High-Impact HIV Prevention: CDC's Approach to Reducing HIV Infections in the United States’ [Accessed May 13, 2015]
- 31. CDC (2015) ‘Effective Interventions: HIV Prevention that works – PROMISE’ [Accessed May 12, 2015]
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- 33. CDC (2014, May) 'New CDC campaign inspires life-saving conversations about HIV - Press release'
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- 35. CDC (2015) ‘HIV Among Youth’
- 36. Martinez, Gladys, PHD et al, (2010, September) ' Educating Teenagers about Sex in the United States' NCHS Data Brief, No 44
- 37. Kaiser Family Foundation (2014) ‘State Sex and HIV Education Policy’
- 38. CDC. Youth Risk Behavior Surveillance—United States, 2013 MMWR 2014;63(SS-4).
- 39. Advocates for Youth (2009) ‘Comprehensive Sex Education: Research and Results’
- 40. SIECUS (2015) A Brief History of Federal Funding for More Comprehensive Approaches to Sex
- 41. SIECUS (2015) A Brief History of Federal Funding for More Comprehensive Approaches to Sex
- 42. J. Skarbinski (2015) ‘Human Immunodeficiency Virus Transmission at Each Step of the Care Continuum in the United States’ JAMA Internal Medicine 175(4)
- 43. CDC (2014) Recommendations for HIV Prevention with Adults and Adolescents with HIV in the United States, 2014
- 44. CDC (2014) Recommendations for HIV Prevention with Adults and Adolescents with HIV in the United States, 2014
- 45. FDA (2012, July 16th) ‘ FDA Approves First Medication to Reduce HIV Risk’
- 46. Aidsmap (2015, 14 October) 'At least 25,000 people in the US may now be using PrEP'
- 47. CDC (2015, November) ‘Daily Pill Can Prevent HIV’
- 48. Kaiser Family Foundation (2014, May) 'HIV Testing in the United States'
- 49. CDC (2006, 22nd September) ‘Revised recommendations for HIV testing of adults, adolescents, and pregnant women in health-care settings’. MMWR Weekly Report, Vol. 55
- 50. CDC (2010, June 25th) ' Expanded HIV Testing and Trends in Diagnoses of HIV Infection District of Columbia 2004-2008' MMWR 59(24);737-741
- 51. Dietz, P. M., et al (2015) ‘HIV Testing among Outpatients with Medicaid and Commercial Insurance’, PLoS ONE
- 52. The Henry J Kaiser Foundation (2014, June) 'U.S. Federal Funding for HIV/AIDS: The President’s FY 2015 Budget Request
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- 54. The White House Office of National AIDS Policy (2010, July) ' The National HIV/AIDS Strategy for the United States'
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- 57. AIDSMAP (2012, May) 'Only 20% of US HIV-positive people have high levels of engagement with specialist HIV care'
- 58. CDC (2015) ‘CDC Fact Sheet - HIV Testing in the United States’
- 59. The White House Office of National AIDS Policy (2010, July) ' The National HIV/AIDS Strategy for the United States'
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- 61. Journal of Infectious Diseases (2011, February) ' Sex, Race, and Geographic Region Influence Clinical Outcomes Following Primary HIV-1 Infection' 203(4):442-5
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- 63. Monterroso, E.R et al (2000, 1st September) ‘Prevention of HIV infection in street-recruited injection drug users’. The Collaborative Injection Drug User Study (CIDUS)
- 64. Don, C et al (2005, August) ‘HIV incidence among injection drug users in New York City, 1990 to 2002: Use of serologic test algorithm to assess expansion of HIV prevention’, American Journal of Public Health, Vol. 9, No. 8
- 65. Kaiser Health News (2011, 21st December) ' Needle-Exchange Programs Face New Federal Funding Ban'
- 66. Global Network of People Living with HIV (July, 2010) ' Global Criminalisaion Scan Report 2010'