Annual new HIV infections in the U.S. fell by 12% in recent years, with the greatest declines seen among young gay and bisexual men and people in the South, according to the latest HIV surveillance report from the Centers for Disease Control and Prevention. Increased PrEP use played a role in this decline, experts say.
While everyone did not benefit equally, all groups saw some improvement.
"We see some bright spots in the data — our nation's HIV prevention efforts are working, especially for young people," Dr. Jonathan Mermin, director of the CDC's National Center for HIV, Viral Hepatitis, STD, and TB Prevention, said during a May 23 media briefing. "While we are on the right track, progress is not happening quickly enough or equitably among all people or in all areas of the country."
The CDC estimates that HIV incidence fell from about 36,500 new infections in 2017 to about 32,100 in 2021. But at this rate, "at least three people in the U.S. get HIV every hour," according to Dr. Robyn Neblett Fanfair, acting director of the CDC's Division of HIV Prevention.
About two-thirds of people with new infections were gay or bisexual men and more than half lived in the South. According to the CDC, 87% of the estimated 1.2 million people living with HIV have been tested and know their status.
The decline in incidence was driven by a 34% drop among people ages 13 to 24, from about 9,300 new infections in 2017 to about 6,100 in 2021. This age group accounts for the second largest number of HIV cases, after people ages 25 to 34, of which 80% are among young gay and bisexual men. While HIV incidence dropped by 45% among young white gay and bi men, the declines were smaller — 36% and 27%, respectively — for young Latino and Black men.
Just under 20% of new HIV infections in 2021 were among women, more than half of whom were Black. The good news is that the United States has met its goals for eliminating perinatal HIV, with the mother-to-child transmission rate falling below 1% for the first time in 2019 and continuing to decline.
In 2021, the South saw more new infections (16,700) than the West (6,600), Midwest (4,400) and Northeast (4,400) put together, but it was the only region to see a statistically significant decrease, falling by 12%.
Turning to HIV care, the portion of people with diagnosed HIV who were on antiretroviral treatment with an undetectable viral load rose slightly, from 63% in 2017 to 66% in 2021. But here, too, everyone did not benefit equally: Viral suppression rates ranged from 62% for Black people to 72% for white people.
The drop in HIV incidence and the rise in the proportion of people on treatment in the United States pales in comparison with some other high-income countries such as the United Kingdom and Australia. In the U.K., efforts to curb HIV among gay and bi men have been so successful that they now account for fewer new cases than heterosexuals. The differences can be attributed to "deeply entrenched social determinants of health that drive disparities and make progress elusive," Mermin said.
Treatment
The most successful countries have gotten more people with HIV on treatment, which reduces onward transmission. According to Neblett Fanfair, people who receive care through the federal Ryan White HIV/AIDS program have outcomes rivaling those of other countries, showing that lack of health insurance and access to care is contributing to disparities.
SF data
Some American cities have done better than the nation as a whole but still face challenges. San Francisco, for example, is struggling with HIV among people experiencing homelessness, who accounted for 24% of new diagnoses in 2021.
New diagnoses in San Francisco fell from 240 in 2017 to 138 in 2020, before rising to 160 in 2021, according to the Department of Public Health's most recent HIV epidemiology annual report. But health officials say the uptick could have been due to changes in testing in the wake of the COVID-19 pandemic. Preliminary year-end numbers from 2022 suggest new diagnoses are again on the decline, DPH said in a statement to the Bay Area Reporter.
The role of PrEP
The nationwide decline in HIV incidence mirrors an increase in PrEP use. Among the 1.2 million people the CDC estimates could benefit from prevention pills or shots, about 30% had a prescription in 2021, up from 13% in 2017. But Black and Latino people are less likely to use PrEP even though they account for a majority of people at risk for HIV. According to the new report, 78% of white people at risk were taking PrEP in 2021, compared with 21% of Latinos and 11% of Black people.
President Joe Biden's FY2024 budget proposal includes $850 million to accelerate efforts to end the HIV epidemic, and he has also proposed $237 million for a national PrEP program. But these requests may not be met as some legislators have called for deep cuts in federal spending to balance the national budget.
"It appears that our investments in HIV prevention are providing some positive results, but the persistent high number of new diagnoses and the low usage of PrEP among the communities most impacted by HIV point to the need for increased resources, particularly for a national PrEP program," Carl Schmid, executive director of the HIV+Hepatitis Policy Institute, said in a statement. "While there have been some increases, they have not been at the level needed to put the U.S. on a path to end HIV."
The availability of generic versions of Truvada has helped increase PrEP access, Mermin noted. More people are now insured than in 2017, thanks in part to the Affordable Care Act and Medicaid expansion during the pandemic. But these gains could be reversed now that the national COVID-19 public health emergency has ended. Likewise, mandatory insurance coverage of PrEP is also in jeopardy due to a Texas judge's ruling in March that is currently on hold pending appeal.
At the current rate, the country is not on track to meet the goals of Ending the HIV Epidemic initiative, which calls for a 90% decrease in new infections and for 95% of people diagnosed with HIV to be on treatment with viral suppression by 2030.
To get there, CDC officials stress the need for increased investment in proven prevention programs, maximizing innovation—such as expanding self-testing, greater use of long-acting injectable treatment and PrEP, and offering services in more settings—and centering equity to better reach people disproportionately affected by HIV.
"In prevention, patience is not a virtue," Mermin said. "A challenging task that once seemed impossible — to end the HIV epidemic in America — is possible. We need the will, the resources, and the resolve to make it happen."
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