The COVID pandemic has taught America’s health-care system a lot about fighting a highly contagious, deadly virus. There have been victories and failures, and we hope both will make us better prepared for the next infectious disease threat. But other medical providers and I working in HIV prevention say we should not wait to put those lessons to work. We need to apply some of the urgency and innovation we are using to fight the raging inferno of the COVID pandemic to extinguish the smoldering embers of the still deadly HIV/AIDS epidemic.
The HIV/AIDS community has racked up heroic, lifesaving victories with medications that make HIV a survivable chronic condition. When taken properly, these treatments may render the infection nontransmissible. And when preexposure prophylaxis (PrEP) is taken as prescribed by HIV-negative people, it confers nearly perfect protection against contracting the virus through sex. Both HIV infections and AIDS deaths have dropped steadily, and this outcome is worthy of celebration. Nevertheless, there are new infections every day in the U.S. and around the world. In spite of treatments and PrEP, there are still too many people lacking access to good HIV care and education about prevention. Here at Nurx, a telemedicine company where we order home HIV tests and prescribe PrEP, we have to inform a newly infected patient of their status at least twice a week, or about 100 times a year. It is never an easy call to make.
We often hear people ask whether HIV even still exists, which makes my colleagues and me angry—not at the person asking the question but at public health authorities’ inertia and the media’s silence around the virus. In the U.S., approximately 1.2 million people are living with HIV, and 14 percent of them do not know they have it. Persistent stigma and a lack of testing keep this population in the shadows.
In 2019 the approximately 34,800 new infections in the U.S. were mostly in Southern states and were not evenly distributed across their populations. This is because testing, prevention and treatment are not reaching those who need it most: men who have sex with men, Black and Latino Americans, and transgender people. That being said, education must be shared with all groups. Statistics do not matter when you are the one affected.
For instance, we fail women when we leave them out of the discussion. Whenever we tell a cisgender woman that she is HIV-positive, she is completely shocked, and often she says she never thought it was even a possibility. Our patients have included a divorced grandmother in her 60s who contracted HIV from a single sexual encounter at her college reunion and a student attending a privileged, prestigious university. The student was very sick and had full-blown AIDS by the time she was diagnosed, but none of the many doctors she had consulted about her illness had thought to test her for HIV.
After what we have witnessed this past year, it is hard not to see HIV’s persistence in the U.S. as a failure of will. COVID showed that our health-care system can rapidly reorganize to provide things such as drive-through testing centers in sports stadiums; a warp-speed vaccine effort; and public education efforts that had everyone talking about antibodies, antigens and viral load as easily as they had once chatted about the weather. We can certainly exert the much less disruptive effort required to end HIV. Here’s how:
• Test, test, test. With COVID we saw that frequent testing, including that of asymptomatic people and especially of those working or living in high-risk environments, was essential to containing the virus until a vaccine came along. Medical providers should recommend that sexually active patients be tested for HIV unless they are certain these people are at particularly low risk. Often they do not offer HIV testing to patients who they assume have little risk, and patients do not know to ask. Going forward, we should act more like the University of Chicago Medical Center, which set up a combination HIV-COVID testing site for the public during the pandemic.
• Destigmatize. Health-care providers should not judge or shame people for COVID infection—whether they caught it working at an essential job or attending a high-risk social gathering out of a human need for interpersonal connection. Similarly, we should destigmatize HIV and the ways people contract it. Health-care providers can be uncomfortable talking about sex, and when their schedules allow for only 15 minutes per patient, they may feel there is no time for what are actually crucial conversations about a patient’s sex life. The combination of these two things may leave patients without the care they should get because they are being treated within a system that does not normalize and prioritize sexual health as a crucial component of comprehensive care. All people should be asked about their sexual health so they can get tested for HIV at the frequency that is right for them and be prescribed PrEP if their sex life puts them at risk for contracting HIV.
• Meet people where they are. During COVID we have brought tests and vaccines to stadiums, schools, supermarkets, and more—so let’s make HIV prevention and treatment that easy by moving testing and prevention outside the clinic to where people live and work. Patients who need HIV testing and prevention have to jump through too many hoops to get care. The first hoop is finding a provider that they can trust. Imagine living in a small town where everyone knows you and your family or where the lab technician or pharmacist is also a member of your church community. The shame and fear associated with disclosing one’s sexual behavior prevent many from seeking care face-to-face.
One way to bring informed, nonjudgmental HIV prevention to people is through telehealth, which allows them to reach out to a medical provider any time, day or night, from their smartphones to request an HIV test or a prescription for PrEP—no looking for a clinic, waiting for an appointment, taking time off from work, or letting shame or stigma lead them to cancel their appointment. At-home tests and PrEP medication then can be sent to the patient’s door in discreet packaging, and communications with medical providers can happen in the comfort and convenience of the person’s home.
But to fulfill the potential of telehealth, we need policy changes. A step is to change laws that prohibit providers from offering care across state lines. Acknowledging that medical professionals can effectively give preventive care to patients across states or time zones will improve access to the best HIV care (often concentrated in cities) for those who need it most (those in poor, rural areas). During the pandemic, those in-state requirements were waived, dramatically reducing the burden on clinics and keeping patients at home when that was the safest place to be.
Another way to make this lifesaving and cost-saving care more accessible is to improve telehealth reimbursements. State laws requiring that care begin in person or that a patient have a prior relationship with a medical provider before telehealth can be used or reimbursed create an often insurmountable barrier to access for populations that need it most, face stigma and in many cases are at greater risk of contracting HIV.
The city of San Francisco has had low rates of COVID compared with other dense cities. Its success has been attributed to a public health infrastructure that learned hard lessons from the AIDS epidemic and was prepared to sound the alarm early, test people and trace contacts of infected individuals. Now let’s take those lessons, alongside what the health system as a whole has learned from COVID, and apply them to ending HIV in all communities around the country.