40 Years of HIV Progress
June 4, 2021
On June 5, 1981, the Centers for Disease Control and Prevention’s (CDC) Morbidity and Mortality Weekly Report (MMWR) described the first cases of a rare pneumonia among five men in Los Angeles, California, marking the first official reporting of what would later become known as human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS). In the 40 years since these initial cases were reported, we have witnessed the tragedy of approximately 700,000 lives lost in the United States. Simultaneously, we have also witnessed the triumph of HIV prevention and treatment bringing the number of new HIV infections to all-time lows both in the United States and around the world.
As the HIV epidemic grew in the United States, profound disparities by race and ethnicity emerged that persist today, and too many people are still not receiving the medical care they need.
In a new study published this week in MMWR, CDC authors found that during 1981–2019, estimated HIV incidence in the United States decreased by 73 percent from its peak in 1984 and 1985 (130,400 annually) to its lowest point in 2019 (34,800 annual infections). Reductions in incidence during this timeframe likely reflect increased availability of HIV prevention tools including testing, antiretroviral therapy, and pre-exposure prophylaxis (PrEP). For example, routine HIV screening, point-of-care tests, and over-the-counter self-tests broadened the reach of HIV testing, leading to improvements in HIV diagnosis. The Department of Health and Human Services’ Adults and Adolescents Antiretroviral Guidelines Panel recommends antiretroviral treatment regardless of immune status or disease stage. This recommendation led to earlier treatment and achievement of viral suppression, while programmatic efforts to increase linkage-to-care, re-engagement in care, use of PrEP and post-exposure prophylaxis, and syringe service programs (SSPs) helped put new, powerful prevention tools into the hands of more people who needed them. In addition, advances in HIV research, prevention, and treatment have made it possible for many women with HIV to give birth to babies who are free of HIV, dropping the annual number of HIV infections through perinatal transmission in the United States and dependent areas by more than 95 percent since the early 1990s.
Despite these major breakthroughs and achievements, serious disparities continue—and some have worsened. In 2019, Black Americans accounted for almost half of incident infections, but only 12 percent of the U.S. population. An increasing proportion of infections occur among Hispanic/Latino persons (29 percent in 2019), although they represent 17 percent of the population. Infections among men who have sex with men (MSM), including those who inject drugs, accounted for 70 percent of infections in 2019, but only an estimated two percent of the population are MSM. Transgender women also face significant barriers to prevention and care services; a recent CDC report found that four in 10 transgender women surveyed in seven major U.S. cities have HIV. Following the implementation of SSPs, which have been widely effective in preventing transmission of HIV, persons who inject drugs (PWID) experienced the greatest relative reductions in HIV incidence—from 34,500 during 1988–1990 to 2,500 during 2019. However, incidence among PWID has not decreased during the past decade, likely, in part, because of the ongoing opioid epidemic. Clusters of cases among PWIDs continue to be present across the country.
Globally, more than 32 million lives have been lost to HIV and today, there are over 38 million people living with HIV. In 2003, the U.S. launched the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) to address the increasing HIV-related mortality that resulted in negative population growth in some nations. To date, PEPFAR is the largest commitment ever by any nation to address a single disease. With PEPFAR support, CDC provides technical expertise to countries as they work to achieve ambitious global HIV epidemic control targets by 2030, which call for 95 percent of all people living with HIV to know their status, 95 percent of those who know their HIV status to be taking antiretroviral treatment, and 95 percent of those taking antiretroviral treatment to achieve and sustain viral load suppression. Several African countries have achieved or are on the cusp of achieving these global HIV epidemic control targets, based on data from CDC-supported population-based HIV impact assessments.
People with HIV can live long, healthy lives thanks to improved antiretroviral treatment. Powerful prevention tools, such as simple and effective HIV treatment and PrEP, can help prevent HIV transmission if taken as directed by all who need them. However, longstanding, systemic health and social inequities—including discrimination, homophobia, transphobia, stigma, poverty, systemic racism, homelessness, and unequal access to quality healthcare—prevent access to testing, treatment, and other prevention services and further drive inequities.
We can, and must, do better.
Only by addressing the root causes of these inequities and pursuing innovative solutions designed to reach people where they are with effective treatment and prevention strategies can we end this epidemic. This means expanding self-testing, increasing the number of mobile options for service delivery, and employing creative community outreach and engagement strategies for groups disproportionately affected by HIV. Prevention and care efforts must expand beyond traditional healthcare settings in ways that respond to community needs, including:
- providing or linking to transportation, housing, employment, mental health, or substance use disorder treatment services necessary to access and stay in care;
- giving people one place to pursue their health needs and engage in care, whether for substance use disorder, sexual health, or HIV; and,
- engaging people in need of care with love and respect, rather than defining them by their HIV status or risk.
The AIDS crisis of the 1980s gave rise to a new civil rights era in the United States: we marched, fought for recognition and resources, and worked tirelessly to dismantle discriminatory and dehumanizing systems that prevented our friends, family, and loved ones from achieving their best possible health. We can honor that hard-won legacy and the 700,000 lives lost to AIDS-related illness in the United States by working together to ensure that people who are affected by HIV today have equal and unfettered access to the high-quality care they deserve.
Through the new Ending the HIV Epidemic in the United States initiative, which funds the nation’s hardest hit areas to expand key prevention strategies and tailor them to local community needs, we have set a course to end the HIV epidemic in the United States over the next decade. Although we cannot fix deep-seated social determinants of health like systemic racism overnight, we can commit to providing quality HIV care services that are accessible, equitable, and culturally affirming. Today, the global community has the tools to control the HIV epidemic. By monitoring our collective impact and holding each other accountable for progress, we believe that 10 years from now, with the infusion of new resources, community innovation, and collective commitment, we will reach our goals of health equity and celebrate together the end of the HIV epidemic.
/Rochelle P. Walensky, MD, MPH/
Rochelle P. Walensky, MD, MPH
 https://clinicalinfo.hiv.gov/en/guidelines/adult-and-adolescent-arv/whats-new-guidelinesexternal icon
 www.unaids.org/en/resources/909090external icon