The HIV pandemic, like the virus itself, is opportunistic and parasitic. AIDS is a disease of poverty, disruption, stigma, and chaos. Wherever the social fabric is torn, HIV enters and occupies. Wherever communities struggle, HIV thrives. Here in the U.S., where I sit, it is no different.
We can applaud the advances described in this top-10 review and elsewhere; we can marvel at how far we have come and at a future bright with the possibility. But the gaps between the haves and have-nots stare at us, and they force us to look back and acknowledge that our successes are hollow if they're not equally shared.
For African-American men, the risk of acquiring HIV has been increasing at the same time that the risk for white men has been declining. Moreover, once they acquire HIV, African-American men who have sex with men (MSM) hit lower numbers at each step of the HIV cascade of care, compared with white MSM.
Early in 2018, the U.S. Centers for Disease Control and Prevention (CDC) detailed the clinical outcomes of young African-American men in HIV care from 2009 to 2014 using data from the Medical Monitoring Project, a dataset representative of the adult HIV-positive population in the U.S. During the study period, antiretroviral prescriptions generally increased from 61% to 88% among black men. However, self-reported adherence to HIV therapy remained unchanged at around 70%. Similarly, there were no significant temporal changes in the rate of viral suppression at last visit (~60%) or more durable viral suppression over the prior 12 months (~36%).
A number of factors were associated with poor clinical outcomes, including homelessness, depression, poverty, and smoking. Even taking a step back, before looking at the end analyses, the baseline characteristics of the men included were telling: Over half were living at or below the federal poverty level, 45% used illicit drugs, and 20% were depressed.
A similar story is told by an analysis of viral suppression among patients cared for at one of the eight U.S. Centers for AIDS Research Integrated Clinical Systems (CNICS) clinics. Looking at viral suppression trends from 1997 to 2015, the investigators describe rates of HIV treatment success that increased markedly but unevenly over this period, with the odds of not having a suppressed viral load being significantly higher for African Americans compared with whites (odds ratio = 1.68 - 95% CI: 1.57-1.80).
The Bottom Line
Many of us are called to HIV care by a confluence of medicine, public health, and social justice. The CDC and CNICS data show us that disparities within the reach of advances in HIV care remain hard-baked into the system. Both papers call for tailored interventions that address adherence and social determinants of health. What these interventions should look like is unclear, and missing is a deep look at why outcome gaps are petrified -- i.e., enduring over time, even as all boats rise.
Most who consider such determinants, even those that are considered social, design their interventions for the individual: They aim to encourage health-seeking behaviors or inoculate against toxic structural forces. But what about interventions that deal with racism and disenfranchisement, incarceration and the injustice of our justice system, underfunded basic education, and uneven economic playing fields? What do these interventions look like? Will they come from well-intentioned social scientists with conceptual models and five-year grants, or through a reckoning with a status quo that is fiercely defended even as it is simultaneously literally killing people?
HIV often reveals what ails a society, be it war, migration, or infanticide. Here in the U.S., of course, it is no different. When we fix how our society treats people of color, the poor, and the marginalized, we will fix shameful disparities in the treatment of HIV. The biomedical and behavioral can be powerful, but advances in policy are what we desperately need.
David Alain Wohl, M.D., is a professor of medicine in the Division of Infectious Diseases at the University of North Carolina (UNC). He is site leader of the UNC AIDS Clinical Trials Unit at Chapel Hill, director of the North Carolina AIDS Education and Training Center (AETC), and co-director of HIV services for the North Carolina state prison system. In 2014, he became co-director of the UNC-Duke Clinical RM Ebola Response Consortium.