Ending the AIDS Epidemic, Once and for All

Eight years ago, I wrote about New York State’s Ending the Epidemic (ETE) blueprint for eradicating AIDS by the end of 2020. Ending the epidemic means that new infections become so rare that the epidemic essentially peters out. Technically, it means that the number of new HIV diagnoses decreases to less than 750 per year.

New York had a good plan with a clear goal and a deadline. The pillars of the plan were to:

• Identify people with HIV who remain undiagnosed and link them to health care;
• Facilitate access to high-quality prevention, including pre-exposure prophylaxis (PrEP) to protect against new HIV infections among those at highest risk; and
• Connect HIV-positive New Yorkers to therapies that maximize viral suppression to keep them healthy and lower the risk of transmission.

What once seemed impossible was within reach. The numbers were moving in the right direction; newly diagnosed cases of HIV were decreasing and the proportion of people with HIV who’d achieved viral suppression (which makes it virtually impossible to transmit HIV) was growing. After so many years of death, suffering, and activism, we were on track to eradicate the AIDS epidemic in New York.

But then, COVID hit. Obviously and appropriately, financial and human resources were redirected to responding to the pandemic; everything else took a back seat. In its 2021 report called Ending the Epidemic: Beyond 2020, the New York State Department of Health acknowledges: “Since the start of the COVID-19 pandemic, there have been increases in HIV cases in certain parts of the state, significant reductions in HIV testing and reporting of diagnoses, and decreases in the number of persons accessing PrEP.” Consequently, the State renewed its commitment to eradicating the AIDS epidemic, but pushed back the timeline to the end of 2024.

Where do we stand now? It’s a mixed bag. Let’s start with the positives:

• New HIV infections trending down over the last decade. Although the latest data available show that the numbers did tick up slightly in both 2021 and 2022, New York State saw a 42% decrease in newly-reported HIV infections between 2011 and 2022.
• Gains in the use of PrEP. We saw a slight dip during 2020 but got right back on track. In 2022, more than 50,000 New Yorkers were using PrEP — nearly 15 times as many as in 2014.
• Elimination of perinatal HIV transmission. The latest New York State HIV/AIDS Annual Surveillance Report showed zero cases of perinatal transmission of HIV in 2022. That’s amazing.
• Widespread syringe service programs (SSPs). Thirty years ago, New York introduced one of the nation’s first SSPs (then known as needle exchange programs), a pioneering HIV harm-reduction measure that has proven to be highly effective. Today, New York has 26 active SSP programs across the State, many of them government funded. The New York Health Foundation recently made a grant to the Drug Policy Alliance to build a unified statewide network of harm reduction providers.

Along with the good news, there are areas of concern. Chief among them:

• Persistent inequities in HIV infection. In 2022, rates of new HIV infection among Black and Hispanic New Yorkers were 7.6 and 4.8 times higher, respectively, than among white New Yorkers. The New York State Department of Health estimates that “eliminating racial disparities in new diagnoses, linkage to care, and viral suppression could have prevented 18,000 HIV diagnoses over the last 10 years.”
• Insufficient funding. When I first wrote about the Ending the Epidemic blueprint, I said the effort was underfunded. That’s still true and maybe getting worse. Just recently, New York City — home to 78% of New Yorkers living with HIV — proposed $5.3 million in budget cuts to HIV outreach, education, diagnosis, and treatment programs. One of the programs that stands to lose the most is The Undetectables, which I highlighted in the 2016 column. Originally piloted by Housing Works in 2014, The Undetectables is now in place in organizations across the City and has been shown to be extremely effective in suppressing participants’ viral loads. If New York is going to meet its goal to end the epidemic, the solution is to double-down on effective programs, not cut back.

We’ve all been living with AIDS for well over 40 years now. More than 700,000 Americans have died from AIDS-related causes. The end of HIV/AIDS in New York is possible, maybe even tantalizingly close. But progress can be fragile; we saw it erode during the height of the COVID pandemic. Now is not the time to pull back resources or get complacent; now is the time to go all in and end the epidemic, once and for all.