Achieving health equity to end the HIV epidemic: An important step Congress can take

Dec. 1 marks the 34th World AIDS Day — a global day of remembrance for the 40 million people who have died from HIV-related illnesses and a global day of commitment to end HIV as a pandemic and improve the lives of the more than 38 million people living with HIV worldwide.   

As an infectious diseases physician specializing in HIV, World AIDS Day can be a day of mixed emotions and reflection for me, along with many in the HIV community. Every day in the patients we care for and help, we see how the collective efforts of the last 40 years in diagnosis, treatment and prevention should be celebrated. But as a nation, we have failed in ensuring that the populations who are most in need of lifesaving tools and care have access to them.  

In the U.S., more than 1.2 million people are living with HIV, and more than 30,000 new diagnoses were recorded in 2020, even with COVID-19 limiting access to HIV testing. Unacceptable racial and geographic disparities persist among the populations most heavily affected by HIV. Forty-three percent of new HIV diagnoses occur among Black Americans, although they represent just 12 percent of the population; 27 percent occur among Latino/Hispanic Americans, although they represent just 19 percent of the population. There are great disparities in geography too — in 2020 more than 50 percent of new HIV diagnoses occurred in the southern U.S. Parts of rural America heavily impacted by the opioid epidemic also report dramatic increases in HIV diagnoses, predominantly due to injection drug use.  

It is not a coincidence that the populations most impacted by HIV also have been disproportionately impacted by the COVID-19 pandemic, the monkeypox outbreak and other infectious diseases. Structural barriers in accessing health care, including lack of access to an infectious diseases or HIV provider, help to fuel these disparities. Eighty percent of counties in the U.S. do not have a single infectious disease (ID) physician, and in New York, more than 50 percent of counties do not have a single ID physician. A study focused on 14 southern states found that 80 percent of counties do not have any experienced HIV clinicians, with the shortage being most acute in rural areas.  

Improving access to expert HIV clinicians is critical to make progress toward ending HIV as an epidemic. People with HIV managed by an experienced HIV provider have better outcomes and lower health care costs. Despite the rewards that come from saving lives as an HIV physician, it is tough to compete with other specialties. Medical students on average accrue more than $240,000 in educational debt, while infectious diseases and HIV physicians are among the lowest paid of the medical specialties. 

Educational debt poses an even greater barrier for populations historically under-represented in medicine who may be interested in pursuing careers in infectious diseases and HIV, making it difficult to recruit the diverse workforce necessary to address health inequities. Research has shown that patients have a more positive health care experience, including improved outcomes and lower health care costs, when their provider is of the same race. According to the most recent demographic data available, just 4.7 percent of infectious diseases trainees were Black/African American and 6.8 percent were Hispanic or Latinx. These demographics are far from reflecting the racial and ethnic demographics of people with HIV.  

Congress can help remove the cost of education as a barrier and help ensure that every community has an infectious diseases or HIV clinician by advancing the BIO Preparedness Workforce Pilot Program as part of the PREVENT Pandemics Act before the end of the year. The Pilot Program would incentivize physicians and other health care professionals to pursue careers in ID and HIV and work in underserved areas or certain federal facilities, including Ryan White HIV/AIDS Clinics, by offering targeted loan repayment for their service. This will help build the diverse and culturally responsive workforce needed to make progress in ending HIV as an epidemic in the U.S. and ensure that every county, state and our country are better prepared for future pandemics and public health emergencies.  

Advancing health equity to end HIV is an ambitious but achievable charge to all of us. Congress can take an important step by advancing loan repayment for infectious diseases and HIV health care professionals. 

Michelle Cespedes, MD, MS, is the chair of the HIV Medicine Association and an HIV clinician and professor of medicine in the Division of Infectious Disease at the Icahn School of Medicine at Mount Sinai.