Facing a yearlong siege from the coronavirus, the defenses in another, older war are faltering.
For the last two decades, HIV/AIDS has been held at bay by potent antiviral drugs, aggressive testing and inventive public education campaigns. But the COVID-19 pandemic has caused profound disruptions in almost every aspect of that battle, grounding outreach teams, sharply curtailing testing and diverting critical staff away from laboratories and medical centers.
The exact impact of one pandemic on the other is still coming into focus, but preliminary evidence is disturbing experts who have celebrated the enormous strides in HIV treatment. While the shift in priorities is nationwide, delays in testing and treatment carry particularly grievous risks in Southern states, now the epicenter of the nation鈥檚 HIV crisis.
鈥淭his is a major derailing,鈥� said Dr. Carlos del Rio, a professor of medicine at Emory University in Atlanta and head of the聽. 鈥淭here will be damage. The question is, how much?鈥�
Clinics have limited in-person visits and halted routine HIV screening in doctors鈥� offices聽and , with physicians relying instead on video calls with patients, a futile alternative for those who are homeless or fear family members will discover their status. Rapid-testing vans that once parked outside nightclubs and bars and handed out condoms are mothballed. And, in state capitals and county seats, government expertise has been singly focused on the all-hands-on-deck COVID response.
Concrete signs of the impact on HIV surveillance abound:聽聽reported nearly 700,000 fewer HIV screening tests across the country 鈥� a 45% drop 鈥� and 5,000 fewer diagnoses between March and September 2020, compared with the same period the year before. Prescriptions of PrEP, a preexposure prophylaxis that can prevent HIV infection, have also fallen sharply, according to聽聽presented at a conference last month. State public health departments have recorded similarly steep declines in testing.
That dearth in new data has led to a precarious, unknowable moment: For the first time in decades, the nation鈥檚 lauded HIV surveillance system is blind to the virus鈥檚 movement.
Nowhere will the lack of data be felt more profoundly than in the South: The region 聽51% of all new infections, eight of the 10 states with the highest rates of new diagnoses, and half of all HIV-related deaths, according to the most recent data available from the Centers for Disease Control and Prevention.
Even before the COVID pandemic,聽聽of any state, though lower than that of Washington, D.C.聽The Georgia Department of Public Health recorded a 70% drop in testing last spring compared with spring 2019.
The slowdown in HIV patient services 鈥渃ould be felt for years,鈥� said Dr. Melanie Thompson, principal investigator of the AIDS Research Consortium of Atlanta.
She added, 鈥淓very new HIV infection perpetuates the epidemic and will likely be passed to one or more people in the months to come if people are not diagnosed and offered HIV treatment.鈥�
Coronavirus testing has commandeered the machines previously used for HIV/AIDS testing, further straining surveillance efforts. The polymerase chain reaction 鈥� or PCR 鈥� machines used to detect and measure the genetic material in the human immunodeficiency virus are the same machines that run COVID tests around-the-clock.
Over the decades, as HIV migrated inland from coastal cities like San Francisco, Los Angeles and New York, it took root in the South, where poverty is endemic, lack of health coverage is commonplace, and HIV stigma is pervasive.
鈥淭here is the stigma that鈥檚 real. There is legacy racism,鈥� said Dr. Thomas Giordano, medical director of Thomas Street Health Center in Houston, one of the largest HIV clinics in the U.S. The state鈥檚 political leaders, he said, view HIV as 鈥渁 disease of the poor, of Blacks, Latinos and gay. It鈥檚 just not mainstream at the state level.鈥�
Black people represent 13% of the U.S. population but about 40% of HIV cases 鈥� and deaths. In many Southern states, the disparities are stark: In Alabama, Black residents account for聽听补苍诲听; in Georgia, Black people make up聽听补苍诲听.
HIV clinics that serve low-income patients also face limitations using video and phone appointments. Clinic directors say poor patients often lack data plans and many homeless patients simply don鈥檛 have phones. They also must contend with fear. 鈥淚f a friend gave you a room to sleep and your friend finds out you have HIV, you might lose that place to sleep,鈥� said del Rio of Emory University.
Texting can be tricky, too. 鈥淲e have to be cautious about text messages,鈥� said Dr. John Carlo, chief executive officer of PRISM Health Care North Texas in Dallas. 鈥淚f someone sees their phone, it can be devastating.鈥�
In Mississippi, HIV contact tracing 鈥� which was used as a model for some local efforts to track the coronavirus 鈥� has been limited by COVID-related travel restrictions meant 鈥渢o protect both staff and client,鈥� said Melverta Bender, director of the STD/HIV office at the Mississippi State Department of Health.
Of all regions in the U.S., the South has the weakest health safety nets. And Southern states have far fewer resources than states like California and New York. 鈥淥ur public health infrastructures have been chronically underfunded and undermined over the decades,鈥� said Thompson, the Atlanta researcher. 鈥淪o we stand to do worse by many metrics.鈥�
Georgia鈥檚 high HIV infection rate and the state鈥檚 slow pace of COVID vaccinations 鈥渁re not unrelated,鈥� Thompson said.
The porous safety net extends to health insurance, a vital need for those living with HIV. Nearly half of Americans without health coverage聽, where many states have not expanded Medicaid under the Affordable Care Act. That leaves many people with HIV to rely on the federal Ryan White HIV/AIDS Program and state-run AIDS drug assistance programs, known as ADAPs, which offer limited coverage.
鈥淎s a matter of equity, insurance is critical for people to live and thrive with HIV,鈥� said Tim Horn, director of health care access at NASTAD, the National Alliance of State and Territorial AIDS Directors. Ryan White and ADAPs 鈥渁re not equipped to provide that full sweep of comprehensive care,鈥� he said.
Roshan McDaniel, South Carolina鈥檚 ADAP program manager, says 60% of South Carolinians enrolled in ADAP would qualify if her state expanded Medicaid. 鈥淭he first few years, we thought about it,鈥� said McDaniel. 鈥淲e don鈥檛 even think about it nowadays.鈥�
Enrollment in the Ryan White program jumped during the early months of the pandemic when state economies froze and Americans hunkered down amid a grinding pandemic. Data from state health departments reflect the increased need. In Texas, enrollment in the state鈥檚 AIDS drug program increased 34% from March to December 2020. In Georgia, enrollment jumped by 10%.
State health officials attribute the increased enrollment to pandemic-related job losses, especially in states that didn鈥檛 expand Medicaid. Antiretroviral treatment, the established regimen that suppresses the amount of virus in the body and prevents AIDS, costs up to $36,000 a year, and medication interruptions can lead to viral mutations and drug resistance. But qualifying for state assistance is difficult: Approval can take up to two months, and missing paperwork can lead to canceled coverage.
Federal health experts say Southern states have generally lagged behind getting patients into medical care and suppressing their viral loads, and people with HIV infections tend to go undiagnosed longer there than in other regions. In Georgia, for example,聽nearly 1 out of 4 people聽who learned they were infected developed AIDS within a year, indicating their infections had long gone undiagnosed.
As vaccinations become widely available and restrictions ease, HIV clinic directors are scouring their patient lists to determine who they need to see first. 鈥淲e are looking at how many people haven鈥檛 seen us in over a year. We think it鈥檚 over several hundred. Did they move? Did they move providers?鈥� said Carlo, the doctor and health care CEO in Dallas. 鈥淲e don鈥檛 know what the long-term consequences are going to be.鈥�