US can end HIV, but we're failing those who need care most | Opinion

I’ve spent much of my career caring for people in places most Americans never see. I’ve worked in refugee camps, on the streets of large cities, in rural communities cut off from care, in clinics where resilience was the only constant, and in health systems held together by the determination of the people working inside them.

In each of these settings, the same truth kept rising to the surface. Epidemics don’t end in laboratories or policy documents. They end in the "last mile," the place where health care rarely reaches people who need it the most. What makes the last mile even more urgent today is that the national commitment to HIV has been shaken.

For the first time since 1988, the U.S. government declined to formally recognize World AIDS Day on Dec. 1. This after the federal budget cut funding for HIV prevention and surveillance. Globally, similar donor cuts have disrupted HIV programs and reversed years of hard earned progress.

These shifts reveal a difficult truth. Science cannot end HIV if the systems that deliver it are dismantled or out of reach. What we need now is access and care models like HIV Street Medicine that bring dignified, equitable treatment directly to the people who have been left behind.

More than 1 million people live with HIV in the US

HIV, a human immunodeficiency virus, attacks the body's immune system. Without treatment, it can lead to AIDS, acquired immunodeficiency syndrome. Since 1981, HIV has killed more than 700,000 Americans. Over a million people are living with HIV in the United States.

According to HIV.gov, "While new HIV diagnoses have declined significantly from their peak, progress on further reducing them has stalled with an estimated 38,000 Americans being newly diagnosed each year."

When we talk about ending the HIV epidemic, it’s tempting to focus on the scientific victories. Antiretroviral therapy (ART) works. PrEP works. Long acting treatment is transforming the landscape. But innovation isn’t the barrier. Access is the barrier.

The distance between innovation and the people who need it is immense because the systems we’ve built don’t reach the people most affected by HIV. Until we acknowledge that and, most important, act on it, the HIV epidemic will continue to take root in the places where traditional health care fails to go.

Why homelessness is the last mile to ending HIV

This failure is felt most sharply by people experiencing homelessness ‒ their HIV infection rates are significantly higher than those of their peers who are in stable housing.

The reasons are not mysterious. Homelessness creates daily instability that makes keeping clinic appointments nearly impossible. It strips away privacy, safety and continuity. It disconnects people from the very systems meant to keep them alive. It also increases the likelihood of needle sharing and high-risk sexual behavior.

Homelessness is the last mile because it exposes the limits of our HIV approach. It shows us exactly where the epidemic continues to thrive. Ending HIV requires us to bring care to the streets, not wait for the streets to come to us.

This is the heart of HIV Street Medicine. It’s work that my team and I at Wellness Equity Alliance devote ourselves to because we’ve seen what happens when you eliminate the distance between a person and the care they deserve.

Our HIV Street Medicine teams operate in encampments, under overpasses, beside riverbeds, outside shelters and in motels where families are surviving day to day. We bring rapid testing, confirmatory testing, PrEP, antiretroviral therapy, wound care, harm reduction supplies, behavioral health support and primary care directly to people who are often ignored by the traditional health care system.

When we shift our thinking to embrace this model, we stop blaming individuals for failing to navigate systems that were never designed for them in the first place.

The HIV epidemic can end. The science is already there. What remains is the harder part, the moral obligation to ensure that the most marginalized have the same access to that science as everyone else. 

The last mile is where the epidemic will end. The epidemic’s final chapters will be written in the exact places we have historically abandoned.

Dr. Tyler Evans, cofounder and CEO of Wellness Equity Alliance, is author of "Pandemics, Poverty, and Politics: Decoding the Social and Political Drivers of Pandemics from Plague to COVID-19."