Notes from the TN Dept of Health: Addressing inequalities and HIV

The following information was written by and is provided in partnership with the Tennessee Department of Health:

World AIDS Day is observed on the first of December every year. Established in 1988, this day has been committed to raising awareness of the HIV/AIDS epidemic and mourning those who have died of the disease. According to World Health Organization (WHO), the theme for the 2021 observance is “End inequalities. End AIDS”. WHO and its partners are spotlighting the many inequalities in access to vital HIV services. They are calling on global leaders and citizens to challenge the inequalities that drive the AIDS epidemic and to extend support to people who are not receiving essential HIV assistance. They are placing a special focus on “reaching people left behind.”

Inequalities are pervasive in our world, and WHO has a series of key messages for this year’s World AIDS Day observance to help focus on those which impact people living with HIV and their care significantly:

  1. Re-commit to end HIV
  2. Tackle HIV and COVID-19 together
  3. Focus on equality
  4. Concentrate on those left behind 

What does it mean to re-commit to ending HIV?

The public health community has reported that at every level (local, state, regional, and national) there are a constellation of obstacles to engagement in HIV care and treatment, substantially hampering the effectiveness of concerted efforts to improve health outcomes for those living with HIV. For individuals with HIV who experience poor access to comprehensive healthcare services, the benefits that come with undetectable equals untransmittable status (U=U) — a long life free from complications due to their HIV — are not in their reach. People need to be able to learn that they have HIV quickly after exposure, to be connected to treatment as soon as possible after learning their status, and to be securely engaged in a care regimen that will be lifelong. 

In Tennessee in 2019, only 61% of people diagnosed with HIV were linked to care within 30 days.  Being linked is just the beginning of the story; people living with HIV need ongoing access to care to achieve the undetectable status that will most benefit their health. For people diagnosed within a year, 59% had two sets of labs run by their HIV medical providers in 2019 and 65% achieved viral suppression (Tennessee Department of Health). 

When looking at who is getting into HIV care quickly and who is not, there are significant disparities. Non-Hispanic Black people and young people (ages 15-24 years old) had consistently lower rates of linkage to care compared with their peers living with HIV. While Hispanic people in 2019 who were diagnosed with HIV had higher rates of linkage to care, they were the least likely to stay engaged in that care (where engagement is measured by at least two visits to a provider with lab work in a year) and the least likely to achieve viral suppression within a year. And while newly-diagnosed men living with HIV who have sex with other men were the most likely to achieve viral suppression in 2019, Black people living with HIV (men included) were less likely to enjoy that positive health milestone (Tennessee Department of Health). 

This does represent modest improvement over the last five years. For Tennesseans in their first year living with HIV, there are higher rates of rapid linkage to care (within 30 days of diagnosis) and of viral suppression in the first year for people of every age, race, ethnicity, and gender as compared with 2015.  

Re-committing to ending HIV means refusing to be satisfied with progress and continuing to push for the rapid linkage to care, ongoing and active engagement in care, and viral suppression outcomes that demonstrate that Tennesseans living with HIV are able to enjoy long, healthy lives free from HIV-related health consequences and fear that they will pass it to their partners.

 

What does it mean to tackle HIV and COVID-19 together?

 

In Tennessee, 1.3 million people have contracted COVID-19 and ~17,900 people have lost their lives to it. Hospital systems in every part of the state have been overwhelmed with patients fighting COVID since the pandemic began, and health care systems have felt that impact from the hospital to the clinic level. The last three years have been marked by dramatic shifts in how people come together, and the changing social distancing recommendations and practices caused by the pandemic have impacted HIV prevention and care activities for better and worse. In 2021, more people living with and vulnerable to HIV have access to telehealth and virtual peer support than ever before — but this access is not universal; it is also true that there are fewer in-person opportunities for peer support, HIV testing, HIV prevention, and in some cases longer wait times for HIV care appointments now than pre-pandemic. According to the Tennessee COVID-19 Unified Command Data Dashboard, only ~50% of people in our state are vaccinated, leaving many Tennesseans at risk for the foreseeable future.

 

Some people living with HIV are at higher risk for severe complications from COVID-19 than others. If their HIV is poorly controlled, their weakened immune system puts them in this higher risk category. People living with HIV may also have one or more additional health concerns that puts them in this category. They might be at higher risk because of their age (65 and up), or because of where they live (in long-term care facilities or in incarcerated settings). CDC has more information about how COVID-19 impacts people living with HIV here. Everyone living with HIV needs ready access to the vaccine and to medical providers they trust who can answer their questions with accurate information. In Tennessee, HIV Centers of Excellence are all places where people living with HIV can get access to testing, information, and vaccinations. To best protect themselves from COVID-19, all people living with HIV should be fully vaccinated and receive the recommended additional dose. 

 

People who are not living with HIV have a role to play here as well. Regular testing, removing yourself from social situations when sick, vaccination, and masking in public spaces all help control the spread of COVID-19 and mitigate the harm it brings for people living with HIV. 

 

What does it mean to focus on equality in our efforts to end HIV?

 

Issues of equality outside of access to health care can and do create significant barriers to HIV prevention and success in HIV treatment. One obvious and well-demonstrated example is housing. A person who lacks stable housing is more likely to contract HIV if they do not have it and less likely to succeed in HIV treatment if they do. Recent homelessness doubles a person’s risk of contracting HIV, and groups of people who experience homelessness at higher rates (including LGBTQ youth, parenting youth, and transgender adults) also experience increased risk of contracting HIV. Housing instability is the most reliable predictor that a person will delay HIV testing, and that people will struggle at every step once diagnosed with HIV. For more information about all the research related to HIV and homelessness, click here. For information about the Tennessee Department of Health’s HOPWA Program, which provides federal housing assistance for people living with HIV, click here.

 

Beyond housing, poverty itself has a profound impact on what living with HIV is like for Tennesseans. According to the 2019 State of Tennessee HIV Epidemiologic Profile, the median household income in Tennessee is significantly less than the national average ($53,320 versus $62,843), and our state “continues to experience racial and ethnic disparities in household income, with white households reporting higher median income ($56,725) compared to Black and Hispanic households ($38,791 and $43,885, respectively).” 

Low-income Tennesseans are more likely to be diagnosed with HIV. Black and Hispanic households struggle with lower incomes and Black and Hispanic people living with HIV have poorer outcomes in HIV care. Young adults, parenting young adults, gay, bisexual, and same-gender loving men, and transgender people also often work with fewer financial resources and are more likely to struggle to attain HIV viral suppression. Aging Americans, and especially LGBTQ seniors, experience higher rates of poverty and homelessness, and people living with HIV are aging with it (SAGE, 2021).

People living with HIV who are impacted by poverty are more likely to make decisions about their health that reflect compromises due to their lack of resources. While people living with HIV in Tennessee who are enrolled in the Ryan White program are more likely to be in care by the end of the first year (99% compared with 80% for people with HIV outside the program), more likely to be engaged in their care (76% versus 41%), and more likely to be virally suppressed (80% versus 50%), for some this comes with a significant trade off: their HIV care under Ryan White is exceptional, but ~28% remain uninsured. 

One way to shift our efforts that address equality for people living with HIV is through the Ryan White Part B Insurance Assistance Program. People who are a part of the Ryan White Part B program can get comprehensive health insurance paid for, which greatly expands their access to medical services beyond just what is needed to treat and control their HIV. While most Ryan White clients have taken advantage of this benefit, more than one in five are still uninsured. Ryan White Part B clients can explore this option with their case manager. 

What does it mean to concentrate on those left behind?

We know that when it comes to HIV, different types of people are left behind in different ways. Young people still lack access to HIV testing, are taking longer to get connected to care, and are struggling to achieve viral suppression. Black and Hispanic people in Tennessee living with HIV are less likely to be engaged in care and virally suppressed. We know that transgender people living with HIV in Tennessee are a large group with significant challenges, but we do not have enough data to paint a clear picture about exactly what those challenges are. People aging with HIV need care that is focused on more than just their HIV, and often struggle with securing the basic daily needs (like housing and food) that contribute to their overall quality of life.  

As we move into 2022, concentrating on those left behind means increasing access to HIV prevention and care, working strategically with groups of people who have historically struggled to control HIV, and changing what it means for someone living with HIV to be supported in their healthcare. 

When it comes to HIV Prevention, Tennesseans can access free condoms, free rapid HIV testing, and free education about and support accessing PrEP. For people without health insurance, there are several resources that cover the prescription costs for PrEP (click here to learn more and/or contact your local PrEP navigator). For people with health insurance, PrEP’s grade A recommendation from USPSTF means that insurance providers must waive all costs including co-pays and deductibles associated with it. For Tennesseans struggling with opioid use, there are more syringe exchange and harm reduction support services now than ever before. There is a significant statewide effort to coordinate support for HIV, STIs, substance use disorder, and Viral Hepatitis that now includes new resources and new agencies funded to support the work. In Memphis, there are new resources and new agencies joining the fight to end HIV through the Ending the Epidemic Initiative

For people living with HIV, the option to use take advantage of Ryan White to obtain comprehensive health insurance is a game-changer. This allows people living with HIV to access the expert support of a Ryan White case manager, their local HIV Center of Excellence, and the resources to prioritize their health concerns beyond just their HIV. 

In 2022, it is time for all of us to recommit our efforts to ending HIV by expanding the fight beyond the narrow scope of the virus itself, making sure no one is left out of the work, taking the necessary steps to fight COVID-19 along the way, and using every available resource at our disposal.

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