Pride and Progress: The Fight for HIV Elimination

In 2024, at least 64 countries are voting in national elections around the world, many of which will influence the future of the rights of LGBTQ+ individuals and their access to health care, including for HIV. These potential political transitions make this a critical moment to ensure that policies affecting healthcare access for LGBTQ+ people are strengthened or at least protected, moving us closer to HIV elimination.

The HIV epidemic is not over

Forty-three years after the New York Times published the famous headline, “Rare cancer seen in 41 homosexuals,” we now have effective treatments and prevention for HIV that we know work and save lives. However, these treatments remain underutilized and inaccessible to many.

UNAIDS has established an ambitious target for 2025: 95% of all people living with HIV  (PLHIV) have a diagnosis, 95% of those diagnosed should be taking lifesaving antiretroviral treatment (ART), and 95% of PLHIV on treatment achieve a suppressed viral load. Yet, global progress toward these targets is uneven, with new HIV infections rising in several regions. At-risk populations continue to experience high rates of new infections, highlighting persistent gaps in prevention coverage and access​ to HIV care and treatment.

The criminalization of homosexuality directly contributes to higher HIV transmission rates and undermines public health efforts to control the spread of HIV. For example, there is grave concern that Uganda’s sweeping Anti-Homosexuality law passed last year, which criminalizes same-sex relationships for PLHIV, may jeopardize access to life-saving services for HIV testing, prevention, and treatment. A 2021 study, Law, criminalisation and HIV in the world, published in BMJ Global Health found that knowledge of HIV status among PLHIV was 11% lower in countries that criminalize same-sex relationships, and viral suppression rates were 8% lower in these countries.

Criminalization forces LGBTQ+ individuals and men who have sex with men (MSM) to seek testing, treatment, and support for HIV in secret or risk legal repercussions or social ostracization. Criminalization also leads to a lack of targeted health services and hampers efforts to provide preventative measures like pre-exposure prophylaxis (PrEP), post-exposure prophylaxis (PEP), condoms, and educational resources. Governments that ban homosexuality often suppress public health interventions targeting LGBTQ+ populations, hindering effective HIV prevention and treatment programs.

Healthcare leaders can support organizations that advocate for LGBTQ+ rights and health access. Supportive coverage for HIV is also a core element to increase access to treatments. Beyond drug coverage, there are additional policies that healthcare leaders can work on with organizations to increase access to HIV care and treatment.

Action is needed: 5 policies for increasing access to HIV care and treatment that healthcare leaders can advocate for in the U.S. and around the world

1. Advocate for the repeal of laws and policies criminalizing or stigmatizing PLHIV. Laws and policies that criminalize or stigmatize PLHIV should be repealed, especially those affecting vulnerable populations like sex workers and people who use drugs. Changing these laws and policies can encourage more people to seek testing and treatment, leading to improved population health. The U.S. CDC recommends several HIV Criminalization Reform Options, including repealing outdated laws, modernizing existing laws, and applying current scientific and medical evidence when using existing laws.
2. Prioritize education, awareness, and outreach to population groups with disproportionately higher infection rates. For example, Black and Brown people make up 12% of the American population, but account for 40% of new HIV diagnoses in the U.S.  Additionally, the U.S. CDC estimates that 94% of White people who could benefit from PrEP have been prescribed it, but only 13% of Black people who could benefit have been prescribed PrEP. Training doctors from these communities on the value of PrEP and addressing mistrust, stigma, and social determinants of health is crucial to lower infection rates and reduce disparities.
3. Expand access points for HIV care. Task shifting can enable more access points to PrEP and other HIV care. Trained non-physician healthcare workers, such as pharmacists, nurses, and community health workers, can provide HIV treatment and care, expanding service coverage and reducing the burden on healthcare systems. For example, San Francisco AIDS Foundation, Los Angeles LGBT Center, and California Pharmacists Association co-sponsored 2019 legislation enabling pharmacists to prescribe for PrEP. Since then, 15 states within the U.S. have enabled pharmacists to prescribe PrEP and PEP. In U.S. states that passed pharmacist prescriber policies for these drugs between 2020-22, fills for PrEP increased by 24% in one year.
4. Adopt opt-out HIV testing models. Opt-out testing in emergency departments not only increases the number of diagnoses but also reduces overall healthcare costs by preventing advanced HIV cases, which are more expensive to treat​. For example, The Elton John Foundation in England pioneered a testing scheme for anyone having a blood test in 33 hospital accident and emergency units (emergency departments) to automatically be offered a test for HIV, Hepatitis B and Hepatitis C. A study by the U.S. CDC found that opt-out testing had a 12% higher uptake than opt-in testing.
5. Promote integrated care models. Encourage healthcare systems to combine HIV treatment with other health services, such as mental health, sexual health, substance abuse treatment, and primary care. Integrated care reduces stigma associated with HIV by normalizing HIV treatment as part of routine healthcare, improves coordination among healthcare providers, and increases the likelihood of PLHIV adhering to treatment plans. For example, Australia’s HIV treatment and care hubs integrate various services, providing a one-stop-shop for HIV care to improve patient outcomes and accessibility.

Moving forward: Achieving HIV elimination through collective advocacy

The fight for HIV elimination is intrinsically linked to the broader struggle for LGBTQ+ rights. As we reflect on the progress made since the Stonewall Riots and as we navigate upcoming political transitions worldwide, it is crucial for pharmaceutical leaders, policymakers, and advocates to push for supportive health policies to help achieve the global goal of HIV elimination.