HIV/AIDS in the United States

The HIV epidemic in the United States has shifted over four decades. In 2021, an estimated 1.2 million people were living with HIV, with 32,100 new infections that year.¹ Gay and bisexual men account for the majority of new diagnoses (about 70%), with African Americans and Latinos disproportionately affected. The South now bears the heaviest burden, representing over half of new diagnoses, driven by poverty, stigma, and limited healthcare access.²

Geographic disparities are stark: the District of Columbia has the highest diagnosis rate, while rural areas often lack testing and treatment services. Women, particularly African American women, also face significant risk, with heterosexual contact being the primary transmission route.¹

The first cases were reported in 1981 among gay men in Los Angeles and New York, leading to initial stigmatization and slow government response. The Reagan administration's silence and the activism of groups like ACT UP in the 1980s pressured for research and drug approval.³ The Ryan White CARE Act (1990) provided federal funding for care, and the advent of combination antiretroviral therapy (ART) in 1996 transformed HIV from a death sentence to a chronic disease.

In 2019, the Trump administration launched 'Ending the HIV Epidemic' initiative aiming to reduce new infections by 75% by 2025 and 90% by 2030, focusing on 57 priority jurisdictions.⁴ The Affordable Care Act expanded insurance coverage, improving access to prevention and treatment.

Prevention has evolved with pre-exposure prophylaxis (PrEP), a daily pill that reduces HIV acquisition risk by about 99% when taken consistently. Approved in 2012, PrEP uptake has increased but remains low among African Americans and Latinos due to cost, awareness, and stigma.⁵ Undetectable = Untransmittable (U=U) is a scientifically proven concept that people with an undetectable viral load cannot sexually transmit HIV, reducing stigma and encouraging testing.

Treatment with ART can achieve viral suppression, and newer long-acting injectable regimens offer alternatives to daily pills. However, only about 65% of people with HIV have achieved viral suppression, highlighting gaps in care continuity.¹

Racial and ethnic disparities persist: African Americans represent 13% of the population but 42% of new HIV diagnoses in 2021.¹ Social determinants such as poverty, housing instability, and medical mistrust contribute to these inequities. The South's higher rates are linked to conservative policies, lack of Medicaid expansion, and rural healthcare shortages.²

Stigma remains a major barrier, particularly in minority communities, leading to delayed testing and treatment. Incarceration also plays a role, as the US has high HIV prevalence among prisoners, and reentry programs are crucial for continuity of care.

Beyond the well-known narrative, several lesser-known aspects merit attention. The first documented case of HIV in the US was a teenager, Robert Rayford, who died in 1969, suggesting the virus entered the country earlier than thought.⁶ The epidemic also fueled the development of the first protease inhibitors, which were initially tested in small clinical trials with activist involvement.

In the 1990s, the US government's policy of banning HIV-positive immigrants was not lifted until 2010, a fact often overlooked. Additionally, the epidemic has had a profound impact on the arts, with works like Tony Kushner's 'Angels in America' and the AIDS Memorial Quilt, which began in 1987 and now has over 48,000 panels.⁷

ART

Antiretroviral therapy, a combination of drugs that suppress HIV replication.

PrEP

Pre-exposure prophylaxis, a daily medication to prevent HIV infection.

U=U

Undetectable = Untransmittable, meaning an undetectable viral load prevents sexual transmission.

Viral suppression

Having a viral load below the detection limit, typically <200 copies/mL.