Sidebar: Working to Eliminate HIV in This Decade

In North Carolina, members of historically marginalized populations (HMP) continue to be disproportionately affected by the HIV epidemic. Rates of newly diagnosed HIV are nine times higher in African Americans and four times higher in the Hispanic population compared to the rate in non-Hispanic whites. Within the year following diagnosis, a lower proportion of African Americans (68%) and Hispanics (57%) achieve viral suppression compared to non-Hispanic whites (77%) [1].

Continued racial and ethnic disparities in HIV outcomes point to the clear need to link persons living with HIV in HMP to HIV care and the services necessary to support retention. The proportion of newly diagnosed persons living with HIV (PLWH) who achieve virologic suppression within the first year following diagnosis is higher than the average proportion of PLWH who have achieved virologic suppresion statewide, suggesting that providing enhanced linkage to care services at the time of diagnosis may improve HIV outcomes [1]. North Carolina has a robust HIV partner notication and linkage to care program that aims to provide culturally competent prevention services to newly diagnosed PLWH and individuals at high risk for HIV. Additionally, North Carolina has a statewide bridge counseling program specifically focused on improving retention in care and a database that enables these counselors to identify who may have fallen out of care or out of viral suppression.

With continually improving therapeutic HIV treatment and prevention options and the scientific certainty that you cannot transmit HIV if virally suppressed, North Carolina chose to update the Public Health Administrative Code in 2018 to state that PLWH who were reliably virally suppressed for at least six months did not need to tell their partners of their HIV status [2]. This aligns North Carolina with HIV science and is a critical step toward reducing the stigma of living with HIV.

It is now time to craft a detailed plan for how to eliminate the HIV epidemic in North Carolina, incorporating significant community, provider, and public health stakeholder input. In 2019, the North Carolina Division of Public Health (DPH) partnered with the North Carolina AIDS Action Network (NCAAN) to host 11 community meetings and two steering committee meetings across the state to engage communities in better understanding the social and structural barriers to HIV care. During these meetings, commonly mentioned barriers to retention in HIV care included the lack of transportation, stable housing, insurance, and flexible work hours that allow for care visits during standard clinic hours. DPH and NCAAN also heard clearly that stigma remains a significant factor in determining whether people feel comfortable seeking care. PLWH report stigma-related barriers to care including shame/embarrassment, judgmental behavior by providers (based on sexual orientation or gender identity, HIV transmission route, race/ethnicity, and even HIV status itself), and anxiety that family or friends will find out they sought care for HIV. In one-on-one interviews, the majority of PLWH reported feeling the need to be careful about to whom they disclose their HIV status, and nearly 40% reported being hurt by others’ reactions to learning of their HIV status (data not shown). It is apparent that work needs to be done in every setting to ensure that people seeking care or prevention services are respected and valued. DPH plans to create a new cultural humility trainingto address these issues since we understand that even one judgmental comment may prevent some clients from ever wanting to access care again. This training will be focused on HIV providers (case managers, social workers, and prescribers) with the stated intention of continuous learning about systemic racism, stigma, and cultural bias and its effect on health disparities.

The North Carolina Ending the Epidemic Plan has been written and will be released in the summer of 2021. The plan focuses on three main pillars required to end the HIV epidemic in North Carolina. Each pillar has three strategies outlining the action items needed to achieve success:

Pillar 1: Engage and Embrace in Care

• Improve access to antiretrovirals

• Normalize assessment and offer pre-exposure prophylaxis (PrEP) in all health settings

• Expand cultural humility training for all stakeholders

Pillar 2: Test and Treat

• Expand and increase testing for HIV/STD/viral hepatitis in traditional and nontraditional settings

• Ensure HIV/STI education for providers including antistigma education

• Social media campaign to promote HIV testing and prevention and reduce stigma

Pillar 3: Policy and Promotion

• Statewide promotion of Undetectable = Untransmittable (U=U) campaign

• Promote youth-serving sexual health programs

• In partnership with NCAAN, raise awareness in the community and with key stakeholders on the benefits of closing the coverage gap

DPH was able to identify certain efforts that can begin immediately, such as increasing emphasis on oral health, increasing accessing to insurance premium payments, and creating an electronic enrollment/eligibility determination system. As the Ending the Epidemic Plan is rolled out and implemented, all efforts will be assessed for success and failure using an anti-stigma lens to ensure that providing equitable and unbiased HIV prevention and care services remains a statewide priority. Ending the HIV epidemic is within reach in this decade. North Carolina will see the end of HIV if we deliberately and consciously address disparities and unequal access to HIV viral suppression and work to eliminate stigma and judgment around an HIV diagnosis.

• ©2021 by the North Carolina Institute of Medicine and The Duke Endowment. All rights reserved.