Beyond Biomedical Breakthroughs: How Access Gaps Are Slowing the End of the U.S. HIV Epidemic

At U.S. Business Action To End HIV's 3rd Annual Coalition Meeting, hosted by Health Action Alliance in Washington, D.C., business leaders, policymakers, HIV experts, and community partners came together around a shared question: if we already have the tools to end the HIV epidemic, why aren’t we closer to the finish line?

Across plenary discussions and breakout cohorts, conversations converged on a similar observation: we are constrained less by scientific capability than by whether those tools reach the people and places that need them most. Recent U.S. data illustrate this gap:

- 𝗢𝗻𝗹𝘆 ~𝟭 𝗶𝗻 𝟰 𝗽𝗲𝗼𝗽𝗹𝗲 𝘄𝗵𝗼 𝗻𝗲𝗲𝗱 𝗣𝗿𝗘𝗣 𝗮𝗿𝗲 𝗰𝘂𝗿𝗿𝗲𝗻𝘁𝗹𝘆 𝗼𝗻 𝗶𝘁: Reaching the U.S. 2030 goal (90% fewer new infections) requires ~2.25M people on PrEP; as of 2024, only ~591K are.

- 𝗢𝗻𝗹𝘆 ~𝟲𝟳% 𝗼𝗳 𝗽𝗲𝗼𝗽𝗹𝗲 𝘄𝗶𝘁𝗵 𝗛𝗜𝗩 𝗮𝗿𝗲 𝘃𝗶𝗿𝗮𝗹𝗹𝘆 𝘀𝘂𝗽𝗽𝗿𝗲𝘀𝘀𝗲𝗱: ~1 in 3 adults living with HIV are virally suppressed, versus the 95% goal set by NHAS for 2025.

- 𝗣𝗿𝗼𝗴𝗿𝗲𝘀𝘀 𝗮𝗴𝗮𝗶𝗻𝘀𝘁 𝗻𝗲𝘄 𝗶𝗻𝗳𝗲𝗰𝘁𝗶𝗼𝗻𝘀 𝗵𝗮𝘀 𝘀𝗹𝗼𝘄𝗲𝗱: Year-over-year declines are ~25% slower than during the early 2000s–2018.

The costs of this access gap are substantial:

- 𝗛𝗜𝗩 𝗶𝘀 𝘁𝗵𝗲 𝗰𝗼𝘀𝘁𝗹𝗶𝗲𝘀𝘁 𝗽𝗿𝗲𝘃𝗲𝗻𝘁𝗮𝗯𝗹𝗲 𝗰𝗼𝗻𝗱𝗶𝘁𝗶𝗼𝗻 𝗶𝗻 𝘁𝗵𝗲 𝗻𝗮𝘁𝗶𝗼𝗻: HIV’s lifetime medical cost of ~$500K–$1M per person, like multiple sclerosis and Crohn’s, puts it among the costliest non-rare U.S. conditions.

- 𝗦𝗺𝗮𝗹𝗹 𝗱𝗿𝗼𝗽𝘀 𝗶𝗻 𝗣𝗿𝗘𝗣 𝗰𝗼𝘃𝗲𝗿𝗮𝗴𝗲 𝗰𝗿𝗲𝗮𝘁𝗲 𝗯𝗶𝗴 𝗲𝗽𝗶𝗱𝗲𝗺𝗶𝗰 𝗮𝗻𝗱 𝗰𝗼𝘀𝘁 𝗶𝗺𝗽𝗮𝗰𝘁𝘀: A modeled 3.3% annual decline in PrEP coverage over 10 years could yield ~8,600 additional infections and ~$3.6B in lifetime medical costs.

Ending the U.S. epidemic hinges on equitable, sustained access to prevention, diagnosis, and treatment. In line with CDC, HRSA, and implementation-science analyses, the discussions underscored recurrent structural barriers to that access:

- 𝗠𝗮𝗿𝗸𝗲𝗱𝗹𝘆 𝗹𝗶𝗺𝗶𝘁𝗲𝗱 𝗮𝘁-𝗵𝗼𝗺𝗲 𝘁𝗲𝘀𝘁𝗶𝗻𝗴 𝗼𝗽𝘁𝗶𝗼𝗻𝘀, driven by disruptive regulatory shifts, despite the need for quarterly HIV testing for oral PrEP and twice-yearly testing for injectable PrEP.

- 𝗖𝗼𝘀𝘁 𝗮𝗻𝗱 𝗶𝗻𝘀𝘂𝗿𝗮𝗻𝗰𝗲 𝗯𝗮𝗿𝗿𝗶𝗲𝗿𝘀, including prior authorizations, step therapy, Medicaid gaps, high copays, and coverage churn.

- 𝗦𝗼𝗰𝗶𝗼𝗲𝗰𝗼𝗻𝗼𝗺𝗶𝗰 𝗶𝗻𝘀𝘁𝗮𝗯𝗶𝗹𝗶𝘁𝘆 𝗮𝘀 𝗮 𝗰𝗮𝗿𝗲 𝗯𝗮𝗿𝗿𝗶𝗲𝗿, which push visits, labs, and medication adherence down the priority list.

- 𝗖𝗹𝗶𝗻𝗶𝗰𝗮𝗹 𝘀𝘆𝘀𝘁𝗲𝗺 𝗴𝗮𝗽𝘀, including under-screening, under-prescribing of PrEP, and weak retention in care.

The initiatives led by Health Action Alliance illustrate how private-sector actors can help address structural barriers to access. As the national response evolves, sustained public–private collaboration will likely shape the trajectory of the U.S. epidemic as much as new biomedical advances, particularly in keeping equitable access central to the coalition’s work.