It is not uncommon to encounter in a hospital emergency room in San Francisco, Atlanta, New York City, or Washington, DC, a young man or woman with the diagnosis of life-threatening cryptococcal meningitis or pneumonia caused by Pneumocystis jirovecii as the first manifestation of HIV infection. How could this be possible in 2010, fully 3 decades into the epidemic in the United States? How could this be possible in a country that prides itself on the widespread availability of HIV testing and treatment options? How could this be possible in a country with broad access to health messages and a plethora of communication tools? How could this be possible in one of the richest countries on earth?
The answers to these questions are sobering. HIV in the United States is currently an invisible epidemic, largely confined to vulnerable and disenfranchised populations. It has disappeared from the public discourse. The prevailing perception is that HIV is a problem of the past, with few new infections and with miracle drugs available for all those living with HIV. Yet, beside the tragic anecdotes cited above, data indicate that there are an estimated 56,000 new infections per year in the United States, with an alarming impact on men who have sex with men and African American men and women. Great disparities remain in access to care and treatment for racial/ethnic minorities with HIV. How to address these disparities is the immediate challenge.
The articles included in this supplement focus on some of the populations who have been most heavily impacted by the domestic HIV epidemic, including disenfranchised women of color, men who have sex with men, transgender persons, and substance users. Some of the articles describe specific venues, both physical and virtual, that are common in the lives of people living with, and at increased risk for, HIV, such as prisons, bathhouses, and the Internet; others discuss some of the factors that potentiate susceptibility to infection, such as substance use and depression. This supplement also features a wide array of approaches designed to slow the tide of the epidemic, ranging from culturally nuanced social, behavioral, and structural approaches to biomedical interventions, such as HIV testing, vaccines, and the use of antiretroviral drugs for prevention. Another paper describes lessons from Africa that could inform the response to the US HIV epidemic. The underlying theme is that HIV is spread in diverse communities, influenced by multiple biological, behavioral, cultural, societal, economic, and structural factors, and that curbing the epidemic will require an extensive variety of tactics carefully titrated to the needs of communities and individuals.
The newly released National HIV/AIDS Strategic Plan, the first in the history of the epidemic in the United States, offers a fitting framework for action. This supplement to the Journal of Acquired Immunodeficiency Syndrome is an attempt at articulating a path ahead. Yet, substantial progress will not be achieved unless there is a concerted effort by the breadth of stakeholders to work together tirelessly and selflessly to reach defined priority goals. From policy makers to funders, researchers, providers, community organizations, and individuals living with HIV, all must be fully engaged in a united front to confront this epidemic in our midst. The time for action is now.