IDWeek 2023 reflections from an HIV clinician in the South

Returning home to Dallas after IDWeek 2023 in October, I reflected on my experience at the conference. While I was energized by the innovative research presented on HIV treatment and prevention, I was conflicted as a front-line HIV provider facing the HIV epidemic and associated health care disparities in the South. 

During the Joseph E. Smadel Lecture, Demetre Daskalakis, MD, MPH, who served as the deputy coordinator of the White House National Mpox Response, reflected on the 54 U.S. deaths attributed to the 2022 mpox outbreak. While listening to his words, my colleagues and I felt a collective gut punch. Three of those 54 lives were lost at our single institution due to concurrent uncontrolled HIV/AIDS, despite our best efforts to save them. (1) According to a Centers for Disease Control and Prevention report, 47% of the mpox deaths in the U.S. were in the South, and almost all deaths were in people with uncontrolled HIV. (2) 

The South carries a disproportionate burden of new HIV diagnoses, late diagnoses and morbidity compared to the rest of the country. In 2021, CDC estimates that 52% of all new HIV diagnoses in the U.S. were in the South, reflecting a higher rate of diagnosis than any other region, 17.5 per 100,000 population in the South compared to 10.9, 10.2 and 8.3 per 100,000 population in the West, Northeast and Midwest, respectfully. (3) Additionally, 1.3 million people with HIV in the U.S. were classified as having AIDS of which 40% were in the South. Deaths of any cause among persons with HIV were also more common in the South, with a 2.3 times higher death rate compared to people with HIV in the Midwest. 

Finally, the uptake of prevention interventions that might make an impact on new HIV diagnoses, like HIV pre-exposure prophylaxis, are lower in the South than in other regions. Despite over half of new diagnoses occurring in the South, only 38% of PrEP users are in the South. (4) Thus, the area of the country that most needs these interventions is struggling to implement them. 

“What is it like to practice in Texas?” This question came up frequently as I reunited with old friends and met new ones. In my state, as in much of the South, we face barriers and threats to providing effective HIV care and prevention to our communities that often feel insurmountable. However, there is no place I’d rather work in HIV medicine. Leading HIV research is often from scientists who witness only a fraction of incident HIV cases or AIDS-related opportunistic infections and malignancies experienced by those of us practicing in the South. There is an immense gap between the pace of scientific advancement in HIV medicine and successful implementation of the science in places that would most benefit. 

I call on the bright young investigators and clinicians who are hopeful to end the HIV epidemic. Come to the epidemic. Join us in the South and implement the science on a large scale. We need your voices to impact meaningful structural change, and we need your minds to find innovative solutions to address the barriers to ending the HIV epidemic in our communities.

References

1. Govind A, Lazarte SM, Kitchell E, et al. Severe Mpox Infections in People With Uncontrolled Human Immunodeficiency Virus. Clin Infect Dis. 2023;76(10):1843-1846. DOI:10.1093/cid/ciad052.
2. Riser AP, Hanley A, Cima M, et al. Epidemiologic and Clinical Features of Mpox-Associated Deaths — United States, May 10, 2022–March 7, 2023. MMWR Morb Mortal Wkly Rep. 2023;72:404–410. DOI: http://dx.doi.org/10.15585/mmwr.mm7215a5 
3. Centers for Disease Control and Prevention. HIV Surveillance Report, 2021; vol. 34. http://www.cdc.gov/hiv/library/reports/hiv-surveillance.html. Published May 2023. Accessed Oct. 18, 2023.
4. Deeper Look: PrEP. AIDSVu. Accessed Oct. 18, 2023. https://aidsvu.org/resources/deeper-look-prep/. 

Photo: Demetre Daskalakis, MD, MPH, delivered the Joseph E. Smadel Lecture, “Mpox: A Case Study of Syndemic Response,” at IDWeek 2023 in Boston on Oct. 12.