Where do we go from here: HIV prevention in Tennessee and beyond

As the HIV scientific community gathers this week for the 30th Conference on Retroviruses and Opportunistic Infections in Seattle to discuss progress and opportunities in HIV prevention and treatment, the HIV community in Tennessee is bracing for major setbacks in our state’s HIV response. This follows an announcement in January by Tennessee officials that effective in May they would reject more than $8 million in HIV prevention funding from the Centers for Disease Control and Prevention that underpins our state’s surveillance and prevention programs.  

The abrupt decision will have long-lasting impacts throughout the state and, we fear, beyond. We in the infectious diseases and HIV community must effectively reach and educate policymakers on what it will mean to turn back the advances in HIV prevention achieved over the last four decades.      

As has been reported in the press, in announcing the decision to discontinue the funding, Tennessee officials indicated their intention to replace the prevention programs supported by the CDC grants with state funding that will support new priority populations — mothers and their babies, people who have been sex trafficked and first responders — that do not reflect the individuals and communities most burdened HIV. In 2020, 59% of new HIV cases in Tennessee were among individuals who identified as Black, and more than 50% of newly diagnosed cases occurred through male-to-male sexual contact. amfAR estimates that eliminating the funding for prevention for key populations in Tennessee could result in more than 500 new HIV infections per year — which could cost the state and health system $255 million in additional treatment costs per year. Further, these changes could worsen disparities in HIV incidence and outcomes among racial and ethnic minorities and vulnerable key populations.

Ending the CDC grant funding also threatens the sustainability of a network of trusted community-based organizations that play an important role in providing HIV and sexually transmitted infection prevention services and more to Tennessee residents without other sources of care. The announcement has already ignited the dismantling of this critical network of community-based providers that we rely on as HIV care providers to conduct routine HIV testing in emergency rooms and other settings, provide pre-exposure prophylaxis, provide condoms, implement harm reduction programs and support our patients with linking and staying connected to care.

Shelby County, home to Memphis, ranks eighth in the nation for new HIV cases per year among large cities in the United States. Because of its high rate of HIV infection, Shelby County is one of 57 geographic areas included in the federal Ending the HIV Epidemic initiative. The county is now at risk of losing $2 million in funding from CDC to increase access to HIV prevention services and connect people with HIV to care — a loss that will be even more hard felt following the COVID-19 pandemic.

Even prior to this announcement, 11 counties in east and middle Tennessee have been identified as being highly vulnerable to HIV and hepatitis C outbreaks. Not surprisingly, rural areas with high rates of opioid use with poor access to primary and behavioral health care services have been found to be more vulnerable to HIV and viral hepatitis outbreaks. We know from past experience that ignoring these risks is costly to public health and to public and private health systems. The 2015 HIV outbreak in rural Indiana affected more than 200 people; it was estimated to upwards of $58 million taking into account lifetime health care costs. Tennessee is not alone in its vulnerability. CDC estimates that 220 counties in the U.S. are at risk for similar outbreaks.

HIV epidemic and pandemic response is not a partisan issue. President George W. Bush created the U.S. President’s Emergency Plan for AIDS Relief, or PEPFAR, in 2003, a program which has saved more than 20 million lives worldwide. More recently, Donald J. Trump launched the federal Ending the HIV Epidemic initiative in 2019 with a commitment to reduce HIV infections by 90% over the next decade.  

While it may be challenging, we as a community and a country must find a path forward for ensuring everyone who needs it can benefit from lifesaving HIV prevention and treatment. Turning our back on HIV prevention efforts will have tragic consequences.

Drs. Ahonkhai, Person and Pettit are IDSA and HIVMA members who provide HIV clinical care and conduct research in Nashville, Tennessee.