The US Latino HIV Crisis – Ending an Era of Invisibility

Vincent Guilamo-Ramos, PhD, MPH, LCSW, RN, ANP-BC, PMHNP-BC, FAAN Leona B. Carpenter Endowed Chair in Health Equity and Social Determinants of Health Executive Director, The Institute for Policy Solutions, Johns Hopkins School of Nursing Director, Center for Latino Adolescent and Family Health

THE U.S. HAS ACHIEVED REMARKABLE PROGRESS IN ENDING THE HIV EPIDEMIC

The national strategy to end the HIV epidemic is working

An impressive multi- sector achievement

We have effective HIV prevention and treatment

o Government o Community o Public Health o Universities & Research o Private Sector o Media

The majority of PLWHIV are aware of their status and linked to care

We have integrated clinical and social HIV care that is highly effective (e.g., Ryan White: ~90% viral suppression)

Overall, there are fewer new HIV infections and life expectancy for PLWHIV has lengthened

There is societal progress in reducing HIV stigma and discrimination

Sources: HIV.gov; CDC. Monitoring selected national HIV prevention and care objectives by using HIV surveillance data — United States and 6 territories and freely associated states, 2022; HRSA. Ryan White HIV/AIDS Program Annual Data Report 2022.

DESPITE SIGNIFICANT OVERALL PROGRESS HIVINFECTIONSFORLATINOS AREINCREASING

New HIV Infections among Latinos (2010-2022 change)

Overall new HIV Infections Nationally (2010-2022 change)

+12%

– 19%

THESE INCREASES FOR LATINOS HAVE BEEN ONGOING

Source: CDC. NCHHSTP AtlasPlus. Accessed September 12, 2024. https://www.cdc.gov/nchhstp/atlas/index.htm

THE EPIDEMIC IS CONCENTRATED AMONG LATINO MEN WHO HAVE SEX WITH MEN A HISTORY OF INVISIBILITY DESPITE PROLONGED INCREASES IN HIV INFECTIONS AMONG LATINOS

Percent Change in Estimated Annual New HIV Infections Relative to 2010

In 2020, a national group of Latino stakeholders collectively raised the alarm about an INVISIBLE HIV CRISIS AMONG LATINOS .

100 15

+95% Latino MSM aged 25-34 +12% Latino

80 10

+24% Latino MSM

-5

-10

+12% Latino

-15

-19% U.S. Overall

-20 -20

-40 -25

Sources: Guilamo-Ramos V, et al. The Invisible Hispanic/Latino HIV Crisis. AJPH. 2022;110(1):27-31. ;

CDC. NCHHSTP AtlasPlus. Accessed September 12, 2024. https://www.cdc.gov/nchhstp/atlas/index.htm

THE EPIDEMIC IS CONCENTRATED AMONG LATINO MEN WHO HAVE SEX WITH MEN A HISTORY OF INVISIBILITY DESPITE PROLONGED INCREASES IN HIV INFECTIONS AMONG LATINOS

Percent Change in Estimated Annual New HIV Infections Relative to 2010

In 2020, a national group of Latino stakeholders collectively raised the alarm about an INVISIBLE HIV CRISIS AMONG LATINOS .

100

+95% Latino MSM aged 25-34

+24% Latino MSM

+12% Latino

-19% U.S. Overall

-20

-40

Sources: Guilamo-Ramos V, et al. The Invisible Hispanic/Latino HIV Crisis. AJPH. 2022;110(1):27-31. ;

CDC. NCHHSTP AtlasPlus. Accessed September 12, 2024. https://www.cdc.gov/nchhstp/atlas/index.htm

THE CURRENT STATE OF THE U.S. LATINO HIV EPIDEMIC

In 2022:

! !

Latinos accounted for 1 in 3 of all estimated new HIV infections in the U.S.

Latino MSM accounted for more estimated new HIV infections than MSM of any other racial or ethnic group

The number of annual new HIV diagnoses among transgender Latina women increased by 94% (between 2014 and 2022) *

(compared to 1 in 4 in 2010)

*Note: Incidence Data Not Available

Source: CDC. NCHHSTP AtlasPlus. Accessed September 12, 2024. https://www.cdc.gov/nchhstp/atlas/index.htm

INEQUITABLE HIV PREVENTION PROGRESS AMONG LATINOS

Number of people on PrEP per new HIV diagnosis, 2021

Prevention: PrEP reach is inequitable

Inequity (avoidable, unjust, unfair)

White

Latino

Adapted from Sullivan et al.

Soource: Sullivan PS, et al. Equity of PrEP uptake. The Lancet Regional Health – Americas. 2024:1;33.

INEQUITABLE HIV TESTING PROGRESS AMONG LATINOS

Testing:

In each year between 2017 and 2022, Latinos living with HIV (compared to people living with HIV overall) were more likely to be unaware of their status.

Latino Overall

18%

17%

16%

14%

13%

2017

2018

2019

2020

2021

2022

Reported percentages correspond to the prevalence-based care continuum (based on diagnosed and estimated undiagnosed cases)

Sources: CDC. NCHHSTP AtlasPlus. Accessed September 12, 2024. https://www.cdc.gov/nchhstp/atlas/index.htm; CDC. HIV Surveillance Supplemental Report 2024;29(No. 2).

INEQUITABLE HIV CARE PROGRESS AMONG LATINOS

Receipt of HIV Care:

In each year between 2017 and 2022, Latinos living with HIV (compared to people living with HIV overall) were more likely to not receive any HIV care.

Latino Overall

29%

28%

27%

26%

25%

24%

2017

2018

2019

2020

2021

2022

Reported percentages correspond to the diagnosis-based care continuum (based on diagnosed cases only)

Sources: CDC. NCHHSTP AtlasPlus. Accessed September 12, 2024. https://www.cdc.gov/nchhstp/atlas/index.htm; CDC. HIV Surveillance Supplemental Report 2024;29(No. 2).

INEQUITABLE HIV CARE PROGRESS AMONG LATINOS

HIV Viral Suppression:

In each year between 2017 and 2022, Latinos living with HIV (compared to people living with HIV overall) were more likely to not achieve viral suppression.

Latino Overall

38%

37%

36%

35%

34%

2017

2018

2019

2020

2021

2022

Reported percentages correspond to the diagnosis-based care continuum (based on diagnosed cases only)

Sources: CDC. NCHHSTP AtlasPlus. Accessed September 12, 2024. https://www.cdc.gov/nchhstp/atlas/index.htm; CDC. HIV Surveillance Supplemental Report 2024;29(No. 2).

STIGMA AND DISCRIMINATION IS COMMON FOR LATINOS LIVING WITH HIV

Types and prevalences of discrimination among Latinos living with HIV who reported any healthcare discrimination

“ HIV stigma and discrimination experiences in an HIV health care setting were commonly reported among Hispanic persons with HIV . ”

Figure visually adapted

Sources: Padilla M, et al. HIV stigma and health care discrimination experienced by Hispanic or Latino persons with HIV — United States, 2018 – 2020. MMWR. 2022;71(41).

LACK OF PROGRESS DESPITE ALARMS

2019

2024

2019

2024

2019

THE LATINO HIV EPIDEMIC – EMBLEMATIC OF BROADER HEALTH AND HEALTHCARE INEQUITIES IN THE U.S.

o In June 2024, the National Academies of Sciences, Engineering, and Medicine released Ending Unequal Treatment

Ending Unequal Treatment in the United States Health Care System

o The consensus report examined the current state of racial and ethnic healthcare inequities in the U.S.

o Health inequities are avoidable , unfair , and unjust

o The report found limited overall progress in reducing inequities over the past two decades

o The report is relevant for understanding and responding to the lack of progress in reducing new HIV infections for Latinos

Source: National Academies of Sciences, Engineering, and Medicine. Ending Unequal Treatment: Strategies to Achieve Equitable Health Care and Optimal Health for All. Washington, DC: National Academies Press, 2024.

THE LATINO HIV EPIDEMIC – EMBLEMATIC OF BROADER HEALTH AND HEALTHCARE INEQUITIES IN THE U.S.

o In June 2024, the National Academies of Sciences, Engineering, and Medicine released Ending Unequal Treatment

Ending Unequal Treatment in the United States Health Care System

o The consensus report examined the current state of racial and ethnic healthcare inequities in the U.S.

o Health inequities are avoidable , unfair , and unjust

o The report found limited overall progress in reducing inequities over the past two decades

o The report is relevant for understanding and responding to the lack of progress in reducing new HIV infections for Latinos

PROVIDING CONTEXT FOR THE LACK OF HIV PROGRESS AMONG LATINOS AND OPPORTUNITIES TO AMPLIFY THE NATIONAL RESPONSE

4 Critical Latino-specific Challenges

Latino Invisibility

Latino Prevention & Treatment Inequities

Latino-Specific Local HIV Service Implementation

Context and Structural Drivers of Latino HIV Inequities

Opportunities to Amplify the Response

o Increase Latino leadership in public health, HIV care administration, and health policy

o Engage national media in framing solutions to the U.S. Latino HIV crisis

o Invest in culturally and linguistically tailored public health communications campaigns in Latino communities

o Prioritize Latino-specific HIV program development in federal and local agencies ’ HIV responses and funding

LATINO INVISIBILITY

o Institutionalize the collection and reporting of Latino patients ’ ethnicity, race, language, sexual orientation, and gender identity data in all health and governmental institutions

o Fund solutions-oriented research to identify Latino inequities and levers to eliminate them (e.g., such as NINR and NIMHD investments)

Opportunities to Amplify the Response

o Establish measurable goals to eliminate Latino HIV prevention and treatment inequities

o Expand comprehensive HIV care models that integrate clinical, behavioral (e.g., substance use services), and social care

o Redefine the HIV workforce ; there is a need for new roles and better representation of the Latino community, and better cultural/linguistic preparedness o Remove restrictions to non-physician HIV care workers ’ ability to practice at the highest levels of their education and licenses (e.g., nurses, pharmacists, PAs)

LATINO PREVENTION & TREATMENT INEQUITIES

o Eliminate implicit and explicit biases, stigma, and discrimination of Latinos in HIV prevention and treatment services

HEALTH WORKFORCE REPRESENTATIVENESS – WE KNOW IT MATTERS FOR ELIMINATING INEQUITIES

Ending Unequal Treatment:

“ A diverse health and science workforce, representative of the communities that it serves, is essential to health care equity .

The nation has made little progress addressing this goal.

Recent court decisions concerning diversity, equity and inclusion serve to further limit progress in achieving a diverse workforce. ”

2024

Opportunities to Amplify the Response

o Implement Latino-specific and contextually tailored response plans within each of the EHE priority jurisdictions

o Ensure meaningful Latino grassroots community engagement in the development and implementation of local HIV prevention and treatment programs o Allow flexibility in local implementation and resource allocation while ensuring accountability to Latino community needs o Engage multisectoral local partners to address HIV in Latino communities, including private sector , universities , local media , community-based organizations , healthcare , public health , and local government.

LATINO-SPECIFIC LOCAL HIV SERVICE IMPLEMENTATION

Opportunities to Amplify the Response

o Enact evidence-based laws and policies that increase (not reduce) access to HIV prevention and care (e.g., ACA section 1557 enforcement; removal of HIV criminalization laws, anti-LGBTQ+ rights laws) o Scale-up of policies/programming to eliminate root causes of Latino health inequities , such as systemic/structural racism, anti- immigrant sentiment, LGBTQ+ discrimination, substance use stigma, medical mistrust (e.g., CDC ’ s Confianza initiative), etc.

CONTEXT & STRUCTURAL DRIVERS OF LATINO HIV INEQUITIES

o Focus greater attention to the harmful SDOH that disproportionately affect underserved Latino communities, including Latinos with undocumented status

o Mobilize collective societal and political will , commitment , and accountability to end HIV among Latinos

ELIMINATING LATINO HIV INEQUITIES IS POSSIBLE

Ending Unequal Treatment identifies societal and political divides as major risks preventing the investments needed to eliminate health and healthcare inequities

A Common Myth :

o Focused investments in eliminating Latino HIV inequities represent a zero-sum game — for Latinos to make progress, others lose

But, evidence shows :

o Eliminating HIV inequities among Latinos has the potential to improve outcomes for everyone

o Not addressing Latino inequities will negatively impact everyone

A CALL TO ACTION – WE KNOW HOW TO ELIMINATE HIV INEQUITIES FOR LATINOS

Yes and No:

2023

o We have made tremendous progress toward ending the U.S. HIV epidemic

o However, there are ongoing HIV inequities among Latinos

o Collectively, we have the responsibility to prioritize Latinos now – we know how to do this

o Without a collective multi-sector investment in the Latino community , we cannot end the U.S. HIV epidemic

A CALL TO ACTION – HELP US END THIS ERA OF INVISIBILITY AND INEQUITY FOR LATINOS

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Source: Guilamo-Ramos, V., Thimm-Kaiser, M., Benzekri, A. (2024). The U.S. Latino HIV Crisis — Ending an Era of Invisibility. New England Journal of Medicine. doi: 10.1056/NEJMp2406595

¡ADELENTE! SUMMIT: A WHITE HOUSE CONVENING TO ACCELERATE OUR NATION ’ S HIV RESPONSE IN HISPANIC/LATINO COMMUNITIES

On September 24, 2024:

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• Had a central goal to elevate visibility of the HIV epidemic in Hispanic/Latino communities and inspire collective action nationwide .

• Was hosted by the White House Office of National AIDS Policy (ONAP)

• Brought together a diverse group of leaders invested in the health and well-being of our nation and Hispanic/Latino communities

Thank You!

Dr. Vincent Guilamo-Ramos Executive Director, Institute for Policy Solutions

Please send any questions or comments to: VincentRamos@jhu.edu

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