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Highly active retroviral drugs, first approved by the FDA in 1995, have vastly improved outcomes for HIV-positive people, but the virus is still spreading. In Harris and five surrounding counties tracked by the Ryan White Planning Council, more than 27,000 people are living with HIV. Each year, another 1,300 are diagnosed.

“We’d like to see new diagnoses going down,” says Amber Harbolt, health planner for the Ryan White Planning Council, “and we’re not moving the needle there for the past decade.” That’s true at the state and the national level, too, she adds.

To reduce the number of people with HIV, Houston must get as many affected people as possible into consistent treatment, while also preventing new people from contracting the disease. To that end, there have been two incredibly positive developments in the world of HIV treatment and prevention.

First, the antiretroviral drugs out now, if used properly, have the ability to suppress the virus. This means they’ll not only live much healthier lives, but also have an almost-zero chance of spreading the disease. Harris and surrounding counties are faring pretty well at treating those receiving consistent care, 84 percent of whom are virally suppressed, but we’re struggling to keep people in consistent treatment. Only 69 percent of those living with HIV here receive it; the hope is to push that number to 85 percent, at which point the spread of the virus will decrease.

The other major development is the 2012 release of PrEP—pre-exposure prophylaxis, a drug that, if taken correctly by someone who’s high-risk, will prevent them from getting HIV. PrEP has great potential to reduce the number of new cases—but only if people who need it can access it. “I can’t stress how much of a game-changer that is,” Harbolt says. “If we can get people who are at persistent high risk onto PrEP, then we can start to move that needle.”

The majority of new diagnoses in Houston are within poor black and Latino communities, which aren’t being adequately reached by traditional education campaigns, and where HIV testing is hard to get.

“HIV doesn’t occur in a vacuum, and the hardest-hit areas are combatting other issues—poverty, structural racism, classism, mental health and substance-abuse issues,” Harbolt says. “The future of prevention is … doing a lot to find people who are exposed to HIV early enough to get them on treatment, and finding people at high risk and getting them onto PrEP.”

Another big challenge locally is the aging population of people living with HIV. In 2015, 22 percent of those  living with HIV in Harris and surrounding counties were over 55. “That’s great because that’s people living longer and healthier lives,” says Harbolt, “but for long-term survivors, who became aware of their diagnosis in the late ’80s or early ’90s before the new medications came out, these people were preparing to die. They didn’t plan for retirement or caring for themselves in senior years.

“And because a lot of people aging with HIV now tend to be older white gay or bisexual men, many didn’t have their own families or children, many had family disinherit them or are estranged. And they’re not there to care for them.”

As the populations affected by HIV change and diversify, the systems in place to treat and prevent the disease—which largely started in the gay community at the grassroots level—also must evolve. That’s a tall task, considering the cultural differences, plus factors like poverty and lack of insurance.

“How do you provide care for people in a system that was built 20, 30 years ago for gay white men?” Harbolt asks. “How do you make that system work for a straight black man, a straight Hispanic woman?”

Adding to these challenges, as of this writing, President Donald Trump has proposed slashing global HIV/AIDS funding in 2019 by $1 billion, a 20 percent reduction that experts say would lead to 300,000 deaths a year internationally. Congress is expected to reject the cuts, but advocates are concerned the overall U.S. commitment to ending AIDS is waning.

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