Over the past 30 years, prevention efforts have helped to dramatically reduce the rate of HIV infections in the United States.1-5 At the height of the epidemic, in 1985, 130,000 new infections were reported.5 That number declined to 41,000 by 2010.2 Since 2013, however, the number of new cases per year has held steady at around 39,000 per year (38,739 in 2017),1-4 prompting the Centers for Disease Control and Prevention (CDC) to conclude that “progress in HIV prevention has stalled.”2,3 In a February 2019 report, the CDC said that the decline in new cases has plateaued “because effective HIV prevention and treatment are not adequately reaching those who would benefit most from them.”4

This article describes the populations at high risk for HIV infection and reports the results of a collaborative, multifaceted educational intervention designed to reduce the documented disparities related to HIV care and prevention. The overarching goal of the curriculum was improving the ability of primary care clinicians to identify individuals at high risk for infection and to implement evidence-based strategies for prevention.

Populations at Greatest Risk
Black/African American and Hispanic/Latino populations in the United States are disproportionately affected by HIV. In 2017, 43% of all new infections were among Black/African Americans, even though they represent just 13% of the population.1,2 Hispanics/Latinos accounted for 26% of all new infections in 2017 but just 18% of the population.1,2 Women accounted for approximately 19% of all new HIV infections in 2017; black women represented 62% of these new infections.1,2

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While overall HIV infection rates in the United States have stabilized in recent years, they have remained highest among men who have sex with men (MSM), who represent about 4% of the US population6,7 but account for 76% of new HIV infections in men and 63% of all new infections (Figure 1).1,2 CDC researchers, reviewing data from 2009 to 2013, projected that 1 in 6 MSM would be diagnosed with HIV in their lifetime, including 1 in 2 black MSM, 1 in 4 Latino MSM, and 1 in 11 white MSM.8

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Figure 1. New HIV infections in the United States, 2017.1,2

A substantial portion of HIV infections occur among young MSM — defined as adolescents and young adults 13 to 24 years of age. In 2016, for example, young MSM accounted for 25% of new HIV infections among all MSM, and young black MSM accounted for 35% of new HIV infections among black MSM.3,4 Young MSM are often subjected to bullying, harassment, family disapproval, social isolation, and sexual violence, leading to poor self-esteem, emotional distress, suicide attempts, substance use, and risky sexual behavior.9

Overall, HIV infection rates among white MSM have declined in recent years, while rates have remained stable among black MSM and have increased among Hispanic/Latino MSM.1,2 Young black and Hispanic/Latino MSM are also less likely to receive adequate information about HIV prevention services or to receive pre-exposure prophylaxis (PrEP) than young white MSM.10-12 These minority groups also tend to have lower rates of adherence to antiretroviral therapy (ART).12

MSM are one of 5 “key populations” identified by the World Health Organization (WHO) who are disproportionately affected by HIV, stemming from specific high-risk behaviors as well as “legal and social barriers that further increase their vulnerability.”13 Key populations, according to WHO, also include people who inject drugs (accounting for 6% of new HIV infections in the US in 2017),1 people in prisons and other closed settings, sex workers, and transgender people.13

The rate of HIV infection among transgender individuals in the United States (1.4%) is nearly 5 times higher than the proportion of people living with HIV across the entire US population (0.3%), according to the 2015 US Transgender Survey, based on responses from 27,715 transgender individuals nationwide.14 Rates of HIV infection were higher among transgender women (3.4%), especially black transgender women (19%), as well as American Indian (4.6%) and Latina (4.4%) transgender women.14