IN FLORIDA—It's a Tuesday afternoon in April, and doctors at the adult HIV/AIDS clinic at Jackson Memorial Hospital in Miami face their usual onslaught of patients. There's the young, recently diagnosed gay man from Venezuela here for his first appointment. An older gay man who emigrated from Colombia and has been treated at the clinic for 18 years. A 37-year-old Massachusetts native who is battling a heroin addiction, has a drug-related heart condition, and has done time for selling sex. Rounding out the queue are an undocumented grandmother from the Dominican Republic, a mentally challenged and occasionally homeless African-American woman, and an elderly Haitian woman in a wheelchair.
The mosaic of patients represents the major drivers of HIV's spread and the communities hard hit by AIDS in the United States. And it helps explain why in 2016, Miami had the highest new infection rate per capita of any U.S. city: 47 per 100,000 people, according to the Centers for Disease Control and Prevention (CDC). That's more than twice as many as San Francisco, New York City, or Los Angeles.
"Miami is the epicenter of the epicenter of HIV/AIDS in the United States," says Mario Stevenson, a virologist with a thick Scottish brogue who heads the infectious disease department at the University of Miami (UM) Miller School of Medicine, which shares a campus with Jackson Memorial. "There's no abatement in our upward slope."
The rest of the state isn't faring much better. Fort Lauderdale, Orlando, and Jacksonville also made the list of top 10 U.S. cities for rate of new HIV diagnoses. And more HIV infections progress to AIDS here than in any other state, in part because many infected people who start taking antiretroviral (ARV) drugs don't stick with them.
Stevenson, who specializes in HIV cure research, left Massachusetts for Florida in 2010. Since then, he has reached beyond probing how HIV hides in chromosomes to also addressing why the virus still infects and sickens so many people walking the streets outside his lab. "Stemming the tide is going to need more than just working at the bench doing molecular biology," says Stevenson, who has pushed UM to bring together affected communities, legislators, and the Florida Department of Health (DOH) to better coordinate the response to their epidemic. "We're saying, ‘Hey, guys, we're in a mess.’
As Florida's HIV/AIDS caseload keeps growing, more leaders are calling for change. Stevenson helped spearhead a task force that last year issued a report called Getting to Zero for Miami. The report built on the treatment-as-prevention principle of the international Ending AIDS movement: Infected people rarely transmit the virus or develop AIDS if they know their status and take ARVs. The report urged Miami to strengthen its testing and treatment efforts—as has happened in San Francisco, New York state, and Vancouver, Canada—and it promoted a proven prevention strategy called pre-exposure prophylaxis (PrEP): giving ARVs to uninfected people who are at high risk. At the state level, the same agenda is at the heart of DOH's plan to eliminate HIV transmission and AIDS deaths, which it has rolled out, albeit slowly, over the past few years.
Florida has made some progress, but Stevenson knows the path ahead will be rough. He and others complain that state officials have turned away federal funding for prevention and care, limited sex education, and generally downplayed the problem. The reformers say that in addition to politics, they must tiptoe around cultural minefields, slash through excessive bureaucracy, and tackle the stigma that compromises HIV/AIDS efforts everywhere. Read more via Science