Over the course of two weeks, hurricanes Helene and Milton devastated parts of the southeast and Appalachia. As of the date of publication, the death toll from Hurricane Helene alone is more than 230, and many are still missing. Storms and other extreme weather events are becoming more common: 2023 was the costliest year for climate disasters in the United States. Communities that are already vulnerable are experiencing disasters more often, and climate havens are now suffering through deadly events for which they have never had to prepare.
While extreme weather events have broad negative health impacts, those with chronic health conditions, such as HIV, are particularly vulnerable during and following these disasters. In 2022, the Centers for Disease Control and Prevention (CDC) estimated that 1.2 million people over the age of 13 in the United States are living with HIV. These individuals are extremely vulnerable to climate change because they depend on consistent access to providers, medications, and other support services to stay alive—and climate crises often disrupt access to these resources.
From 2018 to 2022, the estimated incidence of HIV in the United States fell roughly 12 percent. However, climate change threatens care for a disproportionate number of these new and existing cases: The South, one of the most climate-vulnerable regions in the country, saw 52 percent of all new HIV diagnoses in the United States in 2022, meaning these individuals may face heightened barriers to care.
What does HIV health care involve?
Prevention of HIV includes transmission mitigation tools, such as preexposure prophylaxis (PrEP) and post-exposure prophylaxis (PEP), as well as frequent testing in health care settings or through self-testing.
People diagnosed with HIV can manage the condition through prescription of antiretroviral therapies (ART). ART is a suite of medications that need to be taken daily to prevent HIV from harming the immune system. People living with HIV are also more susceptible to opportunistic infections because of their weakened immune system and need to have access to providers who know their health care history and risks. Patients must follow their daily HIV regimen to remain healthy and reach undetectable viral status, meaning the viral load is so low that HIV can no longer be sexually transmitted. Reaching this stage usually takes six months after starting ART.
If an HIV-positive individual has access to ART and other health care tools, they can live a “long and healthy” life. However, if someone is HIV-positive and does not take ART, they may develop AIDS. The rate of HIV progression varies from person to person, and in some cases, an individual may live with HIV for as long as 15 years before they develop AIDS, even without ART.
To build on these health care tools, in 2019, the U.S. Department of Health and Human Services (HHS) launched the Ending the HIV Epidemic in the U.S. (EHE) program to direct resources to 57 high-priority areas, where almost 50 percent of all HIV diagnoses occur or where a substantial number of diagnoses in rural areas exist. These areas collectively were home to 644,905 people diagnosed with HIV in 2022, according to CAP analysis of the EHE program data. The program aims to improve these areas’ HIV/AIDS prevention and treatment strategies and ultimately reduce the rate of new infections by 90 percent by 2030. The EHE priority areas include 48 counties; Washington, D.C.; San Juan, Puerto Rico; and seven states: Alabama, Arkansas, Kentucky, Mississippi, Missouri, Oklahoma, and South Carolina.
HIV health care and climate resilience
To reduce new transmissions and keep people living with HIV healthy, the goal is to reach undetectable status. Any disruption in medications can make the viral status detectable, which increases the potential for new HIV transmissions and the progression of HIV, as well as the risk of other health conditions and opportunistic infections.
CAP analysis of the Federal Emergency Management Agency’s (FEMA) 2023 National Risk Index shows the average climate risk index score for the 50 high-priority EHE jurisdictions where almost 50 percent of all HIV diagnoses occur is 96.8 out of 100. This means that roughly 1 in 2 people living with HIV are living in some of the nation’s most at-risk areas.
While there is limited research on the direct connection between HIV and climate change in the United States, researchers have shown that heavy rain in Miami led to lower rates of HIV care retention. People living with HIV also experienced worsened health outcomes after wildfires in California.
However, it’s well-documented that climate disasters can cause disruptions to health care access and result in increased severity of chronic conditions, including many of the secondary conditions that people with HIV may develop. People living with HIV are more susceptible to respiratory infections, such as pneumonia or severe cases of flu or COVID-19. This puts them at higher risk of worsening health when disasters increase exposure to air pollutants or extreme heat. Disasters can also exacerbate the side effects of medications, including ART, that people living with HIV take to manage their health.
Social factors contributing to disproportionate climate impacts on certain groups, including many living with HIV
Extreme weather events can also lead to unstable housing, food insecurity, and economic insecurity. These aftereffects pose significant threats to the health, safety, and well-being of those living with HIV.
Solutions
Climate change is a structural problem that needs structural solutions. In October 2024, HHS updated its clinical guidance for providers who need to care for displaced HIV populations. Updated and thorough materials like these are a critical part of a whole-of-government approach in protecting people with HIV from climate change.
Guarantee care for people living with HIV during a disaster
Ensuring that HIV planning councils are part of disaster response and recovery efforts will help connect people living with HIV to appropriate supports. To mitigate mistrust of health care systems, FEMA-coordinated disaster shelters should always include staff who have the most up-to-date information on HIV clinical treatment, support programs, and other tools to create stigma-free shelters.
The CDC’s take-home HIV test program could be mobilized in disaster situations to mitigate postdisaster transmission, since the highest level of infectious viral secretions occurs in the first 10–12 weeks after infection. Ensuring access to ART during and after emergencies is also crucial to keeping patients undetectable. The AIDS Drug Assistance Program (ADAP) and the Emergency Prescription Assistance Program (EPAP) are important programs during climate disasters but are only helpful if pharmacies are still accessible.
Integrate climate adaptation in the Ryan White program
Policymakers can push for additional funding for the Ryan White HIV/AIDS Program to prepare for and respond to climate emergencies. Changes to the ADAP—an initiative under the Ryan White program—could be made to supplement the existing EPAP. The Ryan White program consists of providers, care delivery sites, and community partners, which are already integrated into local health care systems and can make the most efficient use of any climate emergency funding.
Policymakers could use Part F of the Ryan White program to direct funds toward climate resilience and adaptation via the Special Projects of National Significance Program and the AIDS Education and Training Center Program, which provides free online training for providers.
At the local level, public health officials and HIV/AIDS program leaders can work to incorporate climate experts on each HIV planning council; these councils are statutorily obligated to include HIV/AIDS health care providers, HIV/AIDS community-based organizations, social service providers, people living with HIV or AIDS, and other HIV/AIDS expert groups. State and local actors can also make use of existing funding programs, such as FEMA’s preparedness grants, to implement climate resilience strategies in their HIV-related work. FEMA can help ensure preparedness funds and other relevant grants reach the most vulnerable communities.
Leverage data to prepare and respond
Stakeholders at all levels can leverage climate data alongside HIV health data to better anticipate and prepare for challenges. At the federal level, HHS can work with climate-vulnerable areas by providing technical assistance so that local officials can make use of the many data portals available. These portals, which include the National Integrated Heat Health Information System, the emPOWER Program, the Risk Identification and Site Criticality (RISC) Toolkit, the Climate Explorer, the Fifth National Climate Assessment, and the Environmental Justice Index, can help officials target resources to communities that are most vulnerable, such as those living with HIV.
Conclusion
People with HIV are at higher risk of living in an area hit by climate disasters and, due to their health status, of suffering outsize effects.
A holistic approach is necessary to protect these individuals’ health while making sure that climate change doesn’t unravel the progress that the country has already made to end the HIV epidemic in the United States.