HIV in 2026: Four Experts on Aging, Testing, Equity, and Prevention's Next Era

For Contagion's HIV Awareness Month series, four clinicians and researchers across the spectrum of HIV care—a researcher studying ART-associated aging, a testing implementation scientist, a physician-researcher and public health leader, and a clinical development scientist behind the PURPOSE trials—addressed the questions that define the epidemic in 2026. Their answers, taken together, form an unusually coherent picture of where the field stands and where its most consequential unfinished work lies.

That observation, stated explicitly by Oni Blackstock, MD, MHS, founder and executive director of Health Justice, and implied by each of the other contributors, sits at the center of every conversation in this series. Lenacapavir (Yeztugo; Gilead Sciences), a twice-yearly injectable pre-exposure prophylaxis (PrEP) agent, reduced HIV incidence by 100% in cisgender women and adolescent girls in the PURPOSE 1 trial (NCT05568355) and by 96% in gay, bisexual, and other men who have sex with men, transgender women, transgender men, and gender nonbinary individuals in PURPOSE 2.^1,2 The approval of lenacapavir for HIV prevention in June 2025 added to a toolkit that already included oral PrEP, cabotegravir (Apretude; ViiV Healthcare), same-day ART initiation, and Undetectable = Untransmittable (U=U)—a suite of interventions sufficient to end new transmission if equitably deployed.

READ MORE>>The HIV Equity Crisis: What the Data Says About Who We're Still Failing

They are not being equitably deployed. An estimated 13% of people living with HIV in the United States remain unaware of their status.³ Approximately 2.2 million Americans could benefit from PrEP; roughly 600,000 used any form of it in 2024.⁴ Approximately 700 new HIV infections occur in the US each week, disproportionately affecting Black communities in the South, where Medicaid non-expansion compounds insurance barriers and where the legacy of redlining continues to concentrate poverty and limit healthcare access.⁵

Testing is still the front door—and the door is still closed for too many people

Joanne Stekler, MD, MPH, a professor in the Division of Allergy and Infectious Diseases at the University of Washington, has spent her career studying why. The USPSTF recommends universal opt-out HIV screening for all adults aged 15 to 65, regardless of perceived risk. The CDC has maintained similar guidance for 2 decades, and the clinical infrastructure for rapid diagnosis and same-day treatment linkage exists in most settings.⁶ None of this has produced consistent implementation outside of HIV specialty care and select primary care practices.

As Stekler told Contagion, the problem is not technical—it is cultural and logistical. Primary care providers are overburdened, risk-based thinking persists despite guideline recommendations, and HIV testing has not been normalized into the routine of emergency departments, urgent care settings, or inpatient units where undiagnosed patients are most likely to appear. Point-of-care tests, FDA-approved self-tests in both oral fluid and fingerstick formats, and same-day treatment initiation have removed the barriers that once made a positive result the beginning of a long, uncertain wait. What remains is the structural inertia of a system not designed to prioritize this work.

READ MORE>>The HIV Testing Gap and What Clinicians Can Do About It

Structural barriers—not individual behavior—explain HIV disparities in Black communities

Blackstock was direct on this point. HIV disparities in Black communities in the United States are rooted in the absence of universal health care, in the concentration of the epidemic in Southern states that have declined to expand Medicaid, and in the long shadow of discriminatory housing policy. Redlined neighborhoods—those tagged as high-risk for federally backed mortgages in the 1930s—still carry elevated rates of poverty, food insecurity, unstable housing, and limited healthcare access that function collectively as barriers to HIV testing, prevention, and treatment.⁵ The Ending the HIV Epidemic (EHE) initiative showed what investment can accomplish: new infections fell 21% in EHE-funded jurisdictions from 2017 to 2022, compared with a smaller national decline.⁷ The federal funding scaffolding that makes those programs possible now faces significant pressure at a moment when the field has its most powerful prevention tool yet.

Adherence has been the limiting factor in PrEP, but long-acting options change that equation

Jared Baeten, MD, PhD, senior vice president of clinical development and virology therapeutic area head at Gilead Sciences and an affiliate professor at the University of Washington, called out the most consequential data point in the PURPOSE trials: not the topline efficacy numbers, but the adherence data. In PURPOSE 1, more than 90% of women received lenacapavir injections on time and maintained 6 months of protection per injection; just 4% of those assigned daily oral PrEP achieved high and sustained adherence.¹ The implications are direct: removing the burden of daily dosing allowed the populations most at risk to remain protected in ways that a daily pill, however effective in controlled conditions, has not reliably delivered in real-world settings.

READ MORE>>Lenacapavir and the Future of HIV Prevention: PURPOSE Trials, Long-Acting PrEP, and What Comes Next

Lenacapavir is not a one-size-fits-all solution—Baeten emphasized that oral daily PrEP remains appropriate and effective for many patients, and the clinical goal is expanding options so individuals can choose the approach that will work for their lives. But the scale of the efficacy and adherence data from PURPOSE establishes long-acting injectable PrEP as a primary option for patients whose circumstances have historically made consistent daily pill-taking difficult.

People with HIV are aging, and the clinical infrastructure has not caught up

The fourth thread in this series is the least visible in policy debates but among the most clinically urgent. Kristine M. Erlandson, MD, MS, professor of medicine at the University of Colorado School of Medicine, whose research focuses on physical function, frailty, and multimorbidity in older adults with HIV, described a demographic reality that is reshaping ID practice: more than half of people living with HIV in the United States are now over 50,³ they are experiencing accelerated aging across virtually every cellular pathway implicated in the biology of aging; and the clinical frameworks for managing their complexity—geriatric assessment, polypharmacy review, and cardiovascular risk stratification—were not designed with them in mind.

READ MORE>>Aging With HIV: Managing Comorbidities in a Population That Has Outlived Its Prognosis

HIV-associated neurocognitive disorder (HAND) affects an estimated 40% to 50% of people living with HIV across all age groups;⁸ cardiovascular disease remains the leading non-AIDS cause of death in this population, even on suppressive therapy, with REPRIEVE data now driving AHA statin guideline changes specific to HIV;⁹ frailty is documented in people with HIV in their 40s and 50s. For ID clinicians, this means geriatric frameworks—screening with the EACS 3-question cognitive battery or the Mini-Cog, aggressive cardiovascular risk management, and proactive drug-drug interaction review using resources such as the Liverpool HIV Drug Interactions tool—should be applied earlier and more systematically than they currently are.

What will it take to end the HIV epidemic?

The absence of effective tools does not constrain the HIV epidemic in 2026. It is constrained by the structures that determine who can access them — insurance systems, housing policy, provider training, clinical workflow design, and the political will to fund the programs that bring evidence-based interventions to the people who need them most. The four conversations in this series, read together, offer both a clinical action agenda and a broader argument: the patients who have outlived the prognosis of the early epidemic, the people who remain undiagnosed, the people for whom daily pill-taking has never been a realistic option, and the communities that have borne a disproportionate share of the burden since the beginning all deserve a healthcare system built for the complexity and the scale of the challenge they represent.

References

1. Bekker LG, Rabe L, Spiegel H, et al. Twice-yearly lenacapavir for HIV prevention in women. N Engl J Med. 2024;391(21):1966-1980. doi:10.1056/NEJMoa2407001

2. Landovitz RJ, et al. Lenacapavir for HIV prevention in men who have sex with men and transgender individuals: PURPOSE 2. Presented at: International AIDS Conference; 2024; Munich, Germany.

3. Centers for Disease Control and Prevention. HIV Surveillance Report, 2022; vol. 34. Published May 2024. Accessed June 2026. https://www.cdc.gov/hiv/library/reports/hiv-surveillance.html

4. Centers for Disease Control and Prevention. PrEP for HIV prevention in the US. Accessed June 2026. https://www.cdc.gov/hiv/risk/prep/index.html

5. Nardone A, Casey JA, Morello-Frosch R, Mujahid M, Balmes JR, Thakur N. Associations between historical residential redlining and current age-adjusted rates of emergency department visits due to asthma across eight cities in California: an ecological study. Lancet Planet Health. 2020;4(1):e24-e31. doi:10.1016/S2542-5196(19)30241-4

6. US Preventive Services Task Force. Screening for HIV infection: US Preventive Services Task Force recommendation statement. JAMA. 2019;321(23):2326-2336. doi:10.1001/jama.2019.6587

7. Centers for Disease Control and Prevention. Ending the HIV Epidemic in the U.S. (EHE): Program Overview and Progress. Updated 2024. Accessed June 2026. https://www.cdc.gov/endhiv/index.html

8. Saylor D, Dickens AM, Sacktor N, et al. HIV-associated neurocognitive disorder — pathogenesis and prospects for treatment. Nat Rev Neurol. 2016;12(4):234-248. doi:10.1038/nrneurol.2016.27

9. Grund B, Carr A, Dongen MV, et al; REPRIEVE Investigators. Statin therapy to prevent cardiovascular disease in adults with HIV. N Engl J Med. 2023;389(14):1273-1283. doi:10.1056/NEJMoa2307888