As policy makers and HIV activists continue to focus on the optimal ways to stem the pandemic, it would be wise to pay attention to transportation and other social and economic factors that affect HIV prevention and treatment.

In September, the United States Conference on HIV/AIDS met in New Orleans and focused on HIV in the South. While researchers, activists and people with HIV will be flying in from around the country, ironically, many people who live in the South faced challenges in attending the conference due to the transportation challenges within the region. 

This is a chronic problem. The connection between transportation access and healthcare is vital but often overlooked, especially when it comes to HIV prevention and treatment. For those living with HIV or at risk of infection, reliable transportation plays a crucial role in accessing medical services, adhering to treatment, and maintaining health. In regions like the southern United States, where poverty and geographic barriers are more pronounced, transportation can be the difference between life-saving care and deteriorating health.

The Southern Struggle with Transportation

In southern states, challenges around transportation are exacerbated by several factors, including large rural areas with limited public transit and long distances between healthcare facilities. This transportation barrier is significant even within urban areas. According to research, southern cities like Louisville, Kentucky; and Memphis, Tennessee; have far fewer public transportation options compared to cities in other regions like Chicago or Boston. This region also faces historical and ongoing issues related to poverty, segregation, and underfunded public infrastructure. As a result, many people, especially those living in rural or low-income areas, struggle to find affordable, reliable transportation to medical appointments. And racism has also been a factor in the southern transportation systems, as transportation lines that reinforced racial segregation were often developed. The history of the Atlanta MARTA system, for example, demonstrates how public transportation decisions were made to limit the travel of Black people to historically white neighborhoods. 

Given the disproportionate impact of HIV in Black (37% of the new cases vs. 12% of the total population), the health-related transportation challenges are particularly harmful. For individuals with HIV, missing a medical appointment or not being able to pick up medication can have serious consequences, including disease progression and increased transmission risk.

Transportation as a Barrier to HIV Care

Transportation barriers are well-documented in their impact on healthcare access. A review of 61 studies found that transportation issues are a significant factor preventing low-income and uninsured individuals from accessing care. For people with chronic illnesses like HIV, this can lead to missed appointments, delayed treatments, and missed medication doses, all of which worsen health outcomes.

For people living with HIV, consistent access to healthcare is essential. They need to regularly visit doctors, attend follow-up appointments, and pick up medications. However, many individuals face significant hurdles just to get to these appointments. This problem is particularly pronounced in rural areas, where public transit is scarce, and even affordable options like Dial-A-Ride services may require booking trips days in advance. Without reliable transportation, many people are left without the care they need to manage their condition effectively.

Non-Emergency Medical Transportation (NEMT)

Non-Emergency Medical Transportation (NEMT) programs are designed to address some of these barriers by providing rides to medical appointments for Medicaid beneficiaries. These services are a lifeline for many people living with HIV, particularly in rural areas where other transportation options may not exist. However, NEMT has limitations, including strict eligibility requirements and the need for advance booking, which can still leave patients struggling to access timely care.

To qualify for NEMT, individuals must often meet specific criteria, such as not having a valid driver’s license or being unable to travel independently. For people with HIV, the stigma associated with the disease can add an additional layer of complexity. Some may opt to travel further away from home to seek care in a more accepting environment, which increases their transportation challenges.

Despite these obstacles, NEMT remains a critical service for many, but it is not enough on its own to close the transportation gap. There is a need for more comprehensive solutions that can address the broader issues of transportation access for people living with HIV.

Solutions and Innovations

Addressing transportation barriers for people with HIV requires a multi-faceted approach. Some innovative practices are already helping bridge the gap. For example, telehealth services and mobile clinics have expanded access to care in underserved areas, reducing the need for patients to travel long distances. Partnerships with ride-sharing services like Uber and Lyft have also emerged, offering free or subsidized rides to medical appointments.

Community-led initiatives have proven effective during the COVID-19 pandemic, where local networks organized transportation to deliver essential medications and supplies directly to people’s homes. Similarly, street medicine programs that bring healthcare to people experiencing homelessness have integrated transportation assistance into their services.

Additionally, recent federal investments in transportation infrastructure offer opportunities to address these barriers. The Bipartisan Infrastructure Act, for instance, includes hundreds of millions of dollars in new funding for programs aimed at improving public transit for underserved populations, including people with disabilities and low-income individuals. This funding can be used to develop more equitable transportation systems, ensuring that everyone has access to essential services, including HIV care. Furthermore, this Act included billions of dollars in additional funds to fully redesign existing transportation systems with the possibility of altering the decisions that have proven harmful to people of color and those with these least incomes. 

Conclusion

As policy makers and HIV activists continue to focus on the optimal ways to stem the pandemic, it would be wise to pay attention to transportation and other social and economic factors that affect HIV prevention and treatment.

Transportation is a critical, yet often overlooked, factor in HIV prevention and treatment. For people living with or at risk of HIV, reliable transportation can mean the difference between accessing life-saving care and missing essential services. Poverty, rurality, and structural racism have led to poorly developed public transit systems. But the passage of the Infrastructure Act created the resources which could potentially be directed to overcoming these challenges. 

While programs like Non-Emergency Medical Transportation provide some relief, more innovative solutions are needed to address the broader systemic issues. Expanding telehealth, increasing partnerships with ride-sharing services, and investing in better public transportation are all steps in the right direction. By addressing these transportation barriers, we can improve healthcare access and outcomes for people living with HIV, ultimately bringing us closer to ending the HIV epidemic.

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John Auerbach is the Senior Vice President, Public Health, at ICF.  Over a thirty-year career he has held a variety of governmental and non-governmental positions.   Among the positions he has held are CDC’s Director of Intergovernmental and Strategic Affairs, Commissioner of Public Health for the Commonwealth of Massachusetts, Executive Director of the Boston Public Health Commissioner and President and CEO of Trust for America’s Health.  He began his career as the Director of the HIV/AIDS Bureau in the Massachusetts Department of Public Health, a position he held for several years.

Kate Musgrove, PhD, is the Public Health Capture Director at ICF.  In addition, she has overseen HIV initiatives on projects at CDC in the Division of HIV Prevention (DHP), at HRSA HIV/AIDS Bureau (HAB), and Gilead. She was previously the Principal/Project Director at JBS International where her focus was on CDC’s National Prevention Information Network (NPIN) and many SAMHSA projects including the development of a web-based toolkit for behavioral health providers working with justice-involved individuals. She also previously worked for the Georgia Department of Public Health, leading the Care and Prevention in the United States (CAPUS) Project to help reduce HIV among racial and ethnic minorities.

Joseph Yawn is a transportation planner at ICF who works at the intersection of emerging mobility, Transportation Demand Management, and Transportation Planning. Joseph has more than ten years of experience in Transportation Planning, Fixed Route, and Paratransit CAD/AVL software project management experience, GTFS and data standards advisement, Human Service Transportation Coordination Planning, and Transportation Demand Management planning and implementation.