We Know What Shapes Sexual Health Outcomes. So Why Is Change So Hard?
Author: Hannah Worby, Research & Insights Fellow
In public health, there is little debate left about whether HIV and STI outcomes are shaped by more than individual behavior. We know that comprehensive sex education is uneven. We know access to testing, PrEP, and treatment is shaped by insurance, geography, and cost. We know stigma influences whether people seek care and how their local systems respond to them.
The question is: why, despite this clarity, do those inequities persist?
Part of the answer is structural—but not in the way we often describe. Yes, systems shape outcomes. But what’s more, systems are designed in ways that make change difficult even when the problem is well understood.
Take HIV outcomes in the United States. Public health data consistently show that disparities are not primarily driven by differences in individual behavior, but by social and economic conditions such as poverty, education, access to care, and trust in health systems. (CDC) At the same time, decades of research confirm that health outcomes are produced through a layered interaction of individual, interpersonal, institutional, and structural factors. (NCBI)
And yet, outcomes remain stubbornly unequal. In 2025, the Centers for Disease Control and Prevention reported that Black people in this country accounted for 38% of new HIV diagnoses despite representing a much smaller share of the population, with the highest burden of disease concentrated in the South. These disparities persist across their care outcomes: Black individual, American/Alaskan indigenous individuals, women, and people living in the South and West are all less likely to be linked to HIV care within one month of diagnosis or to be virally suppressed within 6 months, measures of HIV care that signal successes or challenges in managing the virus. These inequities reflect differences tied to insurance coverage, income, and housing stability.
Together, these data underscore a consistent pattern: unequal HIV outcomes are enduring features of the current public health landscape shaped by structural conditions rather than individual behavior.
(It is important to note that these data reported in 2025 are retrospective from 2019-2023 and exclude data on PrEP coverage after funding cuts eliminated the statistical expertise needed to report on such findings. Updated data are delayed and the structures we had in place to collect, analyze, and report on their findings have been toppled.)
We also know what happens upstream that shapes individual sexual behaviors and choices. Without knowledge of sexual risks and safer sex options, people cannot make informed decisions in their sex lives and for their health. But sex education policy, as we know, is shaped by state legislatures, local school boards, and political climates that often constrain what can be taught. Even when public health leaders know what works, when they do all they can to communicate and advocate for what works, they cannot implement it.
Further downstream, accessing sexual health testing, treatment, and prevention requires navigating insurance systems, reimbursement structures, workforce limitations, and clinic capacity. National STI and HIV strategies explicitly recognize that housing, transportation, and economic conditions act as barriers to care. Yet addressing these requires coordination well beyond traditional public health programs. (CDC)
Even further, stigma operates in a similar way. We often talk about HIV stigma as something to reduce through messaging or education. But stigma is also embedded in institutional practices in how services are delivered, how risks are communicated to patients in clinics, and which populations are reached during programmatic rollout.
Across these areas, a pattern emerges: we are asking programs to solve problems that are produced by systems. And programs, by design, have limits. They operate within fixed budgets, short timelines, and predefined scopes. They can adapt at the margins, but they cannot easily change the conditions in which they are working.
Picture this: A woman living on the streets gets tested for HIV and STIs at a pop-up testing mobile clinic because they offered a $15 giftcard to the local Walmart. When the woman’s rapid HIV test comes back positive, the medical social worker at the mobile testing unit immediately meets with her to set up an appointment at the free HIV clinic on the other side of town and provides the woman with a bus pass so she can attend her intake appointment and a prepaid cell phone so they can stay in contact. The social worker also discusses how he may be of assistance in other areas like housing, food pantries, MAP insurance cards, and first aid resources. The woman’s new HIV diagnosis is the catalyst for linkage to a multitude of other resources. While her confirmatory results are sent to the clinic’s lab, this client has been warmly brought into the clinic’s patient assistance ecosystem.
But the city’s new homelessness crackdown means police are sweeping encampments monthly. A few days later, the woman’s tent is tossed, along with her bus pass, the note on which she wrote the date, time, and address for the HIV intake appointment, and the contact information for her social worker. She has her phone on her, but it gets stolen overnight by a neighbor whose entire camp was also swept away. All the programs the city’s public health department has mobilized to assist this community member are now useless to her as she searches for a safe place to lay her head. Encampment sweeps just wiped this person’s HIV and medical care off the map. The programs launched cannot overcome the systems already entrenched in the city’s budget priorities.
The medical social worker and the free HIV clinic are now on the search for this individual, but when they finally get in touch with her weeks later, her priorities are finding safe shelter and food. Running her HIV blood panels and receiving her Biktarvy prescription are farther down the list, and the branded bag the clinic provided, which she’s been using to carry her few remaining belongings, are making her friends whisper behind her back. She wants nothing to do with this clinic at this time.
We pilot new interventions, demonstrate impact in specific settings, and scale where we can. And yet the underlying disparities remain because the broader system has not shifted. Despite huge effort and passionate commitment by our public health professionals, lasting change requires alignment across policy, funding, governance, and practice—and that alignment is slow, contested, and often outside the control of any single program or agency.
So what does it mean to move forward?
It means being upfront about where change is possible and where it requires different levers. It means designing programs with an awareness of structural constraints, while also identifying opportunities to influence the systems those programs sit within. It means building partnerships that extend beyond implementation into policy and shared decision-making.
Leading organizations are beginning to move in this direction. For example, the Robert Wood Johnson Foundation has emphasized shifting from programmatic interventions to systems-level investments including funding community power-building, cross-sector partnerships, and policy change as core health strategies. Similarly, the World Health Organization continues to advance frameworks on the social determinants of health that call for coordinated action across sectors such as housing, education, and labor.
These approaches point toward a different future for public health: one where success is not only measured by program outputs, but also by whether systems themselves are becoming more equitable, responsive, and accountable. HIV outcomes in this country will depend upon these kinds of transformations.
Sources:
https://www.cdc.gov/hiv-data/nhss/hiv-diagnoses-deaths-prevalence.html
https://www.cdc.gov/hiv-data/nhss/national-hiv-prevention-and-care-objectives-2025.html