A few years ago, enjoying a beer at a Detroit bar that served as a hangout for university professors and physicians, I met a doctor who ended up taking me on a tour of the Detroit hospital AIDS ward where he worked. He asked me if I was shocked that such a specialized treatment floor existed in a US hospital today.

I was, although I've learned since that I should not have been shocked.

Given that antiretroviral treatment is so effective, I simply would not have supposed that dozens of people at a time in a major American city would be fighting opportunistic infections as physicians struggled to repair their immune systems.

But after many years of untreated HIV infection, or after years of starting and stopping antiretroviral treatment, the struggle can be very difficult indeed.

Almost all of it owes to inequity in treatment access. Almost all the patients in that AIDS ward were poor and lacked health insurance. Some of them never knew they had HIV until opportunistic infections began to develop. Many others did know, but had stopped and started HIV medication many times because they couldn't afford it and didn't know how (or didn't have the means) to jump through bureaucratic hoops to take advantage of the Ryan White Care Act.

And that's in a liberal, Democrat controlled city with strong social services networks.

I'm told problems in Southern and Bible Belt states are much worse. Political opposition to PrEP on moral grounds is a huge obstacle to treatment as prevention, and lack of access to healthcare is a huge obstacle to treatment for those already infected.

We could effectively strangle the circulation of HIV in the United States if we chose to.

We choose not to. And that's tragic, definitely something to remember on World AIDS Day as we reflect that the pandemic in developing nations is even worse than it is here.