Background The number of people living with HIV in the USA increased by 50% to 1.115 million persons from 1996 to 2006 and may exceed 1.5 million by 2015. The rising caseloads are straining the HIV care system, while recession and the unknown fate of health reforms are sources of uncertainty. HIV care in the USA evolved within a fragmented healthcare system. Unique community-based support and education linked to diverse multidisciplinary HIV care teams contributed to ‘AIDS exceptionalism’.

Objective To describe HIV care in the USA in 2011 and to consider future trends.

Methods Literature review.

Results Though evidence for effectiveness of HIV care teams is increasing, HIV care in the USA in 2011 is severely challenged. Low reimbursements, rising caseloads and increasing care complexity are leading to clinician shortages. Access to antiretrovirals through Medicare and Medicaid is worsening, and deficiencies in AIDS Drug Assistance Programs are increasing. Durable health insurance will become available for most Americans in 2014 through new health reforms, but the likelihood of incomplete coverage, fierce political opposition and the uncertain details are reasons for concern. At the same time, recent trends in HIV epidemiology, pathogenesis and care services have reinforced the need for multidisciplinary teams with strong community linkages.

Conclusions HIV advocates have their greatest challenge to date to ensure that the gains and lessons in HIV care learnt from the past are not lost in the transition to national health reform in the next turbulent 5 years in the USA.