The US government currently spends >$29 billion annually on HIV treatment, but only 69% of people with diagnosed HIV (PWH) in the US are virally suppressed, a failure partially related to poverty. Medical providers preferentially treat HIV using higher cost medications, and use of higher cost drugs for PrEP is increasing. New, long-acting antiretrovirals (ARVs) have the potential to improve prevention and care while further increasing costs. We believe that the US approach to HIV should change to increase the use of lower cost HIV medications and promote the selective use of long-acting ARVs to treat people who cannot achieve viral suppression using oral drugs. A portion of the money saved through more efficient medication utilization management should be used to improve access to care and provide socioeconomic support to low-income PWH. Together, these changes have the potential to decrease costs, improve health outcomes, and better align spending with patient preferences.