Despite the obstacles, 85 percent of Open Arms patients achieve viral suppression, Dr. Mena said, meaning they take their pills so faithfully that the virus cannot be found in their blood .

To reach that goal, the clinic has to offer many extra services: counselors to remind clients to take their pills, transportation for those who don't own cars, and even a food bank offering weekly food packages, since many patients are so poor they skip meals and then will not take pills that may trigger heartburn.

Open Arms would like to have an on-site pharmacy too, Dr. Mena said, but has not received a license yet. Mostly, he said, a clinic must offer the right attitude.

“People don’t come back to clinics where the nurse makes you feel guilty for sleeping with men, or keeps saying ‘he’ when it’s ‘she,’ or threatens to stop your meds if you don’t take them all,” he said. “People with H.I.V. are still people.”

Louisiana, next door to this state, goes further: Patients whose blood tests prove they are taking their pills daily get paid.

“For some folks, that’s controversial, but it works,” said Dr. Alexander Billioux, a Louisiana assistant health secretary. “And we’re not sending anyone on luxury vacations. It’s about $25 a month.”

No matter what tactics a state employs, “medication has become the simple part of H.I.V.,” Dr. Mena said. “What’s been missing is the political will.”