The Trump Administration’s Initiative to End the HIV Epidemic: Promise or Illusion?

In his State of the Union address on February 5, President Donald Trump announced that his Administration was committing to ending the spread of HIV by 2030. In his words:

“In recent years we have made remarkable progress in the fight against HIV and AIDS. Scientific breakthroughs have brought a once-distant dream within reach. My budget will ask Democrats and Republicans to make the needed commitment to eliminate the HIV epidemic in the United States within 10 years. Together, we will defeat AIDS in America.”

Since that surprise announcement, HIV and public health activists have sought more information from HHS and other Administration officials on their plans for implementing this vision.

Administration sources have said that there will be more money for the CDC and the Ryan White Program. This could allow those programs to get antiretroviral drugs to more people living with HIV, and PrEP to more people at risk of contracting HIV; and fund research to learn how to more effectively achieve those goals.

We know that we need more outreach and education to reach people who are living with or at risk of acquiring HIV. Administration officials assert that their goal will be to expand access in places where HIV is spreading fastest. Dr. Robert Redfield, Director of the CDC, has stated that the Administration plans to target funding in areas most affected by HIV: 48 specific counties; Washington, DC; San Juan, Puerto Rico; and seven Southern States.

Also since the State of the Union, HHS has announced listening sessions and invited written comments on whether and how the Administration should modify the National HIV/AIDS Strategy, and National Viral Hepatitis Action Plan, which were developed by the Obama Administration. Whitman-Walker will be responding with official comments, but we want to share some thoughts with you here.

As the Administration seems to acknowledge, the tools we need to stop the spread of HIV are ready.We have two well-recognized medical interventions to stop the spread of HIV. PrEP, used daily by people at significant risk of HIV, can reduce one’s risk by up to 99%.For those living with HIV, suppression of one’s viral load through antiretrovial drugs to undetectable levels, not only dramatically improves one’s health, but also makes HIV untransmittable to others. This is known as Undetectable=Untransmittable (U=U).

However, in order to fully realize the promise of these tools, the Administration will need to dedicate substantial additional funds to the fight. It remains to be seen whether the Administration and Congress will appropriate sufficient funds to this initiative. In 2017, the Presidential Advisory Council on HIV/AIDS was disbanded and for the first time since the early 90s, the nation does not have an AIDS Czar. In the past, this Administration has proposed significant cuts in funding for the CDC including a significant reduction in domestic HIV prevention and care funding including Ryan White programs; we hope that it will now support substantial increases.

Funding for the Ryan White CARE Act also needs to be greatly increased. The Administration appears to recognize that HIV treatment works better when people living with HIV have access to housing, transportation, food, and other social supports. Ryan White has been essential in this effort, and has accomplished major improvements in viral suppression rates among people with HIV. We are encouraged that recently Dr. George Sigounas, the Administrator of the Health Resources and Services Administration, indicated that the new effort will use Ryan White as a model.

Realization of the promise of U=U and PrEP also requires expanding the availability of affordable, adequate health insurance. The Affordable Care Act (ACA) has been vitally important to the fight against HIV, by expanding Medicaid, by prohibiting health insurance discrimination against people with pre-existing conditions, and by making health insurance more affordable through premium subsidies. The Administration’s ongoing opposition to the ACA, and attempts to undermine protections in Medicaid, seem to undercut its initiative to end the HIV epidemic.

Even more important, to end the HIV epidemic we must address the epidemic in the communities most affected: people of color and LGBTQ people. More money alone for PrEP and U=U will not be enough without community support. If the Administration is serious about ending the spread of HIV, then they must urgently change their practice of undermining legal protections for LGBTQ people, policies of fear and inequality for Black and Latinx people and supporting immigration and criminal justice policies and practices that oppress and stigmatize residents of our nation.

Public health efforts have come far from puritanical campaigns that taught abstinence or, at the most, condom usage. Best practices now emphasize highlylocalized information and outreach campaigns to fight stigma and reach people living with or at risk of acquiring HIV in the communities where they live. But these efforts are undercut by federal policies and practices that communicate to immigrants, Black and Brown people generally, and LGBTQ people, especially transgender people, that they are the enemy.

We can only stop the spread of HIV by working in relationship with the communities we seek to serve. Since 1973, Whitman-Walker Health has committed to the daily work of serving our patients better and creating a care model devoid of stigma and discrimination.

We are glad that the Administration is proposing to dedicate major new resources to ending the spread of HIV because our families and our communities have been devastated by this epidemic. But to realize the promise, the Administration must substantiate its assertions with substantial new investments, making health care more accessible, and treat our patients and families – including people of color, immigrants and LGBTQ people – with respect and dignity.We urge the Administration to be guided by the detailed roadmap for ending the epidemic that recently was issued by the Act Now: End AIDS Coalition and AIDS United, which Whitman-Walker Health has joined.

Naseema Shafi

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