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Trump's Hazy Plan to End HIV Comes Into Focus

White House

Dehumanizing immigrants, undercutting the Special Counsel, taking credit for the strong economy — with President Trump's State of the Union speech on Tuesday night, it was mostly the usual grim affair. Amid all the old classics, Trump uttered four sentences that were truly surprising.

"In recent years we have made remarkable progress in the fight against HIV and AIDS," Trump said. "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."

Trump quickly moved on to another subject — childhood cancer — offering no details on how he planned to enact his ambitious HIV goal. 

But shockingly, there was no shortage of specifics on HIV.gov, the government website operated by the Department of Health and Human Services. Trump's Health Secretary, Alex Azar, who worked as a pharma lobbyist and executive, as well as George W. Bush's Deputy Health Secretary, was quoted on the site as saying, “[We have] a once-in-a-generation opportunity to end the epidemic, thanks to the most powerful HIV prevention and treatment tools in history and new tools that allow us to pinpoint where HIV infections are spreading most rapidly.

“Thanks to the HIV medicine antiretroviral therapy, individuals with HIV that take their medicine as prescribed and maintain an undetectable viral load can live long, healthy lives and have effectively no risk of sexually transmitting HIV to a partner."

Then a statement, not attributed to Azar, touts the important of pre-exposure prophylaxis (PrEP) in combating infections. The website even mentions how HIV — which about 40,000 Americans contract every year — disproportionately affects groups like gay and bi men and People of Color (there's no mention of transgender women though, and approximately a quarter of trans women are HIV-positive, and more than half of Black trans women have the disease).

HHS lays out its goals plainly — 75 percent reduction in new infections in five years, and an astounding 90 percent reduction in a decade. The administration plans to do this mainly by employing a technique the police departments in New York and Los Angeles used to drastically reduce crime — pinpoint the most troubled areas and swamp them with resources.

An expansion in testing, PrEP, antiretrovirals, and local teams to facilitate all these programs and medications is planned, with funding for the Ryan White HIV/AIDS program beefed up. Pinpointing new HIV "clusters" with data and responding to their needs quickly is also part of the effort. 

The government will focus on 48 "highest burden counties," Washington, D.C., and San Juan, P.R., since 50 percent of all new infections occur in these locations. Seven states with a substantial rural HIV "burden" are also being identified for assistance, with a major focus on areas in the South with sparse populations.

While Azar sees the South as a major HIV trouble zone, it's clear the issue of Medicaid will complicate his efforts. Many Southern states have balked at expanding the federal health insurance program for low-income people, which would provide millions more with access to testing and PrEP. Deep South states like Mississippi, Alabama, Georgia, South Carolina, and Florida have all blocked or delayed Medicaid expansion, and all five states are identified as dealing with major HIV "burdens."

Another obvious reason for skepticism is that Trump's whole plan is a complete reversal of his previous stances, including an earlier proposal of his to cut funding for HIV research and prevention. In June 2017 six members of the Presidential Advisory Council on HIV/AIDS resigned, saying Trump simply didn’t care about fighting HIV, and a few months later he fired the remaining 16 members without explanation. The administration has discharged military members with HIV when there is no medical reason to do so, and both Trump and Vice President Mike Pence have failed to mention the LGBTQ population in World AIDS Day observances. And the administration’s current nominee for attorney general, William Barr, oversaw detention of HIV-positive immigrants at Guantanamo Bay, Cuba, when he held that position in the early 1990s under President George H.W. Bush.

There's also the issue of another possible government shutdown, which would place nearly every new federal initiative on hold.

Considering the past (and present), local organizations are looking at Trump and Azar's plan with trepidation, and at least a little hope.

“President Trump is taking a bold step to design an innovative program and strategy, and commit new resources, to end HIV in the United States," Carl Schmid, Deputy Executive Director of The AIDS Institute, and co-chair of the president's restaffed HIV advisory council, said in a statement. "His proposal to increase access to antiretroviral medications for people living with HIV and for prevention in those communities with the highest rates of HIV and where additional resources are most needed will translate into fewer HIV infections. Under the President’s proposal, the number of new infections can eventually be reduced to zero."

Raniyah Copeland, president of the Black AIDS Institute, said in a statement the president's past actions give major pause, including his threats to Medicare: "Actions speak louder than words and this president fired the remaining HIV/AIDS advisory panel (PACHA) last year with no explanation, allowing the panel to be unstaffed until last week. He has repeatedly sought to cut the President’s Emergency Plan for AIDS Relief, better known as PEPFAR, a multibillion-dollar initiative which has been credited with saving more than 17 million lives around the world, only signing an extension to the program in December. Furthermore, the Trump administration's proposed changes to Medicare Part D would remove most of the protections that ensure people living with serious conditions, like HIV, can access the treatments they need."

Speaker of the House Nancy Pelosi released the following statement to The Advocate:

“While the President’s call for ending HIV transmission in America is interesting, there is certainly skepticism given this Administration's assault on preexisting conditions and the ACA, policies against the dignity of the LGBTQ community, and history of proposing drastic budget cuts to crucial programs like Ryan White, PEPFAR and the Global Fund.

“With recent advances, we certainly stand on doorstep of ending HIV transmission as soon as 2025. Democrats will prioritize protecting preexisting condition protections, expanding Medicaid to ensure health care access, and prescriptions drug costs. We will support proven methods of prevention, including sterile syringe access and PrEP. We will recognize that to defeat this epidemic we must target our efforts where new infections are disproportionately occurring - especially in the South and among young, gay men of color - while protecting legacy communities. We will oppose the harmful proposed Medicare Part D rule that would push lifesaving drugs out of reach for people living with HIV. And we will continue our efforts to ensure key investments in Ryan White, CDC prevention, and lifesaving research.”

Ultimately, the success of Trump's plan will depend on budget allocation and follow-up. Also, Azar and Trump will need to move fast if they hope to achieve their ambitious goals; as Trump must be aware, his future in the White House — beyond even 2019 — is far from certain.

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