If Donald Trump really wants to end the US HIV epidemic by 2030, as he announced in Tuesday’s State of the Union speech, he will have to stop stigmatizing immigrants and trans people, according to health care experts.
About 1.2 million people nationwide have HIV, and every year another 40,000 are infected. One in 2 has the virus for at least three years before they're diagnosed.
"Together, we will defeat AIDS in America. And beyond," Trump said in the speech, lauding scientific advances in the treatment and prevention of HIV. "My budget will ask Democrats and Republicans to make the needed commitment to eliminate the HIV epidemic in the United States within 10 years."
On Wednesday, federal health officials released more details of the "Ending the HIV Epidemic: A Plan for America" proposal, which calls for reducing US HIV infections by 75% by 2025, and by 90% by 2030. They will focus on the 48 US counties with the highest infection rates and seven southern states with high rates of widely distributed infection rates. The goal is to get everyone infected there on treatment to reduce the amount of virus in their bloodstreams to non-transmissible levels and get everyone at high risk of becoming infected on medication that prevents infection.
"The time to end this epidemic is now," CDC chief Robert Redfield said on a phone briefing for reporters.
Such a plan is very doable, HIV prevention experts told BuzzFeed News, applauding recent speeches by Health and Human Services Secretary Alex Azar advocating wider use of drugs that prevent HIV transmission. But groups with highest rates of the virus include gay, trans, black, and Latino men, drug users, and people living in Southern states without public health care — constituencies not exactly embraced by the Trump administration, which is trying to build a wall on the Mexico border and kick trans people out of the military, and disbanded its Office of National AIDS Policy in 2017.
“Ending the HIV epidemic matches the scientific reality — we can do this,” Treatment Action Group project director Jeremiah Johnson told BuzzFeed News. “But it doesn’t match the political reality of our era.”
In January, National Institute of Allergy and Infectious Disease officials released study results confirming that antiretroviral treatments that drive the virus to undetectable levels in the bloodstream prevent people from transmitting the disease to their partners. What’s more, a daily preventive drug, taken by people who haven’t been infected, reduces their risk of acquiring HIV through sex by more than 90%.
Such advances have driven “roadmap” plans by public health experts to reduce HIV infections nationwide in the next decade, saving some $57 billion in long-term health care costs. But experts worry that the Trump administration’s hostility toward trans people and immigrants, in particular, could do more harm than good.
“Many recent immigrants are afraid to access HIV prevention and medical care, out of fear of deportation,” a 2018 AIDS United report noted. “These barriers have the potential to drive dramatic increases in new HIV cases among Latinx gay and bisexual foreign-born men.”
Saying it would be a “pleasant surprise,” Journal of the Association of Nurses in AIDS Care editor Lucy Bradley-Springer told BuzzFeed News that Trump “would be an unlikely messenger for ending the stigma toward people with HIV." Bradley-Springer was one of six experts who resigned from a presidential advisory committee on HIV policy before it was disbanded by the Trump administration. They wrote a scathing letter at the time saying the administration’s policies harmed people with HIV.
The administration’s attacks on the Affordable Care Act and Medicare expansion also hurts people with HIV, prevention expert David Holtgrave of the University at Albany State University of New York told BuzzFeed News. About 85% of people infected with HIV in the US now are eventually diagnosed. Of those who go on to get treatment, almost all see the virus drop to undetectable blood levels. But only about half of those diagnosed get treatment, largely because they don’t have insurance and can’t afford or access it. (About 56% of people with HIV have federal health care coverage such as Medicare, while 30% have private insurance and 14% are uninsured.)
“People who are homeless need stable housing,” he said. “People in the rural South who don’t have a doctor nearby need telemedicine.”
Another contradiction in the Trump administration’s new goal of HIV elimination is Vice President Mike Pence’s history of only reluctantly allowing needle exchanges in Indiana after an HIV outbreak among drug users became rampant in 2015. Similarly, the Justice Department has not supported safe injection sites, places where drug users could be tested for HIV and receive treatment.
Azar, though, has called for both the widespread use of the HIV preventive drug PrEP and for lowering drug prices, which could make for a good combination, TAG’s Johnson added. The list price for PrEP is around $18,000 a year. “That’s an expensive drug by anyone’s measure,” he said.
A precedent does exist for a president making a perhaps unexpected and useful pitch for treating HIV, some noted. In 2003, then-president George W. Bush called for the creation of the US President’s Emergency Plan for AIDS Relief (PEPFAR), which has provided HIV treatment to 14 million people in more than 50 countries worldwide. Last year, the Trump administration proposed a $1 billion cut to PEPFAR’s budget and a $425 million cut to the Global Fund to Fight AIDS, tuberculosis, and malaria.
“The question is, will it be the right policies that create a less stigmatizing environment for these people living with HIV,” said Holtgrave.
In their phone briefing, both CDC's Redfield and NIAID head Anthony Fauci reaffirmed a commitment to ending stigma against trans people as a necessity of lowering HIV infections. ("These people are at particularly high risk of infection, unfortunately," said Fauci.) Speakers on the call also supported syringe exchanges as a tool to lower infections among intravenous drug users, another population at high risk.
The administration speakers did not have a cost estimate for the proposal, saying new money will be requested from Congress in budget proposals the White House will release this Spring.
This post has been updated with comments from a HHS briefing on the HIV elimination proposal.
This post has been updated with comments from the State of The Union speech.