As teased earlier in the week, President Donald Trump pledged in his State of the Union address Tuesday to “eliminate the HIV epidemic in the United States within 10 years.”
Noting incredibly scientific strides, Trump promised, “Together, we will defeat AIDS in America and beyond.”
Following the speech, Health & Human Services Secretary Alex Azar released additional details about the strategy, which for the most part, contains core components that align with recommendations that AIDS activists have advocated for years.
But the new plan appears to reach for the bare minimum, and contains glaring omissions that advocates have predicted since the announcement was leaked Monday.
At the end of last year, a coalition of HIV/AIDS organizations released a detailed plan to end the U.S. HIV epidemic by 2025. It proposed what it called a “95/95/95” plan, seeking to ensure that 95 percent of people with HIV people know their status, 95 percent have begun treatment, and 95 percent have suppressed their viral load, making it nearly impossible to transmit the virus to others.
Another goal of the plan is to ensure that 40 percent of people vulnerable to HIV have access to PrEP, a daily regimen that has been extremely effective at preventing transmission.
According to Azar, the administration’s plan largely mirrors this framework, focusing on “four key strategies”: Diagnose, Treat, Protect (PrEP), and Respond, which refers to detecting outbreak clusters and responding to them as soon as possible.
But unlike the coalition’s plan, Trump’s plan doesn’t set specific goals like the 95/95/95 marker. It’s also less ambitious over a 10-year time frame, and doesn’t appear to address ways of overcoming some hurdles in the way achieving such goals.
Indeed, the Trump administration has deficits it must rectify first. For example, the plan calls for increasing investments in programs like the Ryan White HIV/AIDS Program, which ensures that people with HIV can get access to treatment even if they face financial limitations. But last year, the administration started skimming funds from the Ryan White program to cover the costs of reuniting immigrant families separated by the administration’s “zero tolerance” policy. It took $17 million from the program in July, and another $6 million in September.
Early in his administration, Trump actually proposed cutting nearly a fifth of the funds that help supply people worldwide with antiretroviral drugs. Policies like the global gag rule and cuts for funding for contraception further endangered HIV prevention efforts abroad. Because of these changes, several members of the Presidential Advisory Council on HIV/AIDS resigned in protest. A year ago, Trump fired the rest of the members, and the board’s membership was only replenished last week.
In 2018, it also came to light that the Trump administration had shut down a study that aimed to find a cure for HIV over its use of human fetal tissue.
Unlike the coalition’s proposal, Trump’s plan does not mention expanding Medicaid or buttressing Medicare to provide support for people with HIV. In fact, the administration has supported plans to restrict Medicaid access, including helping states impose limitations like work requirements that prevent people from accessing the coverage. Trump has come out against “Medicare for All” plans and undermined protections for people with pre-existing conditions.
The plan also calls for reducing stigmas against people with HIV, but it doesn’t explain how it would go about doing that. As it stands, the administration is contributing to those stigmas by kicking people out of the military simply for having HIV. The State Department has also deferred to anti-LGBTQ groups like Focus on the Family to do abstinence-only education abroad, a strategy that is not only ineffective but also makes it harder to prevent the spread of HIV.
Nowhere does the plan even mention laws in 19 states that criminalize the transmission of HIV. Such laws are based on incredibly antiquated understandings of the virus, and studies have shown that they actually increase transmission rates because they discourage testing. After all, a person can’t be guilty of not disclosing their status if they don’t know their status. These laws remain a massive barrier to achieving one of the core goals of any HIV prevention strategy.
The plan also fails to mention needle exchange programs, a remind of how Vice President Mike Pence turned a blind eye to a massive HIV outbreak in Indiana when he was governor.
It likewise makes no mention of decriminalizing sex work. This was one of the clear recommendations made in the coalition’s roadmap to ending the epidemic by 2025.
A study found that decriminalizing sex work would prevent over a third of new HIV cases among sex workers and their clients. It would also ensure that sex workers could more easily access treatment without the fear of prosecution. Countries that have legalized some aspects of sex work also have fewer sex workers living with HIV, demonstrating a prevention effect.
To the plan’s credit, it does recognize that people of color and people living in the southern United States are far more vulnerable to HIV. But as the administration has repeatedly done when discussing HIV, the plan completely erases LGBTQ people, which remains one of the most vulnerable populations.
Indeed, the administration’s discrimination against LGBTQ people has included limiting their access to health care. It has proposed a “religious freedom” rule that would allow health care providers to refuse service to LGBTQ people, and also has sought to roll back LGBTQ nondiscrimination protections that were built into the Affordable Care Act. That’s in addition to a separate HHS proposal that would completely erase recognition of transgender people throughout the federal government. Making it harder for one of the most HIV-vulnerable communities to access care won’t help end the epidemic.
Observers Tuesday night were immediately skeptical of Trump’s proposal. Planned Parenthood President Leana Wen highlighted the administration’s many attacks on reproductive healthcare that very much interfere with HIV advocacy efforts:
To eradicate #HIV:
1) Stop attacks on reproductive healthcare—which is healthcare
2) Repeal the Global Gag Rule
3) Protect Title X
4) Ensure universal healthcare w affordable treatment
5) Stop discrimination against women, LGBTQ people & treat all with dignity & compassion— Leana Wen, M.D. (@DrLeanaWen) February 5, 2019
New York City Council Speaker Corey Johnson, who is HIV-positive, also called out the many ways Trump has created more challenges for people living with HIV:
As an HIV positive person – happy to hear words to end the epidemic..
Details please?
Fund needle exchange? Decriminalize sex work?
Stop pushing abstinence only education?
Provide housing because housing equals health care?
Stop filling key jobs with anti-science ideologues?— Corey Johnson (@CoreyinNYC) February 6, 2019
A commitment to “defeat AIDS” is a noble goal. But as it stands, the administration’s plan is to phone it in rather than stand for the systematic changes necessary to actually eradicate the epidemic once and for all.