I am not in the "ignore President Trump's tweets because they are a distraction from important things" camp. His most recent micro- harangues — accusing (without evidence) a news executive of wrongdoing, hinting that a television host may have been involved in murder and embracing the debunked anti-Muslim rantings of Britain's alt-right — indicate some type of degeneration. The president seems to be in a downward spiral of anger, compulsion, conspiracy theorizing and prejudice that is alternately offensive and frightening.
But the thing is, Trump's tweets are also distracting from other important matters of governance. And here is one that can't get lost in the general madness: The Trump administration is proposing a reduction in funding and a shift in strategy in the fight against global AIDS that together would increase infections, cost lives and threaten the extraordinary progress of the past 15 years.
A little history. In January of 2003 — as a cresting wave of death from AIDS swept across sub-Saharan Africa — George W. Bush proposed the President's Emergency Plan for AIDS Relief (PEPFAR), the largest initiative to fight a single disease in history. (I was one advocate for the plan within the Bush administration.) The legislation passed rapidly, with bipartisan support. The effort — including mass treatment, prevention and compassionate care — was continued and expanded under President Barack Obama.
On this World AIDS Day, the results are truly remarkable. PEPFAR supports 13 million people on lifesaving treatment. Thanks to PEPFAR, the Global Fund to Fight AIDS, Tuberculosis and Malaria , and the increasing contributions of countries themselves, more than half of people in the world needing AIDS treatment are getting it.
But there is a predictable challenge ahead. Africa is experiencing a historic youth bulge and will have more than 800 million young people by 2050. How fast and far the AIDS virus spreads among them will determine much about the future of the epidemic. And the extent of that spread will be determined (in addition to direct outreach to young people) by the level of AIDS treatment.
This is true for two non-obvious reasons. First, the availability of treatment helps determine the level of AIDS testing. Significantly fewer men and women want to be tested for a disease that is a death sentence. And when people don't know their status, they are more likely to transmit the virus. Second, when people living with AIDS are put on treatment, their viral load is dramatically reduced, making them less infectious to others. Treatment is an essential form of prevention. The sooner you treat someone, the more new infections you prevent.
During the George W. Bush and Obama administrations, the strategy on AIDS was pretty consistent: Put as many people on treatment as possible. Use economies within the program, and falling drug prices, to increase that number even further. Focus on the places and groups where transmission is highest, but act broadly enough to block transmission routes across the continent.
For the first time since early in the American AIDS response, a fundamental change in approach is being debated. In its 2018 budget, the Trump administration proposes an $800 million cut in America's bilateral HIV/AIDS programs (along with a $225 million cut for the Global Fund). The State Department, in turn, has written a new AIDS strategy to reflect this lower level of funding. Resources would be concentrated on 13 "priority" countries, while current levels of treatment would be maintained in other places. Neither South Africa nor Nigeria — which together have about a quarter of AIDS cases in the world — would be in the "priority" category.
The results? According to the Kaiser Family Foundation, more than 800,000 fewer people (compared with the current trajectory) would be placed on treatment in the first year of the new strategy, and 2.7 million fewer by 2020. One recent study estimates 26 million additional AIDS infections and 4 million more preventable deaths over the next 15 years. When you are not moving forward against an epidemic, you end up moving backward, and rapidly.
All of which raises a few questions. Are Republicans in Congress prepared to squander a legacy of GOP leadership that has won the United States considerable goodwill around the world? Does Trump really want to be known for undermining an effort he praised during his campaign, as well as in his recent U.N. General Assembly speech? Among evangelical Christians, what definition of being "pro-life" does not include saving millions of lives from preventable disease and death?
There is only one AIDS strategy adequate to controlling this disease: full funding, and full speed ahead.