When President George W. Bush announced the President’s Emergency Plan for AIDS Relief (PEPFAR) in the State of the Union in 2003, many who had worked on HIV/AIDS for years, including me, sat back in disbelief. Bush had never shown any interest in HIV/AIDS, and his own father was pilloried by groups like ACT UP for the lackluster response to the epidemic at the beginning of the previous decade. However, within a few years, the program brought antiretroviral drugs to millions, setting up the United States to become the single largest donor on HIV/AIDS across the globe.
And many of us were equally incredulous Tuesday, when President Trump made a similar commitment in the State of the Union to combat the AIDS epidemic in the United States and eliminate HIV transmission by 2030. Could it be that another Republican president was going to turn out to be a bigger champion of HIV than Bill Clinton or Barack Obama were?
That’s possible. But only if the Trump administration stays out of the way of experts and keeps the ideologies that have marked the past two years from interfering.
By Wednesday, a plan had been issued — one that is in parts sensible and bears the fingerprints of HIV experts within health agencies, such as Centers for Disease Control and Prevention Director Robert Redfield and National Institute of Allergy and Infectious Diseases Director Anthony Fauci, rather than anything that suggests the White House was involved in its conception. The plan will rely on testing and treating people living with HIV in just under 50 counties where the HIV burden is the greatest, as well as seven states that have significant rural epidemics. The effort will also focus on getting pre-exposure prophylaxis out to people at highest risk of contracting HIV in those same places.
What the plan skirts around are the issues likely to set off the White House and its allies — there is no support for syringe exchange in the plan, though many of these rural counties at risk for HIV are suffering through opioid epidemics, and the greatest risk for infectious disease outbreaks there is from shared needles.
I am hoping against hope that some of what’s on paper comes to fruition. But this is not 2003, a time when momentum for extending antiretroviral treatment around the world was at an all-time high. Addressing HIV across the globe, as Bush did, also avoided some of the contentious debates about how to deliver health care in the United States, because PEPFAR was entirely directed internationally and framed as an act of Christian charity, almost missionary work by Bush’s allies in the faith community.
In 2019, by contrast, the White House has railed against the Affordable Care Act, an essential part of treating HIV and AIDS. Medicaid administrator Seema Verma’s efforts are discouraging enrollment and retention in the program at the state level, with new work requirements for beneficiaries that experts already know will not help. Even if new money flows into Trump’s initiative, Medicaid and the ACA have been a lifeline to people with HIV and a key part of their care. The states with the worst HIV epidemics are also the ones that have refused to expand Medicaid eligibility. But we won’t end AIDS in the United States without extending health benefits through Medicaid and the ACA to everyone who needs it. There is no workaround.
Then there are Vice President Pence and Surgeon General Jerome Adams. When Pence was governor of Indiana and Adams was the state’s health director, they presided over a needless outbreak of HIV among people who use drugs there, dragging their feet on doing the right thing and making after-the-fact excuses for an outbreak of HIV in a tiny community in rural southeastern Indiana. It was apparent for years in Indiana that the risks of an HIV outbreak were rising. Opioid use and overdoses were already a public health issue there by the end of the 2000s. There was an outbreak of another bloodborne virus, hepatitis C, among people who use drugs in 2010 and 2011. Local experts and even some Republican state lawmakers, such as state Rep. Ed Clere, were sounding the alarm before the first HIV case was uncovered in 2014 in Scott County. Eventually, more than 200 cases were diagnosed. Eventually, more than 200 cases were diagnosed. Instead of any sort of rational public health response to the crisis, though, Pence was shutting down Planned Parenthood clinics (which in Scott County was the only HIV testing provider around) and pushing policies hostile to gay rights. Once most of the damage was already done, Pence agreed to allow a temporary syringe exchange in Scott County — the same day he signed a bill making possession of a needle a felony. After being criticized by national experts on HIV and substance use, Adams doubled down in the medical press, saying we’d never know if needle exchanges would have done any good anyway in Austin, Ind.
We could be at the beginning of the end of AIDS — as my colleagues Diane Havlir and Chris Beyrer said in 2012, “the core elements of a strategy are arguably now in hand,” many of which mirror elements that are in this week’s plan released by HHS. Researchers, community organizations and policymakers have been laying out the road map for an AIDS-free generation even before President Obama declared this as a national goal in 2011. There is an army of clinicians, researchers, thousands of people working for community-based organizations around the country, thousands more people living with HIV themselves, ready to make our way to the endgame.
So Trump’s appointees don’t exactly constitute my dream team for ending the epidemic in the United States. Yet there are good people in our federal agencies, and all around the country, who have been working tirelessly for years to end this plague. The best thing the White House could do is sign a check and get out of our way.