The HIV/AIDS community has been bracing itself for the Trump budget proposal. The fight against the disease has a decades-long history of bipartisan support, and the US has been a leading funder of the effort. But President Donald Trump hasn’t said much on the issue, and key members of his team have been critical of anti-HIV activities.
That’s why Trump’s budget blueprint comes as a surprise. Amid an 18 percent cut to the Department of Health and Human Services — including one-fifth of the National Institutes of Health’s budget — the administration has said it will prioritize funding for important anti-HIV activities.
On the domestic front, the budget calls funding for Ryan White HIV/AIDS providers — a “high priority” it wants to continue. Ryan White programs provide health care to people living with HIV who cannot get health insurance. With $2.3 billion in funding in the last budget, it’s the third-largest source of federal money for domestic HIV care after Medicare and Medicaid.
The budget also “provides sufficient resources to maintain current commitments and all current patient levels on HIV/AIDS treatment under the President’s Emergency Plan for AIDS Relief [PEPFAR].”
PEPFAR is America’s global heath program to combat AIDS around the world and the largest commitment by any country dedicated to a single disease. The program funds daily lifesaving antiretroviral treatment for 11.5 million people, which is equal to the population of New York and Chicago.
“While this language [in the budget blueprint] isn't that clear about amounts,” said Jennifer Kates, director of global health and HIV policy at the Kaiser Family Foundation, “it implies that current commitments will be maintained.”
The budget blueprint is just an early proposal, and it’s possible broader public health cuts could impact money that’s allocated to these programs in the final budget in May. But the administration has signaled its priorities here, and in a proposal that makes very little mention of specific diseases, the attention paid to HIV is notable.
Why the HIV community was nervous about what Trump might do
President Trump didn’t say much about HIV on the campaign trail. But Vice President Mike Pence has.
As governor of Indiana, Pence first resisted addressing an out of control HIV outbreak in his state for ideological reasons, and then changed his mind based on evidence that clean needle exchanges could slow infections among drug users. He advocated for abstinence-only education and, in 2000, suggested that Ryan White — which provides health care to people who cannot get insurance — only receive funding after an audit, “to ensure that federal dollars were no longer being given to organizations that celebrate and encourage the types of behaviors that facilitate the spreading of the HIV virus.”
Continuity and bipartisanship have been keys to the success of the global fight against AIDS, Elizabeth Radin of Columbia University wrote at Vox. “The Obama administration continued President Bush’s AIDS program as PEPFAR received support from successive Democratic and Republican Congresses. This allowed PEPFAR to keep building on its foundations, advancing its impact and setting an example by focusing on results.”
Since the election of Trump, groups like AIDS United and the National Alliance Of State & Territorial AIDS Directors have been advocating to maintain government support for HIV-AIDS prevention and treatment, as well as important provisions in the Affordable Care Act.
The ACA was a game-changer for Americans living with HIV. More than half are low-income, and Medicaid expansion and the law’s tax subsidies that help people purchase insurance dramatically reduced the rate of the uninsured HIV population. The GOP plan to repeal and replace Obamacare would eliminate Medicaid expansion, reduce tax subsidies for the poor, and throw out other provisions that helped HIV patients gain coverage.
"Dramatic changes to the ACA and cuts to other programs would be devastating even if our important investments in the Ryan White Program are maintained,” said Jeffrey Crowley, program director of the National HIV/AIDS Initiative at Georgetown.
And even if Ryan White and PEPFAR end up being protected, as this budget suggests, the rest of the government’s public health, global health, and development portfolios may not fare so well.
“Cuts to the National Institutes of Health, the Department of Housing and Urban Development, and other public health infrastructure and safety-net programs will roll back our progress reducing new HIV infections and expanding access to care,” said Carl Baloney, AIDS United’s director of government affairs. Trump has also proposed significant cuts to HHS, NIH, and the State Department, and USAID — agencies that are key players in global health.