In his 2020 State of the Union speech, President Trump reiterated his pledge to eradicate HIV in the US by 2030. Here’s our explainer on what that would take, first published in February 2019.
Many American presidents have used the State of the Union address as an opportunity to make grand pronouncements about beating back health scourges. Barack Obama in 2016 called for a “moonshot” to cure cancer. George W. Bush in 2003 announced his intention to “turn the tide against AIDS” with the creation of PEPFAR, the global health program to fight AIDS.
Though health has not been a particular focus of his time in office, President Donald Trump once again highlighted a major medical pledge in his speech Tuesday night: ending the AIDS epidemic in America by 2030.
“And because the Congress funded my request, we are pursuing new cures for childhood cancer, and we will eradicate the AIDS epidemic in America by the end of the decade.”
There are currently more than a million Americans living with HIV, and about 40,000 new infections are diagnosed here every year. African-American gay and bisexual men are the group most affected by HIV in the US, and diagnoses in the mid-20s to mid-30s age cohort have been rising in recent years. But Trump’s proposal is not at all as far-fetched as it may seem.
That’s because we actually know what needs to be done to stop the spread of HIV, even in those high-risk groups. Antiretroviral treatment can now suppress the virus to the point that it’s undetectable in the blood, so people on treatment are unlikely to pass the virus to others. We also have a drug — PrEP, sold by the brand name Truvada — that can prevent people at risk of infection from contracting the virus. (The drug has also recently been linked to riskier sexual behaviors.) Together with public health measures — like diagnosing cases, clean needle exchanges, and messaging about safe sex — ending HIV is truly within reach.
We asked seven HIV and public health experts to weigh in on what Trump’s plan to end HIV in the US should do if the administration is serious about tackling the ongoing epidemic. Here’s what they told us. Their answers have been lightly edited for clarity.
1) Get access to PrEP for people at high risk of HIV
Jennifer Kates, vice president and director of global health and HIV Policy at the Kaiser Family Foundation
One of the big challenges in the US right now is that only about half of people living with HIV are virally suppressed [meaning they’re on medication that reduces their risk of spreading HIV effectively to zero]. If 90 percent of people were virally suppressed, we’d have a different story. So that’s a key part of this: getting people on treatment and virally suppressed. When people are durably virally suppressed, there’s no risk of transmission to an HIV-negative partner.
The second piece is PrEP, [the pill that prevents HIV]. PrEP is recommended for those at high risk of HIV. And there is no mechanism right now in this country to fund PrEP in a stable way. Ryan White money [the federal grant program that funnels federal funds to cities and states to provide HIV health care to low-income patients] does not support PrEP because it’s for people living with HIV. And PrEP is by definition for people not yet HIV-infected.
Health insurance does cover PrEP. So if you’re insured, you should be able to get Prep, though you may need assistance for paying copays. But if you’re uninsured or underinsured, there’s no Ryan White for PrEP.
So basically right now, the system in the US is that people rely on the pharmaceutical industry to provide PrEP through their assistance programs. So a new initiative would need to address those two things: getting more people on treatment and virally suppressed, and getting those at risk on preventive treatment.
2) Support states to expand Medicaid
Gregg Gonsalves, professor of epidemiology at the Yale School of Public Health and a former HIV/AIDS activist
Is [ending HIV] an achievable goal? Yes, or we could get very close to it. We need people on treatment because if you’re HIV-positive and on treatment, you can’t transmit the disease. That means expanding access to health care.
Medicaid pays for a lot of care for people who have HIV. And the expansion of Medicaid has been a boon to HIV care around the country, except in the places where HIV transmissions [are highest], because they haven’t expanded Medicaid. The states that refuse to expand Medicaid [in the southeastern US] are the ones who are hardest hit by the epidemic.
But the Trump administration spent its first two years trying to get rid of Medicaid expansion. Seema Verma, the administrator of the Centers for Medicare and Medicaid Services under Trump, has tried to weaken Medicaid, for example, by promoting work requirements at the state level. [And] Trump’s attacks on the Affordable Care Act are part of a broader assault on publicly funded health care, including Medicaid. So if Trump was interested in “ending AIDS,” he’d have to support Medicaid expansion and fix the flaws in the ACA rather than tearing it all down.
3) Address HIV’s social context
Greg Millett, vice president and director of public policy at amfAR
Part of the reason we have been so successful at treating and preventing HIV is the incredible research that’s taken place. The problem is we really don’t know how to apply those tools in the field. For treatment as prevention to work, for people not to spread the virus, they have to be continually virally suppressed. The CDC released data showing of all the Americans living with HIV, only 48 percent were continuously virally suppressed at any given point during a year.
There are things we know that militate against viral suppression. One is homelessness: If you don’t have a home or steady housing, you’re less likely to take your pills on time. The same with full-time employment [if you are un- or underemployed, you’re less likely to be virally suppressed]. And the populations primarily affected by HIV are disproportionately marginalized communities with lower incomes.
There’s a recent and important study from the University of Alabama, where researchers looked at the number of adverse events people living with HIV had experienced. If you had more adverse events in your life — loss of a job, homelessness, some social activity that disrupted your life such as a divorce — then you were less likely to adhere to medications or be virally suppressed.
In the midst of a burgeoning opioid crisis, we are also seeing HIV infections rising among people who inject drugs. Because syringe services programs dramatically reduce the risk of HIV transmission by giving people access to clean needles, we need to scale up syringe services. Unfortunately, two-thirds of Americans live 10 miles or more away from a syringe service program making access difficult.
4) Increase funding for public health departments
Jeffrey Klausner, professor of medicine in the division of infectious diseases at UCLA Fielding School of Public Health
We’ve generated phenomenal tools to end AIDS. We have a single pill that can be taken once a day to treat AIDS and a single pill that can be taken once a day to prevent AIDS. The challenge has been how to implement these tools, and the barrier has been a lack of funding.
Congress has done a great job of supporting the National Institutes of Health [for HIV research] and a terrible job of supporting the Centers for Disease Control and Prevention, which is where the implementation of these tools needs to occur.
We know down to the zip code level where new cases are arising in the US. We have to use our surveillance and epidemiological data to find new cases, offer testing, and connect them to the treatment of prevention medicine. And to do that, we have to rebuild local public health departments.
But since the 2008 recession, there’s been a devastation of local public health departments. The lack of funding for public health has eroded our safety net and made it impossible to control infectious diseases like HIV and other STDs. Investing in local public health is the best thing we can do control HIV.
5) Target at-risk communities with treatment and prevention
Jeffrey Crowley, Georgetown Law professor and a former director of the White House Office of National AIDS Policy
Half of new HIV diagnoses in the US are happening in 46 counties. We have over 3,000 counties. And we also know that half the new diagnoses are in the South. So there’s a geographic concentration.
There’s also a population concentration. Gay and bisexual men make up 2 percent of the population and over 70 percent of new HIV diagnoses.
The reason this information is helpful is that if you have money to spend, it’s appropriate to say on a regional basis, new infections are concentrated in the South [so HIV treatment and prevention resources should be concentrated there]. But it is also important for our attention and resources to focus on those specific populations — gay and bisexual men, trans people, and black and Latin communities — most at risk.
6) Protect and advance human rights for LGBTQ communities
Naina Khanna, executive director of the Positive Women’s Network USA
Because the domestic epidemic disproportionately impacts black and Latino gay and bisexual men, transgender women of color, and black and Latino women, especially in the southern US, we need to center these communities in our HIV efforts.
It’s not possible to simultaneously propose to legalize discrimination against people of trans experience in our health care law — to attempt to define being transgender out of existence — and to provide quality health care to trans communities.
We can’t effectively prevent new HIV acquisitions without comprehensive sexual health education for all people of all ages, regardless of sexual orientation and gender identity. We need sex education that speaks to queer and trans youth, and that provides accurate information about reproductive options, including contraception and abortion. Yet under this administration, we’ve seen the resurgence of dangerous shame-based abstinence-only education policies in schools and Title X clinics, which provide family planning services.
We can’t rely on a strategy that depends on surveillance practices when over 30 states still have laws criminalizing people diagnosed with HIV for their health status. These laws create a climate of fear and redouble stigma around living with HIV, generating obstacles to HIV testing, treatment, and health care goals, while making it literally dangerous for people living with HIV to disclose their HIV status.
7) Build trust with at-risk communities
Harold Pollack, the Helen Ross professor at the University of Chicago’s School of Social Service Administration
HIV is a fundamentally intersectional challenge that reflects every social problem, and every political division, in American society.
Some of the most seriously affected epicenters of new HIV transmission are in the southeastern US, involving people of color. When Trump is trying to speak to low-income people of color, his long legacy of practicing white identity politics has made him politically radioactive in these communities.
The Trump administration has also been hostile to transgender Americans and to other sexual minorities [who are disproportionately affected by HIV]. It’d be hard to define a group in America who would be less congenial to the Trump administration than young men of color who have sex with men.
So the administration will have to do some work to get a hearing among those communities. They’d have to find messengers to reach people in these communities. [But] it’s quite feasible to sharply lower the number of new HIV infections in America. President Trump deserves a fair hearing to present how he would accomplish that. George W. Bush is a conservative politician whose most shining legacy is the PEPFAR program.