I had the privilege of serving as President Obama’s first HIV/AIDS Advisor and I led the process of creating our country’s first comprehensive National HIV/AIDS Strategy in 2010. The Strategy was a five-year plan that was updated in 2015.
Yesterday, President Trump acknowledged our country’s great strides and said that his budget will commit the resources needed to end the HIV epidemic in 10 years. This is an important commitment and I commend the President for making it.
What we should look for in a new plan
In the Obama era, we always said we were developing a National Strategy, not an Obama Strategy. We worked hard to ensure that everything we recommended was grounded in the best evidence. The 2015 Update was not a radical departure from the 2010 plan, but it was a useful revision that took account of significant advances in the intervening years, including the approval of pre-exposure prophylaxis (PrEP) that gave us a new, safe and highly effective tool for preventing HIV.
I know that every Administration wants to tout its new and groundbreaking efforts. But, I hope the Trump Plan is just as deeply embedded in the best available evidence. Thus, I am not hoping for a radical change in direction. I am hoping for bold steps to achieve the goals we have already set and to achieve the President’s vision of ending the epidemic over the next decade.
We do not yet know all of the details of the Administration’s plan or if its budget request will match its rhetoric. I am pleased that the Administration is embracing greatly expanded access to PrEP. Data from Centers for Disease Control and Prevention (CDC) show us there is great potential for preventing new HIV infections, but far too few Americans are accessing PrEP. Of an estimated 1.1 million Americans for whom PrEP is warranted, only about 100,000 are currently receiving the medication.
The Administration also recognizes that while we need a nationwide response, the biggest results are achieved by focusing on the areas with the greatest needs. Half of new diagnoses are in the south, well above this region’s share (38%) of the US population. Looked at another way, out of more than 3,000 counties in the US, half of all diagnoses occur in just 48 counties. By recognizing the need for intensive responses in this region and these counties, we will be more effective. Again, this is not a departure from a prior approach, but a useful refinement of it.
At the same time, the HIV epidemic is even more concentrated within specific communities. Gay and bisexual men make up a little more than 2% of the US population (4% of men) yet comprise seven in ten new HIV diagnoses. Transgender people are at very high risk. People who inject drugs and Black and Latinx communities also are at very high risk. In the same way that a geographic focus is needed, to be effective, we also need a corresponding population focus. While the Administration’s initial comments about affected communities are encouraging, we need to ensure that the most heavily impacted communities remain front and center as partners in our collective efforts and that related challenges, such as the burgeoning sexually transmitted infections (STI) crisis, are addressed as well.
Each Administration has its unique political considerations. Following the release of the 2010 Strategy, we updated how CDC allocates its funding for state and local health departments. This led to big winners, often in red states, and big losers in blue states. Speaker Pelosi’s city was perhaps the biggest loser, and then-Chair of the Senate Health, Education, Labor and Pensions (HELP) Committee Senator Tom Harkin’s state of Iowa also lost nearly half of their federal prevention funding. These changes were painful, but we believe they are producing more equitable and bigger results.
To be successful, this Administration needs to tackle its own politics. This means tamping down its attacks on the various parts of the communities most deeply impacted by HIV. President Trump has taken some steps to respond to the opioid epidemic, but it is also known that there are divergent voices within the Administration about how to respond to this crisis. The opportunity is for the President to be truly bold and unequivocal in responding to the opioid crisis by deploying evidence-based strategies at much greater scale, including medication assisted therapy (MAT), syringe services programs, and overdose prevention sites, as well as spurring the adoption of comprehensive models for drug user health that do more to address infectious diseases and treat people dealing with addiction with dignity, and thus, create new pathways to drug treatment.
Finally, an underpinning of our recent progress against HIV, wherein new HIV infections declined by 18% from 2008-2014, was the expansion of access to health insurance coverage resulting from the Affordable Care Act. A successful HIV plan demands that we create new incentives for all states to expand Medicaid. I recognize that this runs counter to this Administration’s past words and actions, but it is unquestionably necessary to meet our HIV goals. The Ryan White HIV/AIDS Program is the proud workhorse of the HIV response and it provides critical lifesaving services to people with HIV with and without insurance. But, it functions best as a complement to and not a replacement for Medicaid, Medicare, or comprehensive private health insurance
We can end the HIV epidemic
While HIV has faded from the headlines, the President put it on many front pages today. I believe that we can end the HIV epidemic, but this means not only stopping new transmissions, but also supporting all people with HIV to lead long and healthy lives. I hope that the Trump Administration combines its pledge with a plan that embraces our communities and moves us closer to our shared goal.