In recent days, the Trump Administration has created an uproar with its abrupt decision to dismiss all members of the Presidential Advisory Council on HIV/AIDS (PACHA). This is a troubling development, but one that has the potential to distract us from what matters: working collectively to end the HIV epidemic in the United States and around the world. I may have a unique vantage point from which to react to this news. I was President Obama’s first HIV Advisor and I oversaw the decision to revamp PACHA by terminating all appointees of the prior Administration and starting fresh at the beginning of the Obama Administration. More than that, President Obama came to office having pledged to develop a National HIV/AIDS Strategy for the United States, something we require from our partner countries in our global AIDS program, the President’s Emergency Plan for AIDS Relief (PEPFAR), but which we never had for the United States. It was my task to coordinate this effort. I was originally somewhat skeptical that any “Strategy” could produce lasting change, yet nearly eight years after the release of the first Strategy, I am amazed at the quantifiable results that have been produced. As a sign of its success, this nonpartisan plan that identifies priority actions for government and non-governmental stakeholders alike was updated in 2015 to guide the Nation’s efforts through 2020.
While HIV may be rarely front-page news these days, the United States continues to have a very serious epidemic with 1.2 million Americans living with HIV. Our public and private investments have produced remarkable results for the American people: new infections have begun declining and with effective treatment and quality medical care, people with HIV can live essentially a normal lifespan. Nonetheless, our progress has been uneven with gay and bisexual men and transgender women, along with Black and Latino communities especially disproportionately impacted. Combining HIV treatment for people living with HIV, supplying sterile syringes to people who inject drugs, offering condoms, and providing a daily pill to HIV negative individuals with significant risk for infection (called pre-exposure prophylaxis or PrEP), we have the tools to stop new HIV infections, but we need to get these tools to some of our most marginalized and traumatized communities. Continued progress does not solely depend on the federal government. Yet and still, presidential leadership matters. President Trump has an opportunity to move us dramatically closer to the day when HIV is no longer a public health threat. To get there and be a hero of this story, however, the Administration needs to both step up and step out of the way.
President Trump and his team have every right to appoint whomever they choose to provide advice on HIV policy. The sudden terminations of existing council members are alarming not in isolation, but they are happening after a year in which the Administration has worked strenuously to undermine the Affordable Care Act (ACA), legislation for whom people living with or at risk for HIV infection have been among its biggest beneficiaries. I do not believe that any single policy or action contributed more to achieving the nearly 20% decline in new HIV infections that occurred during the Obama Administration than the ACA’s reforms which expanded access to Medicaid and private insurance for people living with HIV.
In the last month, it also has been reported that the Administration has banned certain words from use in their budget submission to Congress. The Administration has the right to use any words it chooses to justify their priorities, but their priorities must respond to the needs of all communities heavily impacted by HIV. This is among the toughest issues to navigate through the political landscape because it involves sex and drugs, and is like salt in the wound of our cultural divide. In our diverse country, we can have differing views and values, but when investing public money, we need to rely on scientific evidence of what works best. When we released the National HIV/AIDS Strategy, we used such evidence to shift priorities over which interventions we would fund and how we would allocate funding. This did not always make our supporters happy. In some cases, the biggest losers were cities and states in Blue America that had done the most to fight HIV and the biggest winners were jurisdictions in Red America that, even when receiving more federal money, sometimes seemed indifferent to the people living with HIV in their own communities. These were tough changes, but we felt they were the right thing to do because it is what research data told us would have the biggest impact. It is almost laughable that the Administration is apparently asserting that CDC policies are based on science “in consideration with community standards and wishes.” Communities are often divided and we need objective scientific data to pull us out of the morass of conflict in order to show the public we are not wasting their resources and in order to move forward together.
Where does this leave us? For the HIV community, we cannot lose sight of what we need to do. We need to keep doing in 2018 what we did in 2017. That means we shout a little more loudly that we love our trans sisters and brothers, Black, Latino, native, and Asian communities, immigrant families, queer youth and adults, and substance using mothers and fathers. Our diverse American family is amazing and we must rededicate ourselves to fighting for our whole family and doing what we need to do to support all people living with HIV to learn their status, get into care, get on treatment, and lead long, happy, healthy lives. We need to keep spreading the message that U=U (Undetectable=Untransmittable). This means that people with HIV who are on medication and have an undetectable amount of HIV virus will not transmit HIV. We need to keep fighting for access to quality health care and working to create affordable access to PrEP in the communities that need it most. And, in these challenging times, we need to redouble our efforts to spread hope. Getting HIV does not need to be an inevitability in any of our communities. We have never had a broader swath of American society supporting us and invested in our success.
For the President and his team, I say that you still can earn a legacy of leadership of fighting the HIV epidemic. Follow the Strategy. Support all parts of the LGBT community, embrace people of color, take bold action to respond to the opioid crisis, and stop bashing the immigrants who contribute so much to our American greatness. Work with Congress to increase not decrease funding for critical HIV prevention and care programs and AIDS research. And, start working to make our health system function effectively. I cannot imagine who would have more credibility to advise you than the dismissed PACHA members, but no matter who you are listening to, the path forward is clear. And, we will be watching. Jeffrey S. Crowley is the Program Director of Infectious Disease Initiatives at the O’Neill Institute at Georgetown Law. From 2009 to 2011, he served as the Director of the White House Office of National AIDS Policy and Senior Advisor on Disability Policy for President Barack Obama
The views reflected in this expert column are those of the individual authors and do not necessarily represent those of the O’Neill Institute for National and Global Health Law or Georgetown University. This blog is solely informational in nature, and not intended as a substitute for competent legal advice from a licensed and retained attorney in your state or country.