Plan to End HIV an About-Face for Trump Administration

Alicia Ault

February 06, 2019

The Trump administration has announced an ambitious plan to reduce HIV infections in the United States by 75% within 5 years and by 90% within 10 years.

The announcement comes on the heels of President Donald J. Trump's State of the Union speech, in which he said he'd be calling on Congress to help end HIV and AIDS.

It is a huge about-face. For the last 2 years, the president's budget proposals have sought to cut money from HIV and AIDS prevention and treatment. Congress overrode the cuts.

The Trump administration has also targeted LGBTQ rights and instituted a ban on transgender people serving in the military. And, after most members of the Presidential Advisory Council on HIV/AIDS quit in protest in 2017, Trump fired the remaining members, leaving it a nonoperating committee until late 2018, when two new cochairs were named by US Department of Health and Human Services (HHS) Secretary Alex Azar, according to

Now, in the soon-to-be-released 2020 budget, Trump will be making a request for new money to help a handful of federal health agencies coordinate and target prevention and treatment where infections have been rising: among African American and Latino gay and bisexual men, transgender individuals, women of color, and people living in the South; and in 48 counties, seven states (Alabama, Arkansas, Kentucky, Mississippi, Missouri, Oklahoma, and South Carolina), and Washington, DC, and San Juan, Puerto Rico.

More than half of new HIV infections in 2016 and 2017 occurred in those geographic areas, according to HHS.

Federal spending of $20 billion annually on HIV prevention and treatment has helped bring down infections to about 40,000 a year, but progress has plateaued, federal health officials said.

"HIV has cost America too much for too long," said Admiral Brett P. Giroir, HHS assistant secretary for health, on a call with reporters Wednesday. He said that 700,000 Americans have died of AIDS since 1981.

"We are at high risk of another 400,000 Americans becoming infected with HIV over the next decade," Giroir said.

"Now's the time to change this," said Centers for Disease Control and Prevention (CDC) Director Robert Redfield, MD, on the call. "We have the tools to end new HIV infections," he said, noting the ability to identify clusters of infections and apply unique solutions to each community, and the existence of pre-exposure prophylaxis (PrEP), the combination of tenofovir disoproxil fumarate and emtricitabine (Truvada, Gilead) that has been shown to suppress viral loads in individuals recently exposed to HIV.

"We know that pre-exposure prophy works in more than 97% of the cases," said Anthony S. Fauci, MD, director of the National Institute of Allergy and Infectious Diseases (NIAID), on the call. "Theoretically, then if you get everyone who's infected on antiretrovirals and decrease the viral loads to below detectable levels — give those who need PrEP, PrEP — you could theoretically end the epidemic as we know it."

Giroir would not share how much the administration will request from Congress. "We are very confident we will have the sufficient resources provided in the 2020 budget for us to begin this very aggressive plan," he said, adding that the funds will have to be approved by Congress.

The agencies involved — which include Giroir's office, the CDC, the Health Resources and Services Administration, NIAID, and the Indian Health Service — have already begun working together with existing funds, Giroir said.

The close collaboration of these agency leaders — including Fauci and Redfield, who have worked on HIV their entire careers — is "very exciting," said John Wiesman, DrPH, MPH, secretary of health for Washington state and cochair of the newly reformed Presidential Advisory Council on HIV/AIDS.

Wiesman told Medscape Medical News that he looked forward to hearing more details about the plan at the upcoming March 15-16 meeting of the new advisory council.

Terrance Moore, executive director of the National Alliance of State & Territorial AIDS Directors, said that he too was waiting to hear more details. "We have the tools, what we lack is bringing all of these tools to scale," Moore told Medscape Medical News. He said he was cautious, but hopeful, noting that no actual dollar figure had been released yet.

Focus on PrEP

The details released so far indicate a clear intention to improve diagnosis and then steer more Americans who are at risk onto PrEP.

Redfield said that the CDC will establish HIV elimination teams — "for 'boots-on-the-ground' support," and would work with state and local health departments and local communities to tailor approaches to bring people into care.

The agency also wants to enhance the capacity and ability to diagnose, he said, noting that one of two people with HIV infection have been infected for at least 3 years. Seven of 10 of newly diagnosed HIV patients had seen a healthcare provider within the previous 12 months, Redfield said.

But only 10% of the estimated 1.2 million people who should be receiving PrEP — because they are considered high-risk — are getting the drug, Giroir said, adding, "It's an astounding and shocking figure."

In November 2018, the US Preventive Services Task Force (USPSTF), in a draft statement that is still being finalized, gave PrEP an A rating. "The USPSTF recommends that clinicians offer pre-exposure prophylaxis (PrEP) with effective antiretroviral therapy to persons who are at high risk of HIV acquisition," the task force said.

The CDC recently reported that PrEP is vastly underutilized by women and minorities, in particular. In 2016, among 32,853 (41.9%) PrEP users for whom race/ethnicity data were available, 68.7% were white, 11.2% were African American, 13.1% were Hispanic, and 4.5% were Asian, the CDC found.

The agency researchers reported that although black men and women accounted for 40% of people in whom PrEP was indicated, nearly six times as many white men and women were prescribed PrEP as were black men and women.

Cost is a huge barrier to PrEP, and one of the main service programs for HIV and AIDS patients — The Ryan White program — does not allow funds to be spent on the medication.

Giroir said that the federal officials "have planned for and will fund for the ability for those who are in need, and without other resources to be channelled into the community health system," to get PrEP.

Both Moore and Wiesman said that money for PrEP was crucial. "Somewhere in the plan there needs to be a new funding line — there needs to be a vehicle to be able to do this," Moore said.

Rebuffing Stigmatizing Policies

Concern was also expressed that the Trump administration might not be capable of delivering services to a population that it has sidelined with some policies.

But Wiesman said, "The individuals who have been working on this clearly understand the importance of equity issues and stigma." He added that, in talking with the federal officials involved in the HIV and AIDS plan, he believes "they are fully committed to making sure this approach is one that is grounded in respect, that is grounded in understanding and appreciation of many different [life] experiences."

The officials directly addressed the issue on the call with reporters.

Redfield said that stigma "is the enemy of public health," and has been a major barrier to optimal prevention and treatment of HIV. "The transgender population in particular needs to be reached out to, and we need to be able to address in a comprehensive way how to destigmatize HIV infection."

"Transgender people certainly are at high risk for infection and are overrepresented in the group that are infected," Giroir said. He said that all of the agencies involved "will treat transgender people the way we treat any other patient — giving them the respect they deserve whether they are infected or whether they are at risk of infection. That's a commitment that we all have very firmly."

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