A major challenge to ending AIDS in the U.S. is reaching the many HIV-infected immigrants who now slip through the cracks. This clinic in Miami’s Little Haiti neighborhood caters to HIV-infected clients who speak Creole.
Misha Friedman
When news leaked yesterday that U.S. President Donald Trump’s State of the Union address tonight would include a call for ramping up efforts to end the AIDS epidemic in the United States by 2030, many advocacy groups quickly weighed in with guffaws. The nonprofit ACT UP New York, under the rubric “know your scumbags,” published a list of how it says the Trump administration has “further marginalized people living with HIV.” The president of GLADD, which bills itself as the world’s largest LGBTQ media advocacy group, issued a statement that said the planned announcement was “undermined by the Administration’s record and rhetoric” on health issues, and was “designed to distract from what’s really happening behind the scenes every day.”
But many HIV/AIDS researchers and even some leading advocates have a more measured, and even enthusiastic, reaction to the possibility that Trump wants to join an existing ambitious campaign—famously endorsed on World AIDS Day in 2011 by then Secretary of State Hillary Clinton–and position his administration as a champion of a cause that he thus far has not embraced.
“Together, we will defeat AIDS in America and beyond,” Trump said in his speech tonight. “My budget will ask Democrats and Republicans to make the needed commitment to eliminate the HIV epidemic in the United States within 10 years.” He did not specify how much money he will request or whether it will come from existing programs or new appropriations. (Shortly after the speech, the Department of Health and Human services released this fact sheet about the proposal; the White House is expected to release its annual budget request to Congress on 11 March.)
“I’m really excited that this may lead to something,” says Carlos del Rios, an epidemiologist and leading HIV/AIDS clinician based at Emory University’s Rollins School of Public Health in Atlanta, told ScienceInsider prior to the speech. “It’s the last thing I would have expected coming out of Trump,” del Rios says. But he noted that President George W. Bush made a surprise announcement in his 2003 State of Union speech that he wanted to launch a massive HIV/AIDS international assistance program known in shorthand as PEPFAR. “You never know what these guys are going to do,” says del Rios.
Trump’s proposal calls for concentrating the government’s efforts for five years on the places in the United States that have the highest rates of new HIV diagnoses, according to Politico, which broke the story about the HIV/AIDS inclusion in the speech. According to the U.S. Centers for Disease Control and Prevention (CDC) data from 2016, 46 counties in 19 states account for about half of the nearly 40,000 new HIV diagnoses in country (see map, below). About 1 million people in the country are living with HIV.
HIV/AIDS hotspots
The new push to end AIDS calls for more intensive efforts in counties that have the most infected people (dark blue) and the most new diagnoses.
(GRAPHIC) J. YOU/SCIENCE; (DATA) AIDSVU/FLORIDA DEPARTMENT OF HEALTH
The new plan is expected to refine national HIV/AIDS strategies issued by the Obama administration in 2010 and again in 2015. They similarly call for directing resources to the hardest hit geographical locations and the most affected populations, including “marginalized” groups such as men who have sex with men and people who inject drugs. They advocate combining behavioral interventions like condom promotion and provision of clean needles and syringes along with more aggressive testing and use of antiretroviral drugs, which work both as prevention and treatment. (An epidemic requires that each infected person transmit the virus to at least one other, so “ending the epidemic” means dropping below that “reproductive rate” such that it peters out.)
The major challenges, which are spelled out in the previous strategies, is that many people who are infected don’t know their status, and many people on treatment have difficulty sticking with it and thus remain much more likely to develop disease and to infect others. Uninfected people can take anti-HIV pills to greatly reduce their risk of becoming infected but this “pre-exposure prophylaxis” (PrEP) is sparsely used.
“I don’t know that there’s a big gap in the past strategy,” says Jeffrey Crowley, a public health specialist who was director of the White House Office of National AIDS Policy during part of the Obama administration and now works at the O’Neill Institute for National and Global Health Law at Georgetown University Law Center in Washington, D.C. “Maybe there’s a more intentional way to do things and [the Trump administration] might identify new resources.”
Gregorio Millett, who worked with Crowley in the Obama White House and now is director of public policy at amfAR, a leading AIDS research advocacy group in New York City, sees the new proposal as an “incremental” step that might kickstart new interest in HIV/AIDS, particularly within states that have the biggest burdens. “We really need to reinvigorate the response,” says Millett.
Mark Harrington, who heads the Treatment Action Group in New York City and helped launch that state’s progressive ending AIDS campaign, is part of a coalition that in December published a road map for the federal government to end AIDS in the United States by an even earlier date, 2025. The plan “specifically calls out a number of current Trump Administration policies, citing them as major obstacles to getting essential HIV prevention tools into the hands of the people who need them,” says Harrington. He criticizes the Trump administration for policies he says have undermined the human rights of groups disproportionately affected by HIV, including transgender people, communities of color, and undocumented immigrants.
A key proponent of the new campaign is Robert Redfield, an HIV/AIDS researcher Trump appointed to head the CDC. Epidemiologist Chris Beyrer of the Bloomberg School of Public Health at Johns Hopkins University in Baltimore, Maryland, says he twice spoke with Redfield before he got the job about the Trump administration launching just such a campaign. “This is really coming from him,” says Beyrer. “He pressed for this as part of his appointment–saying essentially that President Trump could be the president known for setting the U.S. on a path to success, as George Bush is known for PEPFAR.”
Beyrer notes that Redfield has long promoted condoms, abstinence, reducing the number of sex partners, and testing. But he thinks other necessary strategies pushed by the Obama administration—in particular, theMedicaid expansion portion of the Affordable Care Act that many Republicans “have so bitterly opposed”– may get short shrift now. “HIV is worsening in the American South because low income and working poor African Americans are being excluded from health care access,” says Beyrer. “We might be able to end AIDS as a public health threat in the U.S. by 2030, but we won’t get there with testing and condoms. We have to do better with provision of health care, drug treatment, antiretroviral treatment and PrEP to those who need it most. If this administration can do that, it would truly be wonderful for the American people. Let’s hope the governors of Florida, Texas, Louisiana and the Carolinas are listening to the speech tonight!”