At his State of the Union address on February 5, Donald Trump announced a plan to end the HIV epidemic by 2030. “Ending the HIV Epidemic: A Plan for America” is an initiative aiming to reduce new HIV diagnoses by 75% within five years and 90% in 10 years.
The Obama administration’s “National HIV/AIDS Strategy” was used as a road map for this plan, according to Health and Human Services spokesperson Diane Gianelli, and it, too, aimed to reduce new HIV transmissions. The 2010 strategy—which was updated in 2015—was ambitious, and is still on track to reach some goals. However, it will likely fall short in other areas. Will Trump’s strategy, which is just as ambitious, if not more so, be able to achieve where Obama’s failed?
Both plans emphasize the importance of HIV testing, as well as expanding the use of pre-exposure prophylaxis (PrEP), a daily pill that prevents the transmission of HIV from sex by more than 90% according to the CDC.
Another component of these strategies is getting treatment to those who are living with HIV. When somebody on antiretroviral therapy becomes virally suppressed and has an undetectable viral load, they cannot transmit the virus to others. This prevention method is better known as “treatment as prevention,” or TasP, and it’s nearly twice as effective at reducing new transmission rates than PrEP.
Obama’s 2020 Plan
In 2010, viral suppression had only been achieved by 46% of those diagnosed with HIV in the United States, but Obama’s plan aspired to get that up to 80%. It had been thought that by doing so, it would have a massive impact.
In 2016, the CDC had predicted that achieving this would have prevented an estimated 168,000 new transmissions within five years. Now they claim that that estimate was incorrect, and it would instead only prevent 55,828 new transmissions over five years, which is only about 33% of what they first had estimated. When you take into account that there were approximately 38,739 new diagnosis in 2017 alone, it would seem that TasP isn’t nearly as effective as they once had thought.
The miscalculation is disconcerting, but in any case, the percentage of those diagnosed with HIV who were virally suppressed has gone up to 57.9%, from 46%, as of 2014, which is above target. No data is available about their progress beyond that date.
The number of people using PrEP had increased significantly over the last few years under Obama’s plan, but not among those most at risk, including racial minorities and people under the age of 25.
According to the most recent 2017 progress report, Obama’s plan is off-target in a number of other areas too, including reducing disparities in new diagnosis amongst gay and bisexual men, as well as young black gay and bisexual men, and people living in the South. They’re also behind their goal of reducing the percentage of young gay and bisexual men who have engaged in risky sexual behavior.
According to Bruce Richman, the founding executive director of Prevention Access Campaign and the “undetectable equals untransmittable” campaign (U=U), the cause for this is partially due to “not doing enough to address social and structural factors which lead to disproportionate impact and health disparities in communities of color.” This includes housing, employment, and food security.
There’s also the issue of HIV stigma standing in the way. Stigma prevents people from getting tested, accessing treatment, or getting on PrEP.
William McColl, the vice president for policy and advocacy at AIDS United, also brings up the Affordable Care Act (ACA) and how he believes that the Obama administration was expecting it to help them achieve their objectives with their strategy. When Medicaid wasn’t expanded to all states, McColl believes the administration found that it couldn’t do what it set out to do.
Trump’s 2030 Plan
In contrast to the Obama plan, Trump’s new strategy aims to increase the 60% of those who are vitally suppressed up to 90% by 2030. Whether achieving viral suppression at 90% could bring better results than were anticipated at 80% remains to be seen.
Currently, less than 10% of those who need PrEP are receiving it, but the new plan would increase PrEP usage to 50—60%. But with what we know about Trump’s plan, many of the issues that inhibited Obama’s aren’t explicitly being addressed at this point, such as social and structural factors.
Trump’s HIV/AIDS track record creates another big disconnect with his effort to end the epidemic. In 2017, Trump fired the remaining members of the Presidential Advisory Council on HIV/AIDS without explanation, and new co-chairs were only sworn-in last month. He also attempted to cut funding from the President’s Emergency Plan for AIDS Relief, slashed $5.7 million from the Ryan White HIV/AIDS Program, and his administration sided with pro-lifers and stopped a study aimed at finding a cure for HIV because it used fetal tissue from elective abortions.
He has also rolled back protections for LGBTQ people, who are disproportionately affected by HIV/AIDS. Discrimination and stigma makes people more susceptible to HIV; homophobia is a known barrier in the battle to end the epidemic, as it prevents people from accessing prevention strategies, getting tested, or being treated.
McColl says that the lack of comprehensive sexuality education is also a “potential barrier” in achieving Trump’s plan. There are 21 states where sex ed or HIV/STI instruction doesn’t need to be evidence-based or informed, medically accurate, or culturally or age appropriate—none of this is addressed in the plan. “This education is a critical tool in preventing HIV, other sexually transmitted infections (STIs), and unintended pregnancies,” says McColl.
The Trump administration plans to provide funding for programs in targeted geographic hotspots where high concentrations of new transmissions take place; use data to figure out where HIV is spreading the quickest; and create an HIV HealthForce that will work locally in target areas to expand HIV prevention and treatment efforts there.
But a sobering reality remains: According to Bill Gates, Trump didn’t know the difference between HIV and HPV, so the idea that he’s going to be the savior who ends the epidemic seems questionable. And Trump has had limited success in passing legislation.
And while any progress is progress and would be welcome, even if all goals aren’t met, it’s difficult not to feel as though we’re being baited with unrealistic goals.