It's far too early to predict what will be the Trump administration's most devastating impact on human health, but there's a good chance the answer will involve HIV/AIDS. After all, his support staff includes Mike Pence, who allowed a completely avoidable HIV outbreak in his home state and had the breathtakingly insane idea of moving funds from the Ryan White Program, the payer of last resort for people with HIV/AIDS, into gay conversion therapy. He also hired Katy Talento, a health policy advisor who tried to kill more than $100 million in NIH research funds because she confused studying HIV among sex workers with supporting Russian prostitution. And while Trump himself hasn't said much about the disease, that's part of the problem. On the campaign trail, he illustrated his disregard for the issue by failing to complete an HIV/AIDS strategy survey by the Gay Men's Health Crisis, the first AIDS service organization.
Why should we be worried about Trump's potential impact on HIV/AIDS? Let's count the ways: If the ACA is repealed, Medicaid expansion is reversed, affordable housing and food stamps are cut, immigrants are scared to get tested or treated, and PEPFAR is scaled back or run on morals, not science, Trump's legacy may be igniting a national and global AIDS crisis. Here's why.
ACA and Medicaid
On December 20, 2016, the day after the electoral college confirmed that, yes, we're really doing this, 180 organizations cosigned a letter that urged senators not to repeal the ACA without a replacement that protects Medicaid. Two weeks later, more than 950 medical professionals sent another letter that begged senators to "sustain the federal commitment to the Medicaid program."
Medicaid is the largest insurer of people with HIV/AIDS and, in states that expanded Medicaid to people making below 138 percent of the poverty line, the number of uninsured dropped by six percent. This is a matter of life and death: One study found that uninsured HIV patients were 40 percent more likely to die during a hospital stay than people with insurance.
"Medicaid expansion has been absolutely critical," says Tim Horn, the deputy executive director of HIV and HCV Programs for the Treatment Action Group. "It gave people access to the comprehensive care that we needed."
The GOP's health care plan is basically a fuck you to low-income people: Medicaid expansion will end on January 1, 2020. According to one estimate, more than 55,000 low-income people with HIV/AIDS will lose their insurance.
Housing and Food
Whether the AIDS epidemic is slowed or accelerated depends not only on biological factors, but social ones. "If you really want to stop the AIDS epidemic, obviously there are biomedical interventions that are critical, but they don't work unless you have housing stability," says Charles King, the president and chief executive officer of Housing Works.
Without stable housing, people are ten times more likely to contract HIV; people with HIV have a harder time keeping up with their healthcare. It might seem ideal, then, that the head of the Department of Housing and Urban Development is a doctor, until we remember that that doctor is Ben Carson. While there is no public record of Carson's opinion of HOPWA (the Housing Opportunities for Persons with AIDS federal program), he has made his opinion of government assistance clear: He opposes fair housing desegregation laws and thinks Section 8 affordable housing programs for the poor are the stuff of "communist countries."
"As Trump and Congress work to cut taxes for corporations, cut taxes for the wealthy and generally work to reduce federal spending, that means spending on social programs drops," says John Peller, the president and chief executive officer of the AIDS Foundation of Chicago. "We are going to see new HIV cases if, for example, food stamps are cut or housing is cut."
Food stamps almost certainly will be gutted, even though starving people is predictably a bad public health idea. Food insecurity has been shown to lead to more trips to the hospital, worse infections, and greater risk of HIV. One reason is that people who are hungry or have gone more than a day without eating may engage in riskier sex work to provide food for themselves and their family, including using coke or heroin before sex.
Taking away food stamps obviously makes things worse. Yet food stamps are maybe the only thing that Mike Pence has opposed harder than women's health, and House Republicans have proposed cutting them by $23 billion.
But even if insurance, housing, and food stamps remain in place, not everyone will feel safe accessing those resources because of Trump's aggressively anti-immigrant policies. "People are afraid to come into clinics," says Kathie Hiers, the chief executive officer of AIDS Alabama. "The South has the largest growing Latino and Latina population and they are scared to death. There is a good deal of stigma and people are afraid to get services for fear they might get outed."
Immigration and Customs Enforcement custody is an especially scary place for people with HIV to be—a fact that precedes Trump. A 2009 study found that ICE "delivers a substandard level of medical care to those with HIV" and "HIV-positive detainees are especially vulnerable to lapses in proper medical care."
Take the case of Victoria Arellano. She was taken off her HIV medications once she entered ICE custody at the San Pedro Service Processing Center, according to testimony before the House. She soon became sick, developed a high fever, and began vomiting blood. Arellano died on July 20, 2007.
Last month at the Munich Security Conference, Bono praised Mike Pence for defending PEPFAR—the President's Plan for Emergency AIDS Relief, a program launched by George W. Bush in 2003, which prevented an estimated 2.9 million infections between 2004-2013.
But there is reason to worry that Trump may cancel PEPFAR altogether or dramatically scale it back. During Trump's transition, his team distributed a questionnaire to the State Department that asked, "Is PEPFAR worth the massive investment when there are so many security concerns in Africa? Is PEPFAR becoming a massive, international entitlement program?"
Keeping PEPFAR intact, however, isn't the solution either. Abstinence and faithfulness programs have been a staple of PEPFAR (at one point a third of all funds were required to go to these programs). But a recent study shows that they are not only expensive but completely ineffective, wasting more than $1.4 billion.
"The idea of abstinence and faithfulness was driven by idiotic religious fundamentalism," says Stephen Lewis, the former UN Special Envoy for HIV/AIDS in Africa from 2001 to 2006. "The whole premise was nonsensical." Indeed, there is zero evidence to suggest these programs reduced HIV risk.
Abstinence and faithfulness programming is nothing more than morality masquerading as a prevention strategy. Infectious diseases don't care about our morals; the only thing that has ever stopped them, or will ever stop them, is science.
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