President Donald Trump pledged in his State of the Union address to “defeat AIDS in America and beyond” over the next decade. But over the past two years his administration has repeatedly attempted to slash the budgets of critical federal programs available to the 1.1 million people in the U.S. living with HIV and the nearly 20 million people living with the virus in sub-Saharan Africa.
“My budget will ask Democrats and Republicans to make the needed commitment to eliminate the HIV epidemic in the United States within 10 years,” the president told Congress — the same body that has twice rejected his proposed budget cuts to HIV programs — Tuesday night.
While details of the Trump administration’s proposal are scant — he dedicated only a few minutes to it in the nearly 90-minute speech — officials told the New York Times on Tuesday that it will focus on 48 counties that account for about half of the 40,000 new HIV infections that occur each year. These are primarily communities of color in the rural South and urban areas including Los Angeles, Miami, Brooklyn, and the Bronx.
The rate of new infections in the U.S. hasn’t budged since 2012, according to the U.S. Centers for Disease Control and Prevention. If current diagnosis rates persist, about 50 percent of black men who have sex with men, and 25 percent of Latino men in the same demographic will be diagnosed with HIV at some point in their lives, the CDC said in 2016.
Other details of the campaign include increasing the use of antiretroviral drugs as well the drug PrEP, which can help block infection for those at risk of exposure to the virus.
Advocates say the goal to eradicate HIV transmissions by 2030 is achievable, and federal officials have already committed to reducing the number of new HIV infections by 75 percent in the next five years. But, they add, it will depend on some big funding promises — the polar opposite of what they’ve seen from Trump so far.
“We stand ready to work with him and his administration if they are serious,” AIDS United and 21 HIV advocacy groups said in a joint statement Tuesday night. “But to date, this administration's actions speak louder than words and have moved us in the wrong direction.”
Swings at lauded international programs
For fiscal 2019, the Trump administration proposed cutting $860 million from the extremely successful President’s Emergency Plan for AIDS Relief, established by President George W. Bush in 2003. The bilateral initiative, known as PEPFAR, was instrumental in turning the tide on Africa’s HIV/AIDS crisis and continues to stave off the epidemic. The proposed cut would be about 18 percent of the initiative’s budget.
That was the second time Trump’s administration submitted an annual budget proposal with deep cuts to PEPFAR’s funding. His proposed budget also included a $425 million cut to funding for the Global Fund to Fight AIDS, Tuberculosis, and Malaria.
Congress rejected both cuts — the Senate actually proposed a slight funding increase for PEPFAR — although the budget hasn’t been finalized yet. In fiscal 2018, the White House’s attempt to gut PEPFAR of $859 million and the Global Fund of $225 million was also blocked by Congress.
PEPFAR is the largest-ever global initiative to focus on a single disease, with tens of billions of federal dollars over the past several years pumped into providing antiretroviral treatment, HIV testing and counseling, care for children orphaned by the virus, and safe-sex messaging.
In April 2017, Bush pleaded in a Washington Post op-ed for the administration to fund PEPFAR at its existing levels, writing “we are on the verge of an AIDS-free generation, but the people of Africa still need our help.”
If PEPFAR funding is cut, the world could start to see backsliding on HIV progress, according to Jennifer Kates, the director of Global Health and HIV Policy at the Kaiser Family Foundation. “One of the challenges we’ve faced is that there hasn’t been a scale-up to address the epidemic in a big way,” she said, explaining that funding has been flat for several years.
The program was reauthorized by Trump in December through 2023, after Secretary of State Mike Pompeo announced in November that PEPFAR had saved more than 17 million lives. But despite public statements on the initiative’s successes, advocates fear the Trump administration will attempt to cut the budget yet again for fiscal 2020.
“That’s a lot of hypocrisy, based on what the administration has put forward thus far on domestic and global HIV efforts,” said Keifer Buckingham, a senior policy adviser at the Open Society Foundations.
It’s also unclear whether Trump’s plan to end HIV transmissions by 2030 will have a global component, which many advocates consider necessary to adequately address the HIV epidemic.
Moves to defund programs at home
Established in 1990, the massive Ryan White HIV/AIDS program serves people living with the virus in the U.S. who can’t afford treatment. It trains clinicians, supports community health programs, and provides low-cost medical care and drugs for people living with the virus — services used by more than half a million Americans each year.
The White House attempted to completely defund certain Ryan White programs in 2017, including AIDS Education and Training Centers and Ryan White Special Projects of National Significance. The first funds a network of regional programs that train clinicians in diagnosing and treating people living with HIV. The latter works on better serving those patients, for example, by researching better ways to engage at-risk black men in HIV care and education.
The Ryan White program received a total of $2.34 billion in fiscal 2018 after Congress rejected Trump’s defunding attempts.
The White House has promoted the success of both programs despite their attempted funding cuts. At a World AIDS Day event in December praising both PEPFAR and the Ryan White program, Vice President Mike Pence announced that the Trump administration would invest $100 million to faith-based organizations working on HIV and AIDS, according to NBC News. It’s not clear whether that’s a part of the plan Trump announced Tuesday.
Pence has made controversial statements about the Ryan White program in the past. Nearly two decades ago, during his campaign for Congress, he said the government should only support the program if “federal dollars were no longer being given to organizations that celebrate and encourage the types of behaviors that facilitate the spreading of the HIV virus.”
Threats to the Affordable Care Act
Meanwhile, the Trump administration’s efforts to dismantle the Affordable Care Act could also negatively impact people living with HIV and AIDS, advocates say. The 2010 healthcare law guaranteed people with pre-existing conditions like HIV access to inexpensive medical care. The Affordable Care Act also established state-by-state Medicaid expansion, widening the reach of federal healthcare for the poor, which covers more than 40 percent of people with HIV. The majority of Republicans have rallied behind Trump’s effort to strike down the law.
Getting rid of the Affordable Care Act — currently threatened by a GOP-backed lawsuit in Texas — could cause people living with HIV to lose access to care.
The Kaiser Family Foundation’s Kates said, “On one hand, new investments in HIV in hard-hit communities could really make a difference. On the other, ongoing efforts to scale back the ACA, or stop expansion of Medicaid, or restrict access to programs, really works in the opposite direction.”
Still, even after swings at the Affordable Care Act and programs aimed at ending the epidemic, those fighting to reduce HIV transmissions are cautiously optimistic about the sincerity of Trump’s pledge.
“While we might have policy differences with the President and his Administration, this initiative, if properly implemented and resourced, can go down in history as one of the most significant achievements of his Presidency,” Michael Ruppal, executive director of the AIDS Institute, said in a statement.
Cover: President Donald Trump delivers his State of the Union address to a joint session of Congress on Capitol Hill in Washington, Tuesday, Feb. 5, 2019. (AP Photo/Carolyn Kaster)