If you ask the average person on the street, avoiding HIV is a matter of personal responsibility. It's up to you to wear a condom all the time, to make sure the condom doesn't break, and to always have sex in a predictable, risk-free vacuum that really doesn't exist. But for those of us who discuss HIV ad nauseum every day, we know that any discussion about HIV on a micro-level negates the many structural forces at work that put people at risk for infection, like structural racism, homophobia, and more.
Enter Elizabeth Warren. On Oct. 10, the Massachusetts senator and Democratic presidential frontrunner released a comprehensive plan called "Securing LGBTQ Rights and Equality" that not only offers comprehensive plans and promises on how to help all aspects of LGBTQ life, but also offers real, structural solutions to the HIV epidemic that is still a reality -- especially in communities of color, particularly in black and Latinx communities.
Most impressive is that Warren places decriminalizing HIV transmission as the second part of her HIV/AIDS agenda, right under increased funding for the Ryan White HIV/AIDS program, which provides funding for essential services for people living with HIV. Warren calls the laws criminalizing HIV "completely at odds" with scientific realities surrounding HIV transmission and correctly asserts that they contribute to greater stigma and discrimination by enshrining them in our legal system. Warren proposes federal legislation to repeal all existing statutes and laws criminalizing HIV transmission and exposure.
Aside from her stance on HIV criminalization, one of the most impressive parts of Warren's proposal includes a plan for the federal government to manufacture pre-exposure prophylaxis (PrEP) to drive down costs. The Affordable Drug Manufacturing Act would allow the government to manufacture any generic drug if fewer than three companies are making the drug, if there is a shortage of the particular medication, or if the World Health Organization has deemed it an essential medicine and the companies manufacturing it have set a price point deemed unaffordable.
"No one should contract HIV because they could not afford the medication to prevent it," she writes.
Warren also makes a smart connection between the ongoing opioid epidemic and the HIV epidemic, and highlights her commitment to passing the CARE Act, which commits $100 billion over 10 years to fight substance abuse.
Several other parts of Warren's plan, though not listed under her HIV plans, would certainly make huge strides in ending the stateside epidemic. For instance, one of the most surefire ways to end the HIV epidemic in America is to address the homelessness epidemic. Research has shown that people living with HIV who have secured housing are more likely to be engaged and retained in care and that people living with HIV who lacked housing had worse health outcomes across the board, including less adherence to medication and more trips to the emergency room.
Warren's plans for housing include $500 billion to rehab millions of housing units in the next 10 years, creating jobs, driving down rents, and funding programs specifically aimed at queer and transgender homeless youth. Warren also calls out laws that criminalize homelessness, a problem in many metro areas, especially San Francisco.
Mass incarceration is another huge structural driver of our HIV epidemic, and Warren's proposals include specific items on how to drive down the huge numbers of incarcerated LGBTQ+ people. While pointing out that nearly half of black transgender people will be incarcerated in their lifetime, Warren lays out plans for increased funding for training to stop implicit bias among law enforcement and ending practices that profit off incarcerated people, including cash bail and health care fees. Warren also calls for an end to solitary confinement, a form of inhumane torture often used to separate LGBTQ people from the rest of the prison population.
Finally, in a nod to combat HIV stigma, Warren wants to end the Food and Drug Administration blood ban that bars gay and bisexual men from donating blood. She calls the policy "outdated" and "discriminatory," while noting that it doesn't help with the current scarce blood supply.
Much separates Warren's proposed approach to the HIV epidemic from the Ending the Epidemic plan the current administration has put forth. At the heart of the Trump administration's plan is to focus on the 48 counties; seven states; San Juan, Puerto Rico; and Washington, D.C., that account for roughly half of the United States epidemic. Most of these plans involve increased resources for individual-level interventions like testing, access to treatment, and access to prevention in the form of condoms or PrEP.
However, as I've previously written in an editorial for Out, Trump's plans rely on old, micro-level notions of the HIV epidemic that completely ignore the structures that undergird and fuel it. Where Trump's plans focus on how to get people into the same systems and interventions we already have, Warren's plans suggest that she understands the unique synergy between systems -- the housing crisis, mass incarceration, criminalization -- that keeps the epidemic alive.