In a State of Disunion: HIV, TB, and HCV Elimination Policies and Priorities Under the Trump Administration
During Trump's first-ever State of the Union address on January 30, activists observed a dearth of clear priorities to eliminate HIV/AIDS, tuberculosis (TB), and hepatitis C virus (HCV) in the U.S. Science and longstanding bipartisan interest in global health have paved the way for potential monumental political wins by the Trump administration: federally funded research has brought us multiple effective HIV treatments and PrEP for HIV prevention, PEPFAR catalyzed treatment access to millions of people living with HIV globally, HCV has seen an influx of promising cures, and global recognition of the importance of U.S. government leadership in addressing the growing threat of drug-resistant TB. Eliminating these three epidemics from the U.S. and globally are only a few strategic moves away, and yet ...
The policy moves made by the administration, this year alone, have been illogical. The President's fiscal year (FY) 2019 budget defies what's left of any momentum toward reducing the deficit, which has already been intensified by the administration's disastrous 2017 tax reform package passed at the end of 2017. It is also the clearest signal yet of how Trump prioritizes these epidemics. Cutting the tremendously important Ryan White program, continuing to flat-fund the U.S. Centers for Disease Control's (CDC) Division of TB Elimination, and seemingly shifting money from HIV prevention in the name of addressing the opioid epidemic are only a few ways the administration is turning its back on public health progress and needs. There's also the administration's anti-LGBTQ stances, violent rhetoric towards the drug-user community, rules for protecting discriminatory healthcare providers, attacks on 340B drug pricing program, support for states implementing Medicaid work requirements, constant disarray at the State department, and skimming on commitments to the Global Fund, all of which further muddle the policy routes towards domestic and global elimination of HIV, TB and HCV.
However, as evidenced by last year's successes in stopping full ACA repeal and Medicaid dismantling, progress with a budget deal with relief to the caps, which effectively raises the federal spending limit by nearly $300 billion over two years, as well as saving the Fogarty International Center at NIH from elimination, activism can win in a policy environment that is seemingly stacked against it especially in a critical election year. In addition, the union of HIV, TB, and HCV activists is stronger than ever. But with a bleak, unclear roadmap given by our government, what do we prioritize and where do we as a community go from here?
Money, namely through federal budget appropriations, will be the key driver for public health programs geared towards elimination. As this issue of TAGline goes to press, advocates are preparing FY 2019 budget priorities and asks to Congress. HIV/AIDS, TB, HCV, and sexually transmitted infection advocates collectively hope, for the first time, to push the federal government to increase a single number: $1.12 billion for the CDC's National Center for HIV/AIDS, Viral Hepatitis, STD and TB Prevention (NCHHSTP), which constitutes a miniscule 2% of the total CDC budget.
Research and messaging on investments in prevention as a strategy that can yield significant savings could potentially appease conservative Congressional deficit hawks. For example, averting TB cases has saved an estimated $6.7 to $14.5 billion in societal and economic costs to the U.S. between 1992 and 2014.1 With respect to HIV, CDC projections predict $379,000 in savings across the government, healthcare system, and individuals for every new infection prevented.2 There's also cost-effectiveness data from a New York City-based needle exchange program, with estimated savings of $1,300 to $3,000 per individual.3 Another analysis strongly recommends funding a national syringe program: "three-fourths of HIV treatment costs in the US are borne by the public sector, expanding syringe exchange could contribute to reducing the country's public budget deficit in the long run."4
However, it's vital to underscore that some of these significant cost-saving projections are factoring in the high price of treatment in the U.S., which must be another target for activists. The CDC, while making a case for prevention and syringe exchanges as critical access to treatment, acknowledges a stark unevenness in the math by noting, "HCV treatment can save $14.3 billion in health costs while costing $69.5 billion to implement, raising budgetary issues for Medicaid and other insurance plans."5 The high costs of HCV and other prescription drugs have been recognized by the Trump administration and federal and state lawmakers. But weak proposals and bloated rhetoric have done very little to lower drug prices, leaving this key election campaign promise unfulfilled. Alarmingly, a white paper released from the White House Council of Economic Advisors skirts the issue by scapegoating other countries for the high prices in the U.S., rather than U.S. government capitulation to the PhRMA lobby.
Instead, a questionable two-pronged strategy is recommended to "reduce prices for what Americans pay now for pharmaceutical products" and "raising innovation incentives," which is a cover for manipulation and deregulation tactics.6 The white paper surmises policies that underpricing of drugs in foreign countries has a profound effect on the cost of drugs to the American consumer.7
HIV, TB, and HCV advocates must target the U.S. Trade Representative, a position that will likely be used under the guise of reducing prices domestically to clamp down on other countries' ability to exercise Trade Related Aspects of Intellectual Property Rights (TRIPS) flexibilities. Furthermore, any attempts to deregulate the FDA further, whether through the implementation of the flawed 21st Century Cures Act, to advance dangerous Right-to-Try bills that favor PhRMA must be met with community opposition.
To that end, without real meaningful policy and reform aimed at lowering the price of prescription drugs head-on -- with drug pricing proving to be important structural barriers to HIV, TB, and HCV treatment in the U.S. -- and shoring up underfunded programs, the Trump administration will remain woefully short of achieving much what of it has promised, and we will be even farther as a community from achieving true elimination in the remaining time left in this presidency. But there are policy opportunities in the chaos. In 2018 and in advance of the November midterm elections, advocates and activists will need to continue to be the change we seek by convincing winning conservatives with the cost-effectiveness of prevention to rectify their own tax reform debacle, and come together as a community to push real policy strategies to mitigate high-price of drugs across HIV, TB, and HCV.
- Castro KG, Marks SM, Chen MP, et al. Estimating tuberculosis cases and their economic costs averted in the United States over the past two decades. The International Journal of Tuberculosis and Lung Disease [Internet]. 2016 Jan; 20(7):926-933. www.ncbi.nlm.nih.gov/pmc/articles/ PMC4992985/
- HIV Cost-effectiveness [Internet]. Centers for Disease Control and Prevention. Centers for Disease Control and Prevention, Division of HIV Prevention; 2017 [cited 2018 Mar 11]. www.cdc.gov/hiv/programresources/guidance/costeffectiveness/index.html
- Belani HK, Muennig PA. Cost-Effectiveness of Needle and Syringe Exchange for the Prevention of HIV in New York City. Journal of HIV/AIDS & Social Services. 2008;7(3):229-240.
- Nguyen TQ, Weir BW, Jarlais DCD, et al. Syringe Exchange in the United States: A National Level Economic Evaluation of Hypothetical Increases in Investment. AIDS and Behavior. 2014;18(11):2144-2155.
- Improving Access to prevent the spread of HIV and HCV [Internet]. Centers for Disease Control and Prevention. Centers for Disease Control and Prevention, Office of the Associate Director for Policy; 2016. www.cdc.gov/policy/hst/hi5/cleansyringes/index.html
- Reforming Biopharmaceutical Pricing at Home and Abroad [Internet]. The White House, The Council of Economic Advisers; 2018 [cited 2018 Feb 28]. Available from: www.whitehouse.gov/wp-content/uploads/2017/11/CEA-Rx-White-Paper-Final2.pdf
- April 28, 2016 letter regarding US Senate Finance threats over compulsory license on Novartis cancer drug patents [Internet]. Knowledge Ecology International. 2018 [cited 2018 Mar 11]. Available from: www.keionline.org/23085
[Note from TheBody: This article was originally published by Treatment Action Group in April 2018. We have cross-posted it with their permission.]