In a Trump Presidency, Portents of Stigma and Sickness for People Living With HIV

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Do not listen when someone tells you it will all be OK. It will not. For people living with HIV and those that advocate alongside them, a Trump White House coupled with a Republican-controlled Congress is nothing less than a waking nightmare.

Do not sit by in silence as politicians and pundits implore us to forgive and forget the rancor and blistering hatred of this election so that we might once again unite our fractured nation. We should not, we cannot and America most certainly will not come together under the mock leadership of a man whose entire political existence is dependent on fostering division and discord. To do so would be to accept the systematic degradation, persecution and othering of all those who don't pass the alt-right acid test as the new normal. It would amount to nothing less than an abandonment of women, communities of color, immigrants, non-Christian faiths and much of the LGBT population. To tolerate and accommodate this two-bit tyrant in training is tantamount to giving the green light to a second Redemption that will not abate until every victory and vestige of progressivism over the past 70 years has been chopped down.

Based on President-elect Trump's recently released plan for his first 100 days in office and remarks from Senate Majority Leader Mitch McConnell, it is all but a foregone conclusion that the Affordable Care Act (ACA) will be swiftly and unceremoniously gutted in 2017. Although the Republicans' slim majority in the Senate makes a full repeal of the ACA unlikely, there's little doubt that the Trump administration will work with Congress to strip away some of the health care law's more vital provisions. If this happens, the results will be catastrophic. According to an analysis from the non-partisan Committee for a Responsible Federal Budget, the "repeal and replace" health care plan that Trump touted during his candidacy would force nearly 21 million Americans into the ranks of the uninsured.

Among the ACA provisions sure to be on the chopping block are Medicaid expansion, the individual health insurance mandate and subsidies to assist middle-income families in purchasing health insurance. While all of these policy decisions would affect people living with HIV, the roll back of Medicaid expansion would be particularly harmful.

An End to Expanded Medicaid

From the beginning of the epidemic, Medicaid has played a crucial role in providing medical treatment for people living with HIV. Medicaid is currently responsible for 30% of all federal funding for HIV/AIDS care in the United States and, while removal of Medicaid expansion wouldn't do away with all of that funding, it would greatly diminish it and make Medicaid more difficult for people living with HIV to obtain. Before the advent of the ACA, nearly 7 in 10 people living with HIV who were on Medicaid were forced to qualify for the program through a disability pathway, meaning that they not only had to be living on a very low income, but were also required to prove they were sick and disabled enough to receive services. In states that accepted Medicaid expansion under the ACA, the disability provision was waived and income became the sole measure of whether someone qualified for coverage or not, with anyone living on 138% of the federal poverty level or less eligible for services.

For people living with HIV, the cessation of Medicaid expansion may well mean a return to the days of having to prove to the government that the virus has progressed to such a point that it qualifies you as objectively ill enough to receive Medicaid, a process that stands in direct opposition to all of the scientific and public health guidance we have mandating that people seek out HIV care as soon as they know their status -- for the sake of both prevention efforts and the health of the individual. Should this rollback take place, the preservation of funding for the Ryan White Program will be of paramount importance, as it will become the primary safety net for hundreds of thousands of people living with HIV.

At the same time, the removal of the individual health care mandate puts people living with HIV at greater risk of being denied health insurance based on their serostatus. While President-elect Trump had claimed throughout his campaign that he would not remove the prohibition on denial of health insurance coverage based on pre-existing conditions, recent rhetoric on his campaign site after the election already hints at walking back that promise. To be sure, there is no reason to believe a snake-oil salesman like Donald Trump has any intention of looking after the rights of Americans suffering from chronic physical and mental illness and, even if he did, it would be next to impossible for insurance companies to pay for the care of those with pre-existing conditions if those costs weren't offset by the bevy of healthy, young folk who needed to obtain coverage, as well.

Stigma Will Spread, Misinformation Will Multiply

But, ultimately, all of the issues listed above are technical ones that in many ways pale in the face of the larger threat that Trump poses to people living with HIV and the broader demographics to which they belong. Medicaid expansion is deeply important, but the prospect of its loss does not instill in us the same dread terror that the newly empowered legions of white supremacist, misogynistic, Islamophobic, anti-Semitic and homophobic Trump supporters do. As was the case in the aftermath of Brexit, the stories of people of color, women, Muslims, Jews, and LGBT individuals being both verbally and physically abused in the most vicious manner are flowing in.

We are entering a golden age of ignorance and harassment in America right now, and there are few populations that will serve as more inviting targets for such abuse than people living with HIV. In the coming years, stigma will spread, misinformation will multiply and the need for all of us to circle the wagons and protect one another from the salvos of violence and vitriol that are directed at anyone who doesn't look or love or pray a certain way will grow in equal measure. Now is the time to unite, but only among our brothers and sisters who have the capacity to recognize and respect our shared humanity.

Drew Gibson is a social worker and freelance writer based out of Cincinnati, Ohio. You can follow him on Twitter at @SuppressThis. or visit his blog "Virally Suppressed," which covers a multitude of issues related to public health and social justice.