Ending the HIV epidemic in the United States will take effort far beyond implementing policies about HIV. A president who wants to end the epidemic must consider health care policy, reproductive justice, mass incarceration, housing, immigration and myriad other issues that drive the epidemic’s numbers in marginalized populations across the U.S. As the 2020 Democratic primary begins its early voting, TheBody asked prominent writers and activists to consider how each Democratic candidate, if elected, would fare in ending a health crisis that is now in its fourth decade.
The HIV community is no stranger to hearing catchy slogans, aspirational goals, empty promises, and meaningless platitudes. For an epidemic nearing the 40-year mark, those who have been around have witnessed abject silence, demonstrable derision, outright persecution, miracles of medicine, the savior of science—all perpetrated by leader and layman, victories won by organizing and love of community.
With the latest promise of an end to the HIV epidemic, this time within 10 years—following previous pronouncements of AIDS-free generations within sight and other ambitious quantitative metrics of millions more people on HIV treatment—will we have the leadership between 2021 and 2030 to reduce new HIV infections by over 90% and secure a lasting remission of the leading pandemic of our time?
What we’ve learned even in just the past decade, when President Obama first announced that an AIDS-free generation is within reach, is that “ending HIV” is much easier to say, particularly at the national level, than it is to do. Through the tireless efforts of on-the-ground leaders, community members, service providers, and federal agencies, progress has indeed been made in this past decade:
And yet, despite this indisputable level of progress, we’ve fallen desperately short of the 2020 goals set by the National HIV/AIDS Strategy back in 2010 and then 2015, and we’ve failed to make any significant headway in tearing down the massive racial and geographic disparities that have plagued this epidemic’s response.
Which now brings me to the 2020 U.S. presidential election and Joe Biden, former vice president to the same administration that I also humbly served. Let me say here that this article is not an endorsement of any candidate (though I do know which I will vote for), nor is it a statement of Joe Biden’s personal commitment to people with HIV or his character.
Context, especially for an epidemic as complicated as HIV, matters. There is no way I could write a piece about any candidate’s capacity to end the HIV epidemic without first reciting the first five paragraphs above. The HIV epidemic has, since 1981 to the present day, seen every kind of leader at the federal level. The reality of the present day, with the tools and opportunities resting at our fingertips, is met with the reality of the systems that have created, promulgated, and delivered the epidemic as we know it. It is absolutely clear now that words, quite simply, are not enough.
The first hit of a Google search of “Joe Biden HIV” yields a report from a New Hampshire health care town hall from August 2019 where, to an audience question regarding pledging to end the HIV epidemic by 2025, Biden responded, “Yes.” I could stop right there. Pledging to end the HIV epidemic within the next five years, especially when the current federal government and local governments and communities are preparing for a 10-year program, is, at best, nonsensical. I don’t expect Biden, on the spot, at a political (if health care–focused) event in New Hampshire, to know the ins and outs of the current administration’s HIV policies or programs, but this simple statement is, in my view, emblematic of Biden’s campaign, especially compared to those of his rivals: superficial. And to end the HIV epidemic, what we need is the antithesis of superficial.
Biden’s professional commitment to the government’s response to HIV, domestically and globally, is not what’s in question though. In 2008, Sen. Biden sponsored the reauthorization
of PEPFAR, U.S. funding to the Global Fund, and other related global health programs. During the Obama administration, Biden’s Office of the Vice President staffed a White House advisor on Violence Against Women, which, among its many activities, including reauthorizing the Violence Against Women Act, worked with the Office of National AIDS Policy to address the intersection of intimate partner violence and HIV/AIDS among women, including transgender women.
But simple words and promises, especially without any semblance of a plan to support them, will not end a 40-year epidemic. And in our current political climate, reality, and expectations of voters, empty promises won’t do. Actually ending the HIV epidemic in a serious, systematic way will require more than the discretionary grant programs of the past 30 years, and more than a reliance on the generosity of pharmaceutical companies that stand to increase their profits from their generosity.
During every presidential campaign season, a group of advocacy organizations led by the Act Now: End AIDS Coalition, AIDS United, and others sends each candidate a survey. Last year’s questionnaire asked 15 questions gauging the candidate’s support of policy and program priorities to end the HIV epidemic, expand health care coverage, and address co-occurring health issues. Of the Democratic candidates remaining, only Sen. Warren, Sen. Sanders, and Mayor Buttigieg submitted responses; the Biden campaign failed to return the questionnaire. So we must rely on the other publicly available information.
The Biden campaign’s health care platform has one distinguishable feature: giving Americans “a new choice, a public health insurance option like Medicare,” that would “reduce costs for patients by negotiating lower prices from hospitals and other health care providers.” Aside from that pledge, and a few other generic pledges to lower the costs of prescription drugs, he’s made a promise that Medicaid-eligible people who live in states that refuse to expand Medicaid would be “offer[ed] premium-free access to the public option.”
The campaign has a subpage outlining additional promises to communities of color regarding health care. Despite the massive HIV disparities that have existed among Black and Latinx men—particularly gay and bisexual men—Black and Latinx women, and Black and Latinx trans women for years, the page fails to mention HIV, other than in a brief aside explaining the global gag rule.
The Affordable Care Act was and is vital to the access to health care coverage that millions of people need, and the consumer protections and expansion of Medicaid are of particular import to people living with HIV. Actually ending the HIV epidemic will require massive systemic change. It’s hard to believe, 40 years into this epidemic, that business as usual will guide us to its end. While numerous social, economic, and legal conditions impede efforts—which continue to result in massive racial, gender, and geographic disparities—HIV is foremost a virus, one that requires robust and consistent medical care to treat.
Without universal access to quality health care—where every person diagnosed with HIV is immediately treated regardless of financial status and every person who desires PrEP accesses a medical system that dispenses medication and provides wraparound services to sustain treatment—there is no end to the epidemic.
Look at New York City, San Francisco, and Washington, D.C.. In these cities, impassioned leadership and intense focus on changing the way access to health care—especially through Medicaid expansion, HIV prevention and care services, and support services like housing—is delivered, while promoting HIV prevention and care in radically new and progressive ways, the numbers of people living with HIV in care have increased, community viral suppression has increased, and therefore, new HIV infections have dramatically decreased.
And now look at where health care, using Medicaid expansion as a proxy, is least accessible.
Imagine a world where ending the HIV epidemic within 10 years was a serious effort. Would half that time be spent simply reversing the course of the past four years?
Addressing HIV in a serious way never needed a moderate response. The rays of HIV history shine through lenses of radical transformation: unprecedented organizing by silenced and dying populations, unprecedented creation of single-issue federal programs, and unprecedented scientific discovery.
And yet, the privilege of looking back from our current vantage point displays a clear observation: Despite moments of big, progressive scientific and programmatic change, the system has remained moderate, at best, and obstinately regressive most of the time. Finishing the job will take unprecedented change at the systemic level.
The epidemic as we know it is a direct product of the system—health care, social, and legal—that has been willfully sustained for decades. The epidemic as we know it cannot change, much less end, without massive systemic change.
I haven’t even mentioned the coexisting—and growing—syndemics that drive HIV regionally. Bacterial sexually transmitted infections have increased every year over the past five years. Injection-related HIV infections have increased as the opioid epidemic carries on unabated. HIV status is still criminalized in 34 states. Sexual health education is largely inadequate nationwide, and youth remain vulnerable. And the health care workforce necessary to serve bringing hundreds of thousands of new patients with HIV into quality, lifelong care remains to be seen. A plan that comprehensively addresses each of these medical issues, and at the same time cultivates a system that inherently addresses these issues collectively, is required to end the HIV epidemic.
Personally, I’m not sure any particular candidate’s entire career history is a bellwether for their potential presidential administration. In the same decade, Biden championed both the Violence Against Women Act and the Violent Crime Control and Law Enforcement Act. He also supported the Ryan White CARE Act, investing in HIV research, the creation of PEPFAR and the Global Fund, and our work to implement the National HIV/AIDS Strategy. But Biden also wrote and championed criminal justice legislation in the late 1980s and early 1990s that surpassed increased penalties proposed by the Bush administration and drove expansion of the carceral state that we know America to be today. Our culture of mass incarceration, coupled with the hysteria of the earlier days of the AIDS epidemic, not only led to the creation of HIV-specific state criminal law and the policing of people living with HIV, but also contributed to a system where formerly incarcerated people living with HIV have increased difficulty accessing housing and health care, further exacerbating so many issues associated with the HIV epidemic today.
But at the end of the day, Biden is his identity: a white man of a certain age who has contributed his values to U.S. government policy and its outcomes for five decades. By definition, the system that we have, especially in addressing HIV, is a direct result of the policies promulgated over the past four decades.
No one person can be responsible for ending the epidemic. Even a great leader, presiding over a health care system that is counterproductive and scarcely accessible for those who need it most, cannot end the epidemic. Would a Biden administration undoubtedly improve conditions in access to health care? Of course. Would a Biden administration appoint dedicated leaders to important agencies and inspire community to work toward ending the HIV epidemic? That seems likely. But would a Biden administration pursue a drastically improved health care system that every American has access to and bring to fruition the end of the HIV epidemic? At this moment, at best, that is unclear. Answering the candidate survey would certainly help.