Did anyone expect Donald Trump to be the first president to call for an end to HIV transmission in the U.S.? His administration has promoted a slew of policies that could actually prolong the epidemic -- restricting Medicaid, dismantling the Affordable Care Act, cutting global AIDS funding, opposing fetal tissue research that could lead to a vaccine, and demonizing transgender people and immigrants -- to name just a few.
Tuesday night, of course, in his State of the Union (SOTU) speech, Trump said, "Together, we will defeat AIDS in America. And beyond." He pledged to send Congress a budget request that would "make the needed commitment to eliminate the HIV epidemic in the United States within 10 years."
After the speech, Department of Health And Human Services (HHS) Secretary Alex Azar announced more details, including a colorfully designed fact sheet. On Feb. 7, an article co-authored by Anthony Fauci, M.D., the director of the National Institute of Allergy and Infectious Diseases (NIAID), was published in JAMA further detailing the rationale and broad elements of the strategy.
A number of factors contributed to Trump's head-spinning pivot.
A handful of major AIDS organizations have spent the past two years educating key members of the administration about the scientific data showing that, biomedically speaking, ending HIV in the U.S. is an achievable goal. In the simplest terms, people living with HIV cannot transmit the virus if antiretrovirals reduce their viral load to undetectable levels; meanwhile, pre-exposure prophylaxis (PrEP) protects people who use the medication as prescribed from contracting the disease. And several jurisdictions around the country, after New York State's lead in 2015, have launched or are exploring "end the epidemic" campaigns in about a dozen cities, counties, and states.
"I don't think [the administration officials] needed a lot of convincing -- they have all been involved in HIV. They just needed to know that we can do this, and the community is calling for it," says William McColl, vice president for policy and advocacy at AIDS United. Community unity on eliminating HIV transmissions has strong, demonstrable support. On World AIDS Day 2018, AIDS United and Act Now: End AIDS published the groundbreaking Roadmap to End AIDS, a plan to end the epidemic that has the support of an amazing 250 AIDS organizations.
AIDS United, along with The AIDS Institute, NASTAD, NCSD, and NMAC -- a coalition that calls itself The Partnership to End HIV, STDs, and Hepatitis -- has promoted the goal of ending the epidemic to Azar, Centers for Disease Control and Prevention (CDC) Director Robert Redfield, M.D., HHS Assistant Secretary Brett Giroir, M.D., Health Resources and Services Administration Administrator George Sigounas, M.S., Ph.D., and National Institute of Allergy and Infectious Diseases Director Anthony Fauci, M.D., among others.
The ambitions of these AIDS organizations to stamp out HIV transmission dovetails with these officials' personal ambitions, especially those of Redfield. "I think this would be a career-defining moment for him. He has likely dreamed of something like this his entire career," says McColl.
"Redfield came in, and he was eager to make his mark. He's very much promoting the idea. While he's been controversial, HIV is an area he has an interest in. He saw from a biomedical perspective that the end of the epidemic was feasible," says Housing Works CEO Charles King, who added, "I do think there are good people in the bureaucracy who want to hear from the community. I'm not thinking that they're just going to pick up what we put out there, though."
Timing also played a role in Tuesday's big announcement. Trump may have been looking for bipartisan issues to include in his SOTU, and HHS is in the midst of reviewing the National HIV/AIDS Strategy as mandated by an Obama-era executive order. That bureaucratic mechanism has given HHS a pretext for listening to advocates as well as for reaching out to the White House.
Whatever factors gave rise to Trump's seeming turnabout, AIDS advocates are taking the SOTU with a Mar-a-Lago-sized grain of salt. King says, "I don't see any way that the administration will take on some of the structural problems" necessary to ending the epidemic.
"There is no question that HIV is an epidemic of social injustice and human rights violations," says Naina Khanna, executive director at Positive Women's Network–USA. "That's what allowed it to become an epidemic in the first place. It's not possible to end the epidemic without advancing the dignity of black, brown, LGBT and low-income communities. This administration's track record does not give us reason to be hopeful that any plan will be grounded in protecting the most vulnerable communities in the U.S."
Treatment Action Group's U.S. and Global Health Policy Director Suraj Madoori agreed. "We're concerned about human rights policies that money can't buy. An increase to the CDC or other programs for people living with HIV isn't enough. We need a rollback of anti-immigration and anti-trans[gender] policies that shows [the Trump administration] is serious about ending the epidemic."
In a fiery press release response to the SOTU, Health GAP Executive Director Asia Russell called the Trump Administration "a nightmare for people with HIV in the U.S. and around the world" that "tonight's announcement will not wake us up from."
On a more granular level, McColl is open to the overall HHS plan to focus efforts on stopping infections in key geographical locations, but the proposed creation of an "HIV HealthForce" of local teams on the ground to implement the strategy gives him pause. "I would urge the administration to make sure that this is not some kind of public health group going door-to-door but reaches out to people who are knowledgeable in the community, takes time to build trust, and listens to the voices of people living with HIV," he says.
Likewise, Khanna worries about "molecular HIV surveillance and cluster tracing. We still have laws criminalizing HIV on the books in 30 states. How will rights of people living with HIV be protected? Black gay and bisexual men, Latinx gay and bisexual men, women of color -- they're the most targeted by policing and surveillance. Overreliance on surveillance to address the epidemic as opposed to structural intervention is deeply concerning."
And we haven't even started talking money. HHS, whose budget is expected next month, is only part of the equation.
McColl says having an HHS plan "is hopefully clarifying to the Office of Management and Budget, which has different motivations."
David Thorpe has been a New York-based editor and freelance writer for more than two decades. He writes primarily about gay life, HIV, and pop culture. His work has appeared in, among other publications, The New York Times_,_ OUT_,_ Time Out New York_,_ New York_,_ POZ_, and_ O, the Oprah Magazine_._