President Donald Trump's call for ending the HIV epidemic in the U.S. in 10 years during his State of the Union address last week was lauded by HIV clinical experts who credited his willingness to call attention to an epidemic that still infects nearly 40,000 people a year.
But while most stakeholders say the administration's goal can be realized with the progress that has been made in treatments and prevention in the past two decades, they remain mostly skeptical of the White House's commitment to the effort. They said reducing new HIV infections would require addressing problems that hinder access to healthcare for those with HIV, such as increasing health insurance coverage, reducing the impact of socio-economic health determinants, and eliminating existing stigmas of those living with the virus.
“In so far as the administration is willing to address those issues, which they seem to indicate that they are, then this is definitely an obtainable goal,” said Bruce Packett, executive director of the American Academy of HIV Medicine.
Advocates said the Trump administration could take a huge step toward achieving its HIV strategy by reversing several of its own policies, such as supporting repeal of the Affordable Care Act and rolling back protections for LGBTQ individuals.
“One of the things that concern us is that the Trump administration has done everything that it can to limit healthcare through trying to dismantle the ACA,” said Dr. David Hardy, board chairman for the HIV Medicine Association.
Neither Trump nor federal health officials have specified how much funding the government should dedicate toward reducing HIV infections. During a media call, HHS Secretary Alex Azar said the funding amount would be reflected in the president's annual budget request. At deadline, HHS officials had not responded to requests for comment.
Health officials have indicated many of the plan's initiatives could be implemented by expanding funding to the Ryan White HIV/AIDS program, which provided clinical and support services to more than 530,000 uninsured and underserved individuals living with the virus in 2017.
Yet that program has limitations. It's considered a resource of last resort for those living with HIV who are unable to obtain insurance. But the program doesn't cover preventive services, such as pre-exposure prophylaxis, or PrEP. Health officials, including HHS, say expanding access to PrEP is a key component of strategies seeking to reduce new HIV infections.
Many advocates contend expanding the Ryan White program should occur alongside increasing access to Medicaid, which they say would have an even greater impact for the HIV population. Medicaid is the single-largest source of insurance for HIV care services, covering more than 40% of people with HIV, according to the Kaiser Family Foundation.
Indeed, most of the seven states that HHS will target with resources to reduce their high rate of HIV infections haven't expanded Medicaid, according to Jesse Milan Jr., CEO of the advocacy organization AIDS United. The Trump administration has sought to roll back Medicaid expansion for the last two years, and has supported proposals to turn Medicaid into a block grant program that could cut off thousands of beneficiaries.
Packett acknowledged the administration's past and current actions send mixed messages. Among his concerns is a proposed rule change the CMS issued in January that would effectively end coverage protections for HIV medications obtained via Medicare Part D. Under the rule, insurers would be allowed to impose restrictions such as prior authorization and step therapy. A quarter of U.S. HIV patients receive their antiretroviral therapies through Part D, according to the Kaiser Family Foundation.
Hardy said any meaningful policy to lower HIV infections would have to target interventions that expand care for LGBTQ individuals since gay and bisexual men account for nearly 70% of new HIV infections, according to the Centers for Disease Control and Prevention. Yet the administration has taken a number of actions to either take away or not recognize civil rights protections for LGBTQ individuals.
Such contradictions give stakeholders doubts about Trump's commitment. “I think it was a lot of grand-sweeping promises of what he (Trump) thinks people want to hear with very little specifics,” said Dr. Margaret Hoffman-Terry, board chair of the American Academy of HIV Medicine. “Actions speak louder than words and his actions never match his words when it comes to these very important social issues.”