President Joe Biden marked World AIDS Day yesterday by displaying the AIDS Memorial Quilt on the White House lawn — a historic first — and placing a massive red ribbon on the White House’s southern portico, an annual tradition since 2007. In his speech, Biden noted the over 40 million people still affected by HIV worldwide and he called on states to repeal their outdated HIV criminalization laws to help reduce anti-HIV stigma.
He also noted his administration’s efforts to end HIV/AIDS, including his reauthorization of PEPFAR (the President’s Emergency Plan on AIDS Relief), a program to prevent HIV in Africa; the Food and Drug Administration’s relaxed guidelines allowing gay and bi men to donate blood; and also his protection of the Affordable Care Act (ACA) which requires insurers, Medicare and Medicaid coverage to pay for HIV treatments, medications, and preventative drugs like pre-exposure prophylactics (PrEP).
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But HIV advocates worry that these efforts could all be threatened by the incoming administration of President-elect Donald Trump. Trump has pledged to repeal the ACA, Congressional Republicans seems eager to make massive budget and departmental cuts to HIV-prevention programs and Trump’s administration is filled with anti-LGBTQ+ conspiracy theorists who may undermine the steps Biden and Trump have previously taken to fight the ongoing epidemic.
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The first Trump administration had a mixed record on HIV
During Trump’s first presidency, his four World AIDS Day proclamations never explicitly mentioned gay and bisexual men, and he allowed the Office of National AIDS Policy (an executive advisory task force) to fall apart by terminating all its members and failing to appoint a new director. He also recommended big budget cuts to HIV prevention programs, leaving HIV care organizations feeling very much on their own.
Then, in his 2019 State of the Union Address, he launched the Ending HIV Epidemic (EHE) Initiative, a $291 million plan to reduce the number of new HIV infections by 75% by 2025 and 90% by 2030 by targeting HIV prevention and treatment in the nation’s highest-risk areas. This plan included Ready, Set, PrEP, a program to give 200,000 uninsured Americans free annual access to daily PrEP.
However, the EHE has fallen far behind its goal. While Biden has continued the plan, between 2019 and 2022, the number of new HIV infections in the U.S. dropped from 35,100 to 31,800, a 9.4% decrease, according to HIV.gov.
In 2018, Trump also signed a five-year extension to PEPFAR, a program to prevent new cases of HIV in Africa. Launched by George W. Bush in 2003, PEPFAR has been hailed as a successful diplomatic and humanitarian effort. The program provides antiretroviral treatment for 14.6 million people and has been credited with saving over 25 million lives, preventing numerous opportunistic infections as well as preventing children of people with HIV from becoming orphans.
However, while the program was long hailed as a non-controversial bipartisan program, Republicans seem eager to get rid of it, falsely claiming that it’s a “massive slush fund” for promoting abortion and LGBTQ+ advocacy. Additionally, Project 2025, the blueprint for Trump’s second presidency, seeks to reinstate the Mexico City Policy, (also known as the global gag rule), an executive order denying any U.S. funding to global health organizations that provide any information about abortions.
Slashing PEPFAR and reinstituting the gag rule could force international health providers, particularly ones providing reproductive health services, to choose between losing funding or providing emergency sexual healthcare for those key populations in conflict and other crisis situations, according to John Plastow, the executive director of Frontline AIDS, the world’s largest partnership of civil society organizations working to end HIV and AIDS.
“If we let HIV go unchecked, it will be destabilize countries,” said Ben Plumley, the founding executive director of the Global Business Coalition on HIV & AIDS HIV and former CEO of Pangaea Global. “AIDS targets the economically productive people in the prime of their years. If those people die or are incapacitated, we create generations of orphans, we don’t have people working in factories, generating incomes like we had wanted and we really run the risk of disrupting and destabilizing the concept of nation-states in many countries.”
“You could argue that PEPFAR was very sound investment in preventing the spread of radical Islam or radical anti-Western attitudes in sub-Saharan Africa,” he adds. “And so I think that in any advocacy we have with the administration, we would want to show that investment in PEPFAR was a sound investment in U.S. security and U.S. reputation internationally.”
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Trump’s pledge to repeal the Affordable Care Act could un-insure and endanger millions
Trump has repeatedly pledged to repeal the ACA without any plan for its replacement. Doing so would leave an estimated 21.3 million people without any medical coverage. Without the ACA, young adults between the ages of 18 and 26 would no longer be allowed to stay on their parents’ insurance plans. Additionally, health insurers would be allowed to once again deny coverage to people with HIV and to refuse “essential benefits,” like specific prescription drugs, labs, and mental health services that provide comprehensive HIV treatment.
The ACA’s Medicaid expansion in several states covers healthcare costs for an estimated 40% of all Americans living with HIV. During his first presidency, Trump suggested $1.4 trillion in Medicaid cuts over 10 years by essentially limiting the program’s ability to cover HIV medication and treatment.
This year, Republicans have called for massive budget and staffing cuts in HIV care, according to the Bay Area Reporter, including between $500,000 and $800,000 for the Centers for Disease Control and Prevention, $214 million for the CDC’s HIV prevention programs (including the entire budget of Trump’s EHE), $190 million from the Ryan White HIV/AIDS Program, and $15 million from the Health and Human Services (HHS) Secretary’s Minority HIV/AIDS Fund.
The Ryan White HIV/AIDS Program makes up 12% of the government funding for HIV-related care. An estimated 52% of all people diagnosed with HIV in the nation use the program. During Trump’s first administration, he proposed an 18% cut to the HHS, which cites the program’s maintenance as one of its “highest priorities.” The current suggested Republican budget cuts would severely affect the program’s ability to function.
“Although the funding levels in this bill are far from final and not likely to pass on the House floor, they represent a dangerous move by the House Republican majority to deprioritize support for people living with HIV, women, and people of reproductive age, people of color, low-income individuals, and the LGBTQ community,” Ernest Hopkins, senior strategist and adviser of the San Francisco AIDS Foundation, told the aforementioned publication.
Now that Republicans will have a slim majority in both Houses and Congress, it’s likely that they will try to advance their budget reductions. Doing so would have a trickle-down effect, harming millions of people over time.
If millions of people suddenly find themselves without insurance coverage, they’ll need to rely on state, city, and private programs to help pay for medication; but these smaller groups can’t possibly match the millions in funding provided by the federal government.
Some state and local HIV programs receive financial support from the AIDS Drug Assistance Program (ADAP), a part of the federal government’s Ryan White HIV/AIDS program, which offers services to low-income people living with HIV.
But if tens of thousands of people nationwide suddenly need ADAP services, patients with HIV may find themselves on weeks- and months-long waitlists before they can afford life-saving medication. This is especially concerning considering that people who receive late and inconsistent HIV treatment have worse health outcomes than those who get early and regular care.
In November 2019, the Trump administration also proposed cutting costs for Medicare — the federal medical coverage for people over 65 and those with disabilities. In short, he sought to reduce the number of drugs that the program must make available to people with HIV. Doing so would allow insurers to require Medicare beneficiaries to first get advanced “pre-authorization” approval to obtain certain HIV drugs and possibly undergo “step therapy,” a process of trying less expensive medications before accessing more costly ones.
Such medication restrictions “could be catastrophic” for older HIV patients and Trump’s EHE initiative, says Bruce Packett, the executive director of the American Academy of HIV Medicine, a group representing doctors who care for patients with HIV.
Packett told The New York Times that older patients with disabilities and chronic diseases often take other medications, increasing the likelihood of possible negative drug interactions, Packett said. Furthermore, some patients have drug-resistant HIV strains or respond differently to certain medications. As such, doctors need access to quicker access to the “full arsenal” of medicines to properly treat HIV in these populations, he added.
Cadena and Marnina Miller, co-directors of the Positive Women’s Action Network-USA, told The Body, that if HIV drugs become increasingly inaccessible, “We may need to set up some kind of Underground Railroad to get [HIV] meds across states for people who really need them.” Without proper medical oversight and consistent supply channels, however, the passengers on the railroad could find themselves stuck or at risk of being left behind.
Elevating anti-LGBTQ+ voices and conspiracy theorists harm those most in need
In his first and most recent campaigns, Trump elevated Republican voices that stoke hostility towards queer men, trans women, and people of color — those most at risk of contracting HIV. During his first term, Trump quietly started firing military servicemembers living with HIV. During his recent campaign, Trump and Republicans lied about legalized Haitian immigrants spreading HIV in Springfield, Ohio, something that public health officials said was untrue.
In his first term, Trump announced a “conscience rule” pledging legal protection for medical professionals who cite religious beliefs as a pretext for refusing care to LGBTQ+ people. The 2024 Republican platform has repeated this pledge, increasing the possibility that LGBTQ+ people might not seek HIV testing, medication or treatment for fear of healthcare discrimination.
It’s also unclear if a Trump administration official or a Republican-appointed judge would try to argue, as one has in the past, that forcing insurers and pharmacists to provide HIV prevention or treatment medications violates their religious consciousness.
Additionally, Project 2025 calls for dismantling large parts of the federal government, including any deemed a “waste” of taxpayer funds. Trump has unofficially appointed transphobic billionaire Elon Musk and anti-LGBTQ+ entrepreneur troll Vivek Ramaswamy to head the Department of Government Efficiency (which isn’t an actual federal department). Musk and Ramaswamy will make suggestions on which federal departments and roles to defund, though any defunding may first require congressional approval.
Regardless, Trump has nominated Robert F. Kennedy Jr., who has denied that HIV causes AIDS, to head the HHS. He has called for Dr. Mehmet Oz, a celebrity lifestyle influencer who has peddled quack cures, to head the Centers for Medicare and Medicaid. Trump has also called for Dr. Marty Makary to head the Food and Drug Administration and Dr. Janette Nesheiwat for surgeon general — both are frequent Fox News contributors.
Collectively, these appointees could dramatically change how these federal agencies operate and help execute Project 2025’s plan of purging any departmental officials who try and resist Trump’s agenda.
Jeremiah Johnson, executive director of PrEP4All, said in a statement to Inside Health Policy that the new Trump administration will create an uncertain and unpredictable time for federal HIV policy, leaving HIV healthcare providers unsure of what to expect.
“Will he be the Donald Trump who initiated the Ending the HIV Epidemic initiative in 2019, or will he follow House Republican efforts to gut that same essential program?” Johnson asked. “Will he see himself as a champion of helping to develop and deliver biomedical interventions for infectious disease, as he did with COVID, or will he, with RFK Jr. poised to take a leadership role on healthcare in his administration, turn away from science?”
“And within all of this, how will (advocates) address the HIV-related needs of the communities that we know this administration will attack, including migrants and transgender populations?” he asked.
Jeremiah Johnson, executive director of the PrEP advocacy group PrEP4All, told The Body, “One of the worst things we could do right now is to either completely downplay how dangerous this coming era could be—or to overplay it to such a degree that we lose perspective on where we can actually protect ourselves and our community going forward.”
Cecilia Chung, a transgender advocate living with HIV who is a senior adviser at the Transgender Law Center, reminded the aforementioned publication that constituents can still play a key role in the coming administration. In particular, she mentioned the upcoming 2025 AIDSWatch in March, an annual meetup in Washington D.C. in which people living with HIV visit the offices of their elected officials.
“We should continue to tell our stories and share with people first-person that there’s a human impact [to any policy changes],” she said.
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