President Trump says he has a plan to end the HIV epidemic in America. During his State of the Union address, he noted that “scientific breakthroughs have brought a once distant dream within reach” and that he would request funding from Congress “to eliminate the HIV epidemic in the United States within 10 years.” We don’t yet know the details of the strategy, but reports indicate that it is modelled after the administration’s approach for ending the opioid epidemic and will target communities where rates of HIV infection are highest.
Given the remarkable advances in HIV medical treatment, which make it virtually impossible for people who’ve lowered their HIV load to undetectable levels to transmit the virus to others, it is entirely possible to end the epidemic in 10 years. But it doesn’t matter what’s in Trump’s plan for ending HIV if his administration continues to undermine the Affordable Care Act and implement discriminatory policies that exacerbate HIV stigma and make it harder for gay and bisexual men and transgender women, who have the highest rates of HIV across all populations in the United States, to access health care.
When you have a history of firing people for being HIV positive, as the Trump administration does, a new plan to end the HIV epidemic is not likely to work. In 2018, the Peace Corps, which has denied pre-exposure prophylaxis to prevent HIV infection in at-risk volunteers, dismissed an openly gay volunteer serving in Cambodia after he was diagnosed with HIV. That same year, two airmen were discharged from the Air Force for the same reason.
The Trump administration’s aggressive pursuit of new policies that would permit health care providers to deny medicine and care to LGBT people would also undermine efforts to end HIV. The newly created Division of Conscience and Religious Freedom at the US Department of Health and Human Services tells health care providers that they do not have to offer services that would violate their religious beliefs. The policy is derived from the hundreds of religious refusal bills that have been filed in state legislatures across the country since 2015. To date, 10 states have passed such laws, which permit discrimination against individuals whose sexual orientation, gender expression or identity, or whose actions, such as engaging in sex outside of marriage, violate the sincerely held religious beliefs of a health care provider.
Black and Latino gay and bisexual men are more likely than other gay men to say that having to talk with their doctor about their sex lives is a barrier to accessing pre-exposure prophylaxis for HIV prevention. They also make up 44 percent of new HIV diagnoses in the United States, even though they constitute less than 1 percent of the adult population. The last thing we should be doing — under a twisted interpretation of religious freedom — is making it harder for these men to access preventive care.
Meanwhile, the Trump administration’s continued attacks on the Affordable Care Act (ACA) pose the greatest threat to any new strategy to end HIV within 10 years. Before passage of the ACA in 2010, it was legal for health insurance companies to deny coverage to people with HIV under preexisting condition exclusions. The few plans that were available were prohibitively expensive or came with annual or lifetime spending caps that rendered them ineffective. People with HIV with incomes low enough to qualify for health insurance coverage through Medicaid were often denied coverage because states required Medicaid beneficiaries to be disabled or pregnant. As a result, rates of health insurance coverage among people with HIV were low; in 2010, when 65 percent of all Americans had private health insurance, only 17 percent of those living with HIV did. All that changed after passage and implementation of the ACA, which banned insurance discrimination based on preexisting conditions, eliminated spending caps on coverage, and required states to offer Medicaid based on income alone.
Since taking office, Trump has been absent from leadership on HIV/AIDS policy. In 2017, he disbanded the Presidential Advisory Council on HIV/AIDS (PACHA). For the first time since 1993, the nation does not have an AIDS Czar. Trump’s proposed fiscal year 2019 budget sought to reduce domestic HIV prevention funding by 17 percent and eliminate entire programs from the Ryan White HIV/AIDS Program.
Any steps to reverse Trump’s record on HIV are steps in the right direction. But to make real progress, the Trump administration needs to stop discriminating against LGBT people and those living with HIV.
Sean Cahill is director of health policy research for The Fenway Institute.