Donald Trump used his State of the Union address tonight (Feb. 5) to state his goal of ending the transmission of HIV in the US within 10 years.
The goal is realistic, experts say. If Trump is serious about achieving it, though, his administration needs to radically change its policies.
“The challenge is that the White House and GOP policies so far run counter to any way you should approach [ending HIV],” says Gregg Gonsalves, a Yale University public-health professor who studies epidemiology.
Last year, the president fired the White House’s HIV/AIDS advisory committee and it took nearly a year to replace it. His administration also halted important HIV research because it involved fetal tissue.
Yet it’s the administration’s actions at a policy level—from attempted changes to Obamacare to its push for abstinence-only sexual education—that have most jeopardized progress against the disease, Gonsalves says.
Here’s what Trump should be doing instead:
1. Protect the Affordable Care Act and expand Medicaid
HIV and AIDS affect poor and marginalized communities disproportionately: minorities, men who have sex with men, and people living in poverty. Many of those who are HIV-positive receive treatment through Medicaid or through health insurance bought on the Affordable Care Act (ACA) marketplace created by Obamacare.
By trying to repeal the ACA, the Trump administration risked depriving many HIV-positive patients of access to medication. Though the repeal plan failed, the administration is now trying to undermine the law by removing the individual mandate, a key provision of the policy.
Similarly, says Gonsalves, the HIV/AIDS epidemic is more significant in states that have not adopted Medicaid expansion—pointing to the importance of reaching as many people as possible through affordable health insurance.
2. Get vulnerable people on PrEP
An estimated one million Americans live with HIV and 40,000 contract the virus yearly. Still, experts say the end of the epidemic seems within reach in large part thanks to available treatment that makes lowers the virus concentration to the point where it’s no longer transmittable.
Drugs that protect healthy people from contracting HIV, known as pre-exposure prophylaxis (PrEP), have been a game changer, too. The more available they are, particularly to at-risk populations, the fewer people contract the virus.
In the US, Truvada, the drug used for PrEP, is extremely expensive. The recommended one-pill-daily dose typically costs about $1,500 a month, or $18,000 for a full year of treatment. In many cases, this cost is absorbed by insurance and other assistance programs. But not everyone is covered and this puts an enormous financial strain on states trying to promote access to the medication.
Generic versions of Truvada exist. In some other countries, annual supplies are marketed to patients for as little as $70 per year. In the US, the generic received FDA approval in 2018 but it’s not being manufactured. The government could help make Truvada more accessible, for example, by finding a way to make the generic version available, says Gonsalves.
3. Forget abstinence as sex ed
In order to stop the transmission of AIDS, the Trump administration has to step away from its abstinence-only approach to sex education. It has, for instance, considered banning references to “sexual health” in State Department communications. It eliminated the notion of “safe sex” from the Health and Human Services website, replacing it with the expression “safer sex” to refer to programs that promote abstinence. The administration also has increased its focus on abstinence-only sex education, an approach to sexual health with poor results, putting more youth at a risk of infection.
4. Fund needle-exchange programs
“The Republican party is a big fan of the war on drugs,” says Gonsalves, and prioritizes the fight against illicit drug sales over the health of drug users. This is why it has traditionally opposed needle-exchange programs, which has been criticized as something that promotes drug use. In practice, those programs reduce needle sharing, pushing down HIV rates among participants.
Even Mike Pence, himself an opponent of needle-exchange programs, had to approve one as governor of Indiana to combat an HIV epidemicamong intravenous drug users. Yet several states—including some with the worse rates of HIV—still don’t have sterile syringe programs. The White House could fund them.
5. Remember the rest of the world
HIV/AIDS is a pandemic. As such, there isn’t much of a point fighting it at home while cutting money from programs to reduce transmission of the disease abroad. Yet this is what the Trump administration has been doing since the beginning, by implementing the Global Gag Rule and cutting funds for the UN Population Fund: Both actions, theoretically aimed at reducing access to abortion, end up taking important lines of funding away from organizations that specialize in promoting sexual health, contraception, and HIV/AIDS prevention.
“Infectious diseases know no borders,” says Gonsalves. A serious commitment to eradication can’t stop at domestic impact and should follow the path set by initiatives such as George W. Bush’s President’s Emergency Plan for AIDS Relief (PEPFAR), which has been credited with saving millions of lives in Africa.