A Plan for America
The Trump administration strives to end the HIV epidemic, but at whose expense?
by Jeannie Wraight
In this month’s Destination: Cure I’m going to deviate a bit from my normal interpretation and reporting on HIV cure (remission) news to explore Donald Trump’s version of a cure—Ending the HIV Epidemic: A Plan for America.
Many of us watched Trump’s surprising declaration during the State of the Union Address on February 5, 2019, where he stated: “My budget will ask Democrats and Republicans to make the needed commitment to eliminate the HIV epidemic in the United States within ten years.” Although little more was said by Trump after this declaration, Surgeon General Dr. Jerome M. Adams MD, MPH, later provided more details of the Trump Administration’s goals and plans to ‘end HIV in the U.S.
The goal of Ending the HIV Epidemic is to decrease new HIV transmissions by seventy-five percent in five years and ninety percent by the year 2030. Just how exactly will this occur? According to Adams, basically through what appears to be a very stringent use of HIV antiretrovirals and PrEP.
Now maybe I’m not the sharpest tool in the shed but it appears to me that we’ve been aware of U=U and had PrEP at our disposal for quite some time, and we still have nearly 38,000 new infections a year. Throw the opioid epidemic into the mix with a growing number of intravenous drug users, shake not stir, and PrEP and U=U alone doesn’t appear to be a recipe for success. Ending new infections with what we’ve had all along, in itself, doesn’t sound like much of a plan. However, the President’s plan goes much further than we have and possibly even further than we may be prepared to go, in the name of “ending HIV.” Trump has devised quite the pervasive plan to seek out those with HIV and ensure they are on treatment in the hopes of large scale viral suppression while simultaneously implementing PrEP for those at high risk. With a combination of surveillance and “quick action,” Trump believes we can stomp out HIV within a decade. But how will he do this without also stomping on our civil rights?
The plan tends to use interagency coordination to utilize the resources, programs and infrastructures of the CDC, NIH, Health Resources and Services Administration (HRSA), Indian Health Service (IHS) and the Substance Abuse and Mental Health Services Administration (SAMHSA).
The plan will utilize data that tells us where new infections are occurring most and within what key populations (we already know this). According to the plan’s outline, new laboratory and epidemiological techniques will allow a quick response to outbreaks including provision of PrEP and treatment as prevention. Local HIV “HealthForces” will be created in the hardest hit areas to “expand treatment and prevention.”
The plan has three defined phases. Phase I is a rapid infusion of new resources, technology, and expertise to areas where the most new HIV infections occur (totaling more than fifty percent of new infections). A strong focus will be on forty-eight counties throughout the country, as well as Washington, D.C., San Juan, Puerto Rico, and seven states with the highest HIV rates in rural areas: Alabama, Arkansas, Kentucky, Mississippi, Missouri, Oklahoma and South Carolina.
Phase II will extend these efforts throughout the country. And Phase III will institute “intensive case management” to maintain new infections to below 3,000 per year.
I have to admit, all of this along with the four key strategies of the plan, make me nervous. Maybe it’s the tone, maybe it’s the language, maybe it’s paranoia because, well, it’s Trump, or maybe a combination of the three, but it feels aggressive and scary to me and, quite honestly, Orwellian: Diagnose all individuals as early as possible after infection; treat the infection rapidly and effectively after diagnosis, achieving sustained viral suppression; protect individuals at risk for HIV using proven prevention approaches (aka PrEP); and respond rapidly to detect and respond to growing HIV clusters and prevent new HIV infections.
The entire crux of the President’s plan is based on the simple premise that if we know who you are, we can treat you and make you non-infectious, or treat you and remove the majority of your risk to acquire HIV, and thus eventually eliminate HIV. Whereas theoretically this is possible, it ignores the one simple premise that we’ve learned over and over throughout the past thirty-eight years of the HIV pandemic—nothing about HIV is simple. In addition, the blanket-statement key strategies throw the door open for many questions on how these goals will be accomplished—particularly without a host of potential civil rights violations, i.e., privacy infringement, HIPPA violations, and possible forced treatment, just to name a few.
I’m particularly concerned for those at “high risk.” What defines high risk in this plan? Intravenous drug use? Being gay? Being the partner of someone with HIV, either suppressed or nonsuppressed and despite U=U? What if someone categorized as high risk chooses not to go on PrEP? Will they have a choice? If they choose not to, what then? To achieve the targeted seventy-five to ninety percent decrease in new infections, there simply isn’t room for choice.
In my opinion, not enough information is available yet to make an accurate assessment of Ending the HIV Epidemic:. I don’t want to be an alarmist. But as a writer and long-time treatment activist, I do have concerns and I do think that all eyes should be on this plan to make sure it will be carried out ethically, legally, and to the benefit of all.
Jeannie Wraight is the former editor-in-chief and co-founder of HIV and HCV Haven (www.hivhaven.com) and a blogger and writer for TheBody.com. She is a member of the Board of Directors of Health People, a community-based organization in the South Bronx and an advisor to TRW (Teach me to Read and Write), a community-based organization in Kampala, Uganda. She lives with her husband in New York City.