During his first term, President Donald J. Trump announced a bold initiative to end the US HIV epidemic by 2030 by focusing on the 57 jurisdictions with the most urgent needs.
The plan that Trump announced in a 2019 coalition speech shocked advocacy groups. However, it was widely praised and successful.
By 2022, the plan reduced new infections nationwide by 30% in adolescents and young adults and about 10% in most other groups.
This time, it appears that the Trump administration's stance on HIV is incredibly opposed.
The Department of Health and Human Services is currently considering shutting down the Centers for Disease Control and Prevention's HIV Prevention Division and shifting some of its activities to another agency, federal officials said.
The CDC funds states and territories to detect and respond to HIV outbreaks, prevention, syringe exchanges, emergency care and education and recognition expansion tests. Approximately one of the four new diagnoses of HIV is created with agency funding.
The administration's plans have not yet been finalized, and the potential timing is unknown.
“It's not 100%, but 100% is being discussed,” said a federal official who is not allowed to talk to the media about the issue.
The discussion was first reported by the Wall Street Journal.
HIV prevention efforts, including clinical trials in most parts of the world, have already been stopped due to upheavals at the US International Development Agency.
And because grants are associated with transgender people, some federal funding for prevention and treatment has been cut.
Additionally, the National Institutes of Health has concluded funding for dozens of related studies, including HIV in children. The role of substance use; increase the use of preventive therapy among unserved groups such as black women.
The first Trump administration's HIV plan focused on supporting many of these groups.
The initiative was intended to prevent infection among poor black communities, as well as gay and bisexual men and transgender women.
“It wasn't his constituency,” Brett Giroar, the deputy director of health and human services in the first Trump administration, said in an interview last fall. But “The President was very supportive of that.”
The state, whose initiative's efforts focused, had reduced more than 20% of new infections by 2022. “That was exactly what we were trying to do and we did it.”
The first Trump administration also enforced government-holding patents on preventive drugs to negotiate better deals from manufacturers.
“These actions made a huge difference,” said Jeremiah Johnson, executive director of Advocacy Organization Prep4all. However, he added, “The current administration does not appear to be motivated by previous achievements.”
The administration is considering a tentative plan to move some of the CDC's prevention programs to health resources and services management. Its agency funds state and local health departments and community-based groups that provide HIV services, including the Signature Ryan White program.
“The HHS follows the administration's guidance and carefully consider all sectors to see where there are overlaps that can be streamlined to support the President's broader efforts to restructure the federal government.”
No final decision has been made, she added.
Some organizations welcomed the possibility of a mobility prevention programme to HRSA, which can provide comprehensive HIV and maternal health services, as long as the CDC continues to lead surveillance efforts and treatment guidelines.
“Providing new funding for HRSA opens up new possibilities for efficiency in the biomedical prevention of HIV and other sexually transmitted diseases,” said David C. Harvey, executive director of the National Union of STD Directors.
However, other experts were deeply concerned about the potential loss of CDC involvement.
“The HRSA and Ryan White programs are great, but they focus on HIV care and treatment,” said Mitchell Warren, executive director of AVAC at the advocacy group.
“They are not involved in HIV prevention as a priority, which is why the CDC prevention focus is so important.”
Michael Ruppal, executive director of the AIDS Institute, said HRSA officials have no expertise in how public health prevention was managed and measured.
“The leadership within the CDC and all the institutional knowledge there needs it on the ground. The state needs it, and the community needs it,” Rupal said.
His organization supports Florida County, which includes HIV Services, seven of the 57 high-risk jurisdictions included in the 2019 initiative. “It seems that having this program happen after he gives his name would have counterproductive effects on his personality,” he said, referring to Trump.
Some public health experts were concerned about NIH reductions to stigma and prevention research, particularly those involved in LGBTQ populations. Most new HIV infections lie among gay and bisexual men and transgender women.
“That's where the trend is and if you're not there, you're not working on trends,” said Dr. Chris Baylor, director of the Duke Global Health Institute.
While around 7% of the NIH budget is spent on HIV research, some Republican lawmakers have suggested that funding for HIV should be worth the national prevalence of less than 0.4%.
“It certainly won't be enough to continue research into the vaccines and treatments we need,” said Dr. Beyrer, adviser to the HIV Vaccine Trials Network.
Given changes to HIV programs in the US and overseas, public health organizations will need a new paradigm to continue their work.
This could involve businesses negotiating direct purchase agreements with states or large nonprofits, or with an entirely new partnership model.
“We need to get out of paralysis, mistrust and shock. We really have to see what we need to build in the future,” Warren said.
“One of the biggest tragedy of all this is when this story is written entirely by people who don't understand science, healthcare, research, or foreign support,” he added.
