In his State of the Union address on 5 February, President Donald Trump committed to eliminating the HIV epidemic in the United States by 2030. Many researchers applaud the sentiment but are sceptical that the administration can effectively reach out to communities that it has helped to marginalize through its actions.
They cite the current political climate and recent proposals — including some that would increase discrimination against transgender people and reduce the availability of needle-exchange programmes — that would make eliminating HIV transmission in the United States incredibly difficult. But this hasn’t kept officials at the US Department of Health and Human Services (HHS) from formulating a plan to address the epidemic.
In a press call on 6 February, HHS officials outlined a programme to cut new HIV infections by 75% in five years and by at least 90% in ten. Their strategy is based on lessons learnt through global HIV programmes, supported by groups including the Global Fund to Fight AIDS, Tuberculosis and Malaria in Geneva, Switzerland, and the US government initiative PEPFAR. It involves curbing the rate of new infections by regularly testing people who are at high risk, offering them drugs called PrEP to prevent infection and starting people on virus-suppressing drugs immediately after diagnosis.
“I think the agenda is desperately needed, doable and focused,” says Mark Dybul, the former director of the Global Fund, now at Georgetown University in Washington DC, who isn’t involved in the agency’s plan.
The HHS plans to use existing programmes to target specific groups at a high risk of infection, including men who have sex with men, transgender people and African Americans. In 2017, African Americans accounted for 13% of the US population but 43% of new HIV diagnoses. Researchers and health-care providers will concentrate their efforts in 48 mainly rural counties spread across southern states such as Alabama and Kentucky. These regions, along with Washington DC and San Juan, Puerto Rico, account for more than half of new diagnoses.
Team members also said that only 10% of the roughly 1.2 million people in the United States who could benefit from preventive therapy take it. They suggested that subsidies and lower drug prices would raise that figure.
But money isn’t the only reason people don’t take these daily preventive drugs. Large clinical trials in southern Africa have found that certain groups of people, such as young women, tend not to stay on PrEP because of its side effects, the stigma of taking it or the burden it places on their daily lives.
To address such issues, said Anthony Fauci, director of the US National Institute of Allergy and Infectious Diseases (NIAID) in Bethesda, Maryland, the agency will fund studies that look at the best ways of getting at-risk people into clinics for testing, and of starting them on prophylactics or HIV treatment. These studies have already begun at some of the 19 Centers for Aids Research across the United States, says Fauci, using existing funds. If Congress designates more money for the initiative, NIAID will receive the funding in 2020.
Agency officials also voiced support of initiatives that are backed by public-health research, but are at odds with some of the Trump administration’s policies. Last year, Trump proposed a rule that might allow health-care providers to deny treatment on religious or moral grounds. Some say the rule, if implemented, would result in discrimination against transgender people. But Fauci insists that the HHS programme “will treat transgender people as we treat any other patients”.
Brett Giroir, assistant secretary for health at the HHS, said that the initiative will support comprehensive needle-exchange programmes that have decreased the risk of HIV transmission among drug users. But last year, the US Justice Department threatened to shut down sites where such exchanges occur.
The political climate makes AIDS activists doubt that the Trump administration can succeed in significantly slowing the spread of HIV. “We know HIV feeds on inequality and the criminalization of behaviours,” says Mitchell Warren, executive director of AVAC, an HIV-prevention advocacy organization in New York City. “And this administration has contributed to obstacles that make ending this epidemic impossible by being racist, sexist, homophobic and anti-transgender.”
But Dybul says his experiences with the Global Fund and PEPFAR in Africa have taught him that even when governments have marginalized or criminalized communities, public-health officials have succeeded in places where they had strong support from the community. “You just have to get local,” he says.