Even if you were celebrating with a red baseball cap on your head in the wee hours of November 9, given the available facts, you would be hard pressed to defend the notion that the outcomes of the 2016 election were good for people living with HIV infection. With funding for the Ryan White Care Act and its provisions supporting HIV care and medication already on the chopping block -- despite demonstrably increasing the lifespans of people living with HIV -- history tells us that Republican control of the executive and legislative branches of government spells dark days ahead for this and other such public good works.
Our new president has made clear that a top priority during his first 100 days will be the destruction of the Affordable Care Act (ACA, Obamacare). This will not take an act of Congress. Executive action alone can effectively pull the plug on Obamacare. For instance, simply dropping the administration's appeal of a federal judge's ruling in House v. Burwell that spending funds not appropriated by Congress to reimburse insurers for covering working-poor consumers is unconstitutional will deal a sufficiently fatal blow. Without this subsidy to insurers, their costs will skyrocket, prompting them to pull out of the system and the ACA to implode.
Since it became law, the ACA has expanded health insurance coverage to 20 million people, and it is estimated that less than 9% of all people in the U.S. are now uninsured. People with and at risk for HIV infection have certainly benefited from the ACA. So, with its demise, there will be HIV-positive people left without coverage unless the new administration and Congress provide a responsible alternative.
In addition to the killing of Obamacare, cuts in funding Ryan White support for clinical care, case management and medications would further erode the safety net for poor and working class people living with HIV. An ambitious plan to cut taxes, improve infrastructure, fortify borders and replace the ACA with a new system of coverage will all cost money, and it is reasonable to be concerned that social programs, such as those that benefit the working poor with and at risk for HIV, will be raided.
The Republican sweep can also impact HIV care and prevention through decisions made on National Institutes of Health (NIH) funding, or the lack of it. In the past, funding for federal research has suffered when congressional control rested with the GOP, and many of the most exciting HIV research initiatives, such as developing and testing injectable antiretrovirals and microbicides for prevention, interventions to reduce HIV-associated inflammation, approaches to combating the opioid epidemic and even the HIV cure agenda, rely heavily on NIH funding.
The Bottom Line
Cumulatively, the very altered political reality we shall be living in will be much more significant to the person living with HIV than the buzzy issues described below. Debates about whether HIV replication can be suppressed with two versus three medications is a moot point for the patient who cannot afford her asthma medicine, mammogram or car ride to see her doctor. Predicting what a President Trump will do is a fool's game. Instead, we will see what he and his administration do for the HIV-positive "little guy."
"The only constant is change," wrote Heraclitus 2,500 years ago. He also advised that "people must fight on behalf of the law as though for the city wall." There will be many battles ahead for numerous noble causes, and we who care for people living with HIV and claim to advocate for them will need to be vigilant, or else what we have built will crumble.
What are some other top clinical developments of 2016? Read more of Dr. Wohl's picks.
David Alain Wohl, M.D., is a professor in the Division of Infectious Diseases at the University of North Carolina at Chapel Hill, director of the North Carolina AIDS Training and Education Center and site leader of the University of North Carolina Chapel Hill AIDS Clinical Research Site.