Despite ongoing attempts to throw out legally cast votes in key states and continued Republican denial of the presidential election results, Joseph R. Biden will take office as president on Jan. 20. On that date, he and Vice President Kamala Harris will inherit multiple health crises.
Public health advocates are eagerly awaiting opportunities for new ways to fight HIV/AIDS and other infectious diseases in a post-Trump landscape. While they’ll be grateful not to wake up to irrelevant, inflammatory all-caps tweets from their president every morning, they say they’ll also be looking for actions from Biden that match his promising rhetoric on the campaign trail.
Here are a few ways that top HIV and health advocates think U.S. efforts to eliminate HIV/AIDS could improve starting next year.
Antiviral Teamwork: Fighting Both COVID-19 and HIV
Congress is likely to appropriate more money to fight COVID-19 and help people whose lives have been upended by the pandemic. There are lawmakers who think such funding could provide a chance to further the fight against HIV at the same time.
In June, Sen. Tammy Baldwin (D-WI) urged Senate leadership to include federal funding for HIV treatment, prevention, and housing programs in the next COVID-19 pandemic response package. That included $500 million for the Ryan White HIV/AIDS Program, $100 million for the Division of HIV/AIDS Prevention within the Centers for Disease Control and Prevention (CDC), $65 million for the Housing Opportunities for Persons with AIDS (HOPWA) program, and $58 million for the CDC’s Infectious Disease and Opioid Program.
Jeremiah Johnson, HIV Project director with Treatment Action Group, says that there can be a synergistic approach to fighting COVID-19 and HIV. In fact, he notes that our efforts to fight HIV within the U.S. have already given us knowledge and tools that have been useful in combating COVID-19: “The historic investment in HIV research has helped us [with COVID-19] as far as testing and tracing,” he says. “We look for where we can build upon a COVID response, and that includes building a sustained public health workforce to also address STIs and HIV and hepatitis.”
In one of his first acts as president-elect, Biden unveiled a COVID-19 task force that would, he said in a statement, shape his administration’s approach “to managing the surge in reported infections; ensuring vaccines are safe, effective, and distributed efficiently, equitably, and free; and protecting at-risk populations.”
One member of the task force, Eric Goosby, M.D., has a long history of leadership in HIV/AIDS: Currently the United Nations Special Envoy on Tuberculosis, he formerly served as the U.S. Global AIDS Coordinator in the Obama administration and led the Obama-era implementation of the President’s Emergency Plan for AIDS Relief (PEPFAR).
Although the potential synergy between HIV and COVID-19 seems to create opportunities for making inroads against both viruses, advocates are also concerned that the opposite might happen: that COVID-19 funding might come at the expense of HIV-fighting dollars. An early test for Biden may be whether he will let congressional deficit hawks, and their demands for austerity, hamper his ability to respond to COVID-19 alongside HIV and other health crises.
“The GOP has a record of blocking priorities of Democratic presidents,” Joe Huang-Racalto, the director of government relations and public policy at NMAC, tells TheBodyPro. “All of us in the community must put as much pressure as we can on those who don’t agree with us. It will help if we remind them that EHE [the Ending the HIV Epidemic in America plan] is a Trump plan.”
One major wild card is control of the Senate, which will hinge on two January runoff elections in Georgia. Senate Majority Leader Mitch McConnell (R-KY) just won his own reelection bid, and would stay in his position if the Senate remains in Republican hands. Although he has stated that a “targeted” coronavirus stimulus bill would be a top priority in the lame duck session, he refused to consider the $3 trillion HEROES Act passed by the Democratic-controlled House of Representatives in May, while a $500 billion GOP-led package failed to pass in October.
Nevertheless, there have been some early signs of bipartisan action from Congress on HIV/AIDS budgeting. On Nov. 10, Senate appropriators proposed an increase of $207 million in fiscal year 2021 for ramping up efforts to end HIV, according to the HIV+Hepatitis Policy Institute. In a statement, the institute noted that the increase builds on $300 million Congress previously approved for the first year of the EHE and is considerably greater than the $55 million increase initially proposed by the House of Representatives—but is also far less than the $412 million increase in the president’s initial budget proposal.
Johnson says he is encouraged by the bipartisan support for the funding increase. In particular, he notes that there are additional resources for HIV prevention earmarked in the proposed budget, “which isn’t usually prioritized.”
Such budget proposals are almost always intended more as starting points for negotiations than as firm commitments, but they point to the wide range of possible outcomes as a new administration takes office in a tough political climate.
In Biden, a More Humane, Inclusive Approach to Health Policy
Few public health experts think the outgoing administration’s response to the coronavirus pandemic has been anything but disastrous. From Trump’s downplaying the seriousness of the pandemic, to his politicization of the CDC and the U.S. Food and Drug Administration (among other agencies), his repeated trumpeting of inaccurate information, his touting of potentially harmful unproven treatments for COVID-19, and his sidelining of his own Coronavirus Task Force even as new infections break daily records, a new emphasis on sound, science-driven policy from a Biden administration will be welcomed.
Trump has had little to say about HIV during his presidency, though he paid lip service to the Department of Health and Human Services’ EHE plan aiming to reduce new transmissions by at least 90% by 2030. Biden, for his part, has discussed moving up that milestone to 2025, and he also proposed new funding to support it.
Globally, Trump’s approach to health—as it’s been to many issues—has been both anti-science and highly isolationist, advocates say. “Biden-Harris shouldn’t only undo the harms Trump has set up on global AIDS responses on HIV and COVID, they must blaze a path, using science and evidence-based policies,” says Asia Russell, executive director of Health GAP (Global Access Project).
One of those harms has been the so-called global gag rule, an executive order that prohibits U.S. federal funding from benefiting any organization outside the U.S. that provides or promotes abortion services. The order has been a hallmark of Republican administrations in this century, and it was one of Trump’s first acts in office—though he also expanded it to include more organizations working in global health, including HIV. AIDS advocates have highlighted the harmful impact the gag rule has had on the HIV response in countries like Cambodia and Malawi. Biden has repeatedly pledged to immediately revoke this order.
In addition, on Nov. 9, Biden’s transition team confirmed that the president-elect will, on his first day in office, reverse Trump’s decision to withdraw from the World Health Organization (WHO).
That said, beyond the likely reversal of Trump’s gag order and WHO withdrawal, global funding for HIV/AIDS remains a question mark. For example, PEPFAR has been flat-funded under Trump—but to be fair, that trend had already begun under President Obama.
Biden Is Likely to Reinvigorate the Affordable Care Act
Within a day after being sworn in, President Trump issued an executive order pledging to repeal the Affordable Care Act (ACA) and directing the government to “take all actions consistent with law to minimize the unwarranted economic and regulatory burdens of the act.”
But though the ACA, or Obamacare, has been battered, it has stayed, escaping elimination even despite the GOP briefly controlling both houses of Congress. And on Oct. 10, when the Supreme Court heard oral arguments on the Trump administration’s latest attempt to end the ACA, two key Republican appointees signaled a likelihood that they’d leave the law standing.
Of course, there’s no guarantee that more challenges to the ACA won’t make their way to the now strongly conservative Supreme Court with more convincing arguments. But, from the executive branch at least, the law, which provides health coverage for more than 20 million Americans, is safe.
Biden, who helped wrangle the votes to get the ACA passed 10 years ago, doubled down on his support for it during his presidential campaign, vowing to expand the scope of the law. Speaking on Oct. 10, Biden said, “Come January, we’re going to work quickly with Congress to dramatically ramp up health care protections, to get Americans universal coverage, and lower health care costs as soon as humanly possible.” He left out the details on how that would happen, though several times on the campaign trail he pledged support for a Medicare-like public option.
In a questionnaire his campaign completed for AIDS United earlier this year, Biden said that expansion of the ACA was central to his plan to end HIV. He also went further, tying improved health care to issues of systemic racism, education, climate change, and housing, saying that he would address disparities in all of these areas to “ensure that all Americans have a fair shot [at] living a healthy life.”
Of course, as with any efforts that require congressional approval, any push by Biden to build off the ACA’s foundation could be blocked by Mitch McConnell if the Senate retains its Republican majority.
At the moment, 38 U.S. states and Washington, D.C. have opted to expand Medicaid as part of the ACA, which is crucial to lowering the overall costs of health insurance coverage. Unfortunately, the 12 states that have not yet opted to do so—most of which are run by Republican legislatures and governors—are also the states with some of the highest HIV infection rates. That’s not something the Biden administration can directly do anything about—nor can his administration remove work requirements for Medicaid benefits, which some states have implemented.
Biden could, however, issue new rules to roll back access to inadequate, short-term, non-ACA plans touted by the Trump administration in an attempt to weaken the ACA. He could also roll back Trump-era policies that have made it harder to enroll in ACA coverage and eroded the value of marketplace subsidies. The end result would allow more people living with or at risk of HIV to access necessary health care and services.