As 2020 draws to a close, we asked David Alain Wohl, M.D., a professor of medicine in the Division of Infectious Diseases at the University of North Carolina and a highly respected HIV clinician-researcher, to take stock of the year's most momentous research developments and other critical events. In this exclusive series of articles, Wohl calls attention to 10 such developments that have tremendous short-term implications for our day-to-day efforts to improve HIV prevention, treatment, patient care, and policy in the U.S., and analyzes each development with his trademark wit and clinical savvy.
My top story of 2016, in that year’s edition of the Top 10 HIV Clinical Developments, was Donald Trump’s election as President of the U.S. In that post, I lamented the then President-elect’s bluntly stated threats to destroy the Affordable Care Act (ACA) and his implied threats to cut funding to Ryan White CARE Act HIV/AIDS programming, as well as the National Institutes of Health (NIH).
More than anything, I worried that the four years of his administration would not be good for people living with HIV. At the end of those four years, some of these worries have been validated.
The ACA remains in place—but only due to Supreme Court Chief Justice John G. Roberts Jr., who twice tipped the balance in favor of rescuing the health care law that has provided insurance coverage to millions. The Trump administration has been relentless and consistent in its animosity to President Obama’s signature legislation; arguments about the constitutionality of the ACA were heard again at the court in November, just after Election Day. With the election of Joseph R. Biden Jr., the future of ACA is brighter—but it’s not assured, especially if the Senate retains its Republican majority.
What I didn’t anticipate was the Trump administration’s decision to design and implement a plan to eliminate domestic HIV. The “Ending the HIV Epidemic in America” plan was first announced during a State of the Union address in 2019; it proposed reducing new diagnoses of HIV infection domestically by 90% by 2030 through buttressing the major pillars of the HIV care continuum.
A cynic (hand raised) can claim that this proposal was an opportunistic ploy to take credit for levels of new infections that were already declining. But it must be noted that the plan did allocate funding to the Centers for Disease Control and Prevention, NIH, and the Ryan White HIV/AIDS Program. Even before COVID-19, the feared gutting of these essential entities did not materialize.
However, any assessment of the Trump White House’s achievements in confronting HIV will be unable to ignore its mishandling of the COVID-19 crisis. The loss of life, the strain on our health care infrastructure, the economic damage—all of it deeply overshadows any successes the administration can claim in ending HIV. You can’t win at defeating one pandemic when you badly lose control of another.
The incoming Biden administration is already telegraphing a very different, science-first approach—one that has included consistent messaging about COVID-19. Health care will be front and center in many debates over the next few years, even after the worst of the COVID-19 pandemic is past us. As I ended in 2016, so I end my top 10 this year:
“’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 those who claim to advocate for them, will need to be vigilant, or else what we have built will crumble.”