As 2019 draws to a close, TheBodyPro takes stock of the year's most noteworthy developments in HIV. And not just any developments: We're looking specifically at those with the largest impact for people who provide HIV care and services in the U.S. In this series, veteran clinician-researcher David Alain Wohl, M.D., guides us through the new research and other important moments of 2019 that have the greatest potential to alter the HIV clinical landscape in the months and years to come.
At the start of the year, the U.S. president announced during the State of the Union address that he would include in his budget funding to "eliminate the HIV epidemic in the United States." In the following days, details of the plan were made public.
The big strokes are a 75% reduction in new infections over the next five years, increasing to 90% by 2030. More deeply, the plan calls for funded initiatives in areas of the U.S. with the highest rates of new HIV diagnoses, with a slant toward states that are mostly rural.
Pillars of the programs described in the Ending the HIV Epidemic (EtE) plan include four areas:
- diagnoses (i.e., more and earlier)
- treatment (i.e., rapid and sustained)
- prevention (i.e., PrEP access and persistence; syringe exchange)
- response (i.e., the use of lab and epidemiological technologies to identify and address outbreaks)
In March, $291 million was earmarked in the White House's proposed budget for the EtE plan.
The Bottom Line on the Ending the HIV Epidemic Plan
The attention of this specific U.S. president on HIV is curious. However, while it may be initially disorienting, it makes sense. Rates of new HIV diagnoses have already been declining overall, and supporting this trend is both good policy and good politics. Further, the tools to stem new infections are already at hand, including pre-exposure prophylaxis (PrEP) and treatment as prevention (a.k.a. undetectable equals untransmittable, or U=U), both of which are centerpieces of the EtE plan.
Looking at PrEP, the Trump administration has applied heavy pressure to get large quantities of emtricitabine/tenofovir disoproxil fumarate (Truvada) at low or no cost. Getting more people to achieve and durably maintain viral suppression is trickier, but the plan -- not unintelligently -- identifies hot spots and hot states that are priorities for funding, and has increasingly stressed the integration of implementation science to identify gaps and form appropriate responses.
This is all encouraging. However, much remains to be seen regarding the support for interventions that are evidence-based but may be unsavory to key figures in the administration, such as syringe exchange and sexual education.
An editorial in The Lancet HIV published soon after the State of the Union address also points out a contradiction that many Americans will clearly recognize. While calling for a broad, multi-agency, "whole of society" approach to dramatically decrease the spread of HIV, the president -- along with Republicans in Congress and in state legislatures -- have undermined efforts already in place that are clearly critical to combating HIV.
Foremost is access to healthcare. The persistent attacks on the Affordable Care Act (ACA) have already precluded millions from benefiting from its provisions and, thus, missing out on opportunities for HIV and sexually transmitted infection (STI) testing, counseling, and treatment. By mid-2020, it is possible that the ACA will be completely struck down, leaving millions of those currently covered in the lurch.
The defunding of Planned Parenthood, the editorial also notes, is particularly counter-productive, as the organization conducts over 740,000 HIV tests a year, in addition to STI screening and treatment. Policies that further stigmatize or marginalize men who have sex with men, transgender women, those living in poverty, and racial and ethnic minorities -- all of whom have the highest rates of new diagnoses of HIV -- also drive the epidemic, pulling against the EtE push.
Where the EtE plan goes, and how far, remains to be seen. I'd like to give it and its architects the benefit of the doubt, but it is not easy.