Amid the recent uproar over President Donald Trump’s characterization of Haiti and African nations as “shithole countries,” you might have missed another, equally distressing characterization of Haitians: Trump’s claim, made in June but only reported last month, that they “all have AIDS.”
As deplorable as the remark was, the problem is more than the president’s words. The Trump administration’s dismissive approach to the HIV epidemic is damaging to people with HIV. From inaction to outright sabotage, his administration is threatening our hard-won progress toward ending the epidemic.
The actions ― and inactions ― of this administration have consistently telegraphed its intention to decelerate the fight against HIV by dismantling effective policies and defunding effective programs. On Inauguration Day, the White House website was scrubbed of references to the National HIV/AIDS Strategy, an important policy advance under the Obama administration. A year into Trump’s tenure, the White House Office of National AIDS Policy still has no director. Although defeating AIDS will require ongoing expert advice, including the voices of people living with HIV, Trump dismissed all remaining members of the Presidential Advisory Council on HIV/AIDS in December. His press secretary said that other “options” are being considered.
Furthermore, Trump’s Justice Department has been on the wrong side of cases challenging discrimination due to sexual orientation and gender identity, undermining civil rights for the LGBTQ community. A newly announced religious refusal policy and an ironically named “conscience and religious freedom” division within the Department of Health and Human Services use the subterfuge of religion to sanction discrimination and reduce health care access for women, LGBTQ individuals, people with HIV, and other Americans.
These actions occurred within a broader assault on health care access that particularly affects people with serious conditions, including HIV. The White House budget for fiscal year 2018 proposed cuts to the Centers for Disease Control and Prevention, including programs on HIV, other sexually transmitted diseases, tuberculosis and hepatitis. It proposed cuts to the Ryan White HIV/AIDS Program at the Health Resources and Services Administration, which is the nation’s signature HIV treatment program, caring for over half a million people. The budget also includes an $800 million cut to global AIDS funding and steep spending reductions for the National Institutes of Health. Although the Senate and House appropriations committees rejected many of those proposals, critical health programs still face across-the-board cuts if an agreement to raise budget caps for both defense and non-defense programs is not reached. The president’s plans for fiscal year 2019 will demand equally intense scrutiny, as further cuts to health services and research will lead to rollbacks of essential services.
While Republican efforts to repeal the Affordable Care Act failed, their new tax law eliminates the ACA’s individual mandate, further destabilizing health insurance markets and again putting health care out of reach for millions. The tax law, which adds nearly $1.5 trillion to the federal deficit, sets the stage for massive cuts to health programs requiring annual appropriations such as the Ryan White initiative. Meanwhile, Trump’s regulatory and administrative actions ― such as allowing states to forgo covering essential health benefits, including prescription drugs ― jeopardize life-saving protections for people with HIV. Radical shifts in Medicaid policy that encourage states to impose work requirements as a condition of eligibility also threaten health care access for people with HIV.
The Trump administration’s ambivalence, if not hostility, toward services critical to the well-being of individuals with HIV are also part of its attempt to undermine science- and evidence-based policies and programs. In December, CDC Director Brenda Fitzgerald confirmed that an HHS style guide for budget documents leaned against the use of the words “diversity,” “vulnerable” and “entitlement” and suggested substitution of the politically charged “Obamacare” for the less controversial “Affordable Care Act.” CDC staffers reportedly were urged to avoid terms such as “science-based,” “evidence-based,” “transgender” and “fetus,” and given substitute text suggesting that “community norms” (that is, opinions) would be considered on par with scientific facts. This kind of ideological wordsmithing, while not unprecedented, is unscientific and dangerous.
The goal of ending HIV as a public health threat is within our reach. With continuous treatment, people with the disease can live a near-normal lifespan, and when that treatment suppresses the virus to undetectable levels, they do not transmit it to others. Preexposure prophylaxis (PrEP) and syringe exchange programs further prevent the spread of HIV. The gateway to both prevention and treatment is HIV testing.
But ending the epidemic requires committing to health care access, confronting bias and discrimination, facilitating stable housing, providing comprehensive evidence-based sexual and reproductive health education, and ensuring the civil rights of people with and at highest risk for HIV. All that requires federal support.
Now is the time for legislators to protect our hard-won progress in the fight against HIV and AIDs, for citizens to remind them of their duty and for the White House to reverse course before infection rates rise and more people are lost. The daily fire and fury out of this White House sometimes distracts us from its policies, but with every decision that affects health care and civil rights, real lives are at stake.
Dr. Melanie Thompson, MD, is the chair of the board of directors of the HIV Medicine Association (HIVMA), principal investigator for the AIDS Research Consortium of Atlanta, and a practicing clinician in Atlanta.
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