How realistic is Trump’s pledge to end HIV in the U.S.? – By Judy Woodruff (PBS Newshour) / Feb 6 2019
In his State of the Union address, President Trump promised that his administration would try to end the transmission of HIV/AIDS in the U.S. William Brangham learns more from Jon Cohen of Science Magazine and Carlos del Rio of Emory University School of Medicine about the attainability of this goal, the practical and political challenges and what could help.
Read the Full Transcript
Judy Woodruff:
But first: In his State of the Union last night, President Trump made a bold promise: His administration will try to end the spread of HIV/AIDS in the United States.
William Brangham, who’s covered this epidemic extensively for the “NewsHour,” reports on what it might take to make that promise a reality.
Donald Trump:
Thank you very much.
William Brangham:
It was President Trump’s first major pledge to address HIV/AIDS in America.
Donald Trump:
My budget will ask Democrats and Republicans to make the need commitment to eliminate the HIV epidemic in the United States within 10 years.
William Brangham:
The president; didn’t specify how much money he’d put forward, but administration officials confirmed today it would be new funding, not dollars reallocated from other programs.
Today, more than 1.1 million Americans are living with HIV, and there are some 40,000 new infections every year. The administration says it’s aiming to reduce those new infections by 75 percent over five years and by at least 90 percent by 2030.
It’s focusing on 48 specific counties where over half those new infections occur. It also pointed to seven states in the Southern U.S. with a substantial HIV burden. The Southern U.S. is also home to half of all undiagnosed infections.
Public health task forces will help local agencies in these areas boost prevention and treatment programs. Antiretroviral treatment not only stops an infected person from progressing to AIDS, but it also prevents them from passing the virus to others.
But, today, only about half of HIV-positive people in the U.S. are getting this crucial treatment. Gay and bisexual men and people of color are at particular risk. Administration officials said they will also continue to expand the use of the HIV prevention drug called PrEP. It’s known commercially as Truvada.
It’s effective, but expensive. Officials today said additional funding for PrEP is crucial.
Anthony Fauci:
PrEP works. If you adhere to PrEP, I think we all know now with a number of very good studies that the efficacy of preventing acquisition of infection in a high-risk individual is greater than 97 percent.
William Brangham:
Other proven prevention tools, like needle exchanges, can also help prevent the virus’ spread.
But ending this epidemic still faces many challenges. In our series on HIV/AIDS last year, we visited Miami, Florida, one of the epicenters of HIV in America.
There, Dr. Hansel Tookes, who ran the only needle exchange program in the entire state, described why ending AIDS was still so difficult.
Hansel Tookes:
I think, unfortunately, what’s happened in Florida and here in Miami is, in the absence of needle exchange, in the absence of comprehensive sexual education, in the absence of widespread access to PrEP, this is what happens. You have a city that has no control over the current HIV epidemic.
Donald Trump:
Together, we will defeat AIDS in America and beyond.
William Brangham:
And while the president made the pledge last night, his administration’s policies have, in other ways, undercut that very effort.
The Trump administration has worked to gut substantial portions of the Affordable Care Act and the expansion of Medicaid. About half of those receiving care for HIV in America do so through Medicaid or Medicare. The administration has also cut funding to global HIV/AIDS programs like PEPFAR, the enormously successful program begun by former President George W. Bush.
The Trump administration will give a dollar value indication of how serious it really is about ending HIV in the U.S. when it releases its 2020 budget.
To take a deeper look at the president’s pledge from last night, I’m joined by two men who’ve studied HIV extensively.
Jon Cohen has covered this epidemic for 30 years for science magazine. Many of you will also recognize him as our reporting partner on our two multipart series on HIV/AIDS. And Dr. Carlos del Rio is an HIV/AIDS doctor at Emory University in Atlanta, a city that’s also one of the epicenters of America’s epidemic. He runs the Global Health Department at Emory’s Medical School and co-directs Emory’s Center for AIDS research.
Gentlemen, thank you both. Very nice to see you both here.
Jon Cohen, I would like to start with you.
The president last night said, we are going to end the HIV epidemic in 10 years. How realistic is that?
Jon Cohen:
Well, it’s an international goal that the United Nations AIDS program has been pushing for quite some time.
I think it’s entirely realistic in some places. And the question is, can you do it nationwide? We already see great progress in cities like San Francisco and states like New York that have really tried to bear down and do it with detailed plans and with a lot of self-criticism.
So it’s really going to come down, in my mind, to how much self-criticism there is and how detailed the plans are and how quickly people evaluate their fault lines, and where things aren’t working, adjust and make a stronger response.
William Brangham:
Dr. del Rio, the same question to you. How realistic, from your perspective, is the president’s proposal?
Carlos del Rio:
It’s a long shot.
But, again, in the 1960s, when Kennedy said we’re going to go to the moon, it was a long shot. And when President Bush launched PEPFAR, nobody would guess we would have 20 million people on therapy globally.
So I think what he saw and what is necessary, much needed in our U.S. epidemic response, is leadership. And whether the president provided that initiative, and now we’re going to get all the agencies to work together to achieve that goal, I think it’s doable.
I think it’s not going to be easy. But, again, big things are never easy.
William Brangham:
Jon Cohen, as I mentioned earlier, the administration has laid out that they’re going to target these very specific counties across the U.S.
They’re also going to target seven states that have rural epidemics. What do we know about those places in particular and why and who is particularly at risk in those places?
Jon Cohen:
Well, we know quite a bit.
The people who are most at risk have fallen out of the health care system. They’re hard to reach. A lot of them have mental health issues, they have housing problems.
Dr. del Rio and I earlier today, we were talking about a lot of them changing their phone numbers frequently. It’s hard to connect with them and keep them in care, hard to get them tested in the first place.
It’s a big ask. But there’s something else on the horizon that hasn’t been discussed much. And that’s the possibility that there’s going to be an improvement in anti-HIV drugs so that they’re long-lasting, you don’t need to take them every day, which is a major hurdle for both treatment and prevention.
And if those prove themselves, which could happen in the next couple of years, that will change the equation too.
William Brangham:
Dr. del Rio, let’s pick up on that.
I mean, obviously as Jon is talking about, effective treatment, it works. It saves people’s lives. It stops them from transmitting the virus to others. But only half the people who need that treatment are getting it. Isn’t that really priority number one?
Carlos del Rio:
Absolutely.
I think the biggest challenge that we have as a nation in our response to the epidemic is keeping people in care. We are pretty good at testing. We get them linked to care, but then people fall out of care. And if you’re not in care, you’re not getting therapy, and you’re not having — you don’t have your virus suppressed, and you can transmit it to others.
So I think a big challenge we have is how do we get people engaged in care. And Jon and I were talking earlier today about peer navigators, case managers, all different strategies that we need to make sure that people don’t fall out of care, that people stay engaged in care.
And then we can get them on antiretroviral therapy. And then, of course, long-acting agents like the ones you’re mentioning can also start making a difference.
William Brangham:
Jon, this is something I know that you have reported on, you and I have reported on quite a bit.
Can you talk a little bit about the role that poverty and racism and homophobia and transphobia play in how that complicates our response to the epidemic?
Jon Cohen:
That’s — that’s the root of the problem, is there’s so much stigma and discrimination. And there’s — there are so many communities of people who are outside of systems, outside of health care, and they’re difficult people to help.
I mean, you and I worked with the San Francisco General Hospital in 2016. And, in our series there, we looked at a really concentrated program with about 900 people who were the most difficult people in the world to help. And it took an intensive effort from a really skilled group of clinicians and outreach workers to achieve what was phenomenal, nearly 90 percent long-term suppression of that population of people who are HIV-infected.
But, remember, look at what it took.
William Brangham:
And, Dr. del Rio, the other big leg of this stool seems to be prevention. The administration officials today said that prevention was going to be an enormous part of their effort.
We know that part of that is in education, but also part of that is in the deployment of PrEP. Why has that been so slow to take off across the country?
Carlos del Rio:
It’s been — it’s been a huge missed opportunity.
Since PrEP was approved by the FDA to now, really, there’s been just simply a huge lag time of implementation. This PrEP is effective. PrEP is useful. And the people that are using it the most are the ones that are needed the least.
So when you talk about concentrated epidemics, like the one we have in the U.S., it is critical that you improve the number of people that are suppressed, but you also scale up PrEP in a significant way.
William Brangham:
After the president’s announcement, Jon, I saw there was obviously optimism on the part of people who have been focusing on this issue. They love the attention being put on this.
But others point to the fact that the — this administration has also done other things that seem to torpedo the effort, like chipping away at the Affordable Care Act, pushing to not expand Medicaid.
Doesn’t that seem like they have got one hand fighting the other in this effort?
Jon Cohen:
As someone said to me today who didn’t want to be quoted, it’s Washington.
That’s how politics works. It makes strange bedfellows. It doesn’t make any sense that the administration would be working against itself in this effort, with discrimination against the transgender population or gay men, or the issues that have come up with people of color.
These things have to be addressed holistically, and you can’t win until you do it that way.
William Brangham:
All right, Dr. Carlos del Rio, Jon Cohen, thank you both very much.
https://www.pbs.org/newshour/show/how-realistic-is-trumps-pledge-to-end-hiv-in-the-u-s
