In Tuesday's State of the Union address, President Donald Trump pledged to end the HIV epidemic still affecting more than 1.1 million Americans. "Scientific breakthroughs have brought a once-distant dream within reach," the president said. "Together, we will defeat AIDS in America."
Despite advances in prevention and treatment, 38,739 people received an HIV diagnosis in the United States in 2017, and thousands died from it. The president's 10-year strategy would target states with the highest rates of HIV, concentrated in the South and the Northwest, and those with a "substantial rural HIV burden." This administration has not done much to address the epidemic so far, but unlike much of Trump's rhetoric on Tuesday, it's a truly unifying issue: Mainstream media outlets are hailing the goal as a bipartisan win, and public-health experts say it's also achievable.
The tools already exist: Antiretroviral therapy can suppress the virus so that people living with HIV don't spread it to others, and a treatment known as pre-exposure prophylaxis (or PrEP) prevents people at risk of infection from contracting the virus. The real challenge has been implementation. On this front, research shows there's still a gap between public-health efforts and those who are most vulnerable—and the Trump administration's policies, such as weakening the Affordable Care Act, have not helped.
Here are some of the barriers to "defeating AIDS in America."
- Although HIV rates have been on the decline in some states and remain stable in others, the opioid epidemic has put more people at risk of infection in low-income, rural areas. In 2015, an outbreak of HIV in Indiana was linked to injection of the prescription opioid oxymorphone. Then-Governor Mike Pence was criticized for resisting needle-exchange programs in the state, despite evidence showing that they work. Research suggests that public-health programs must address this risk factor as the opioid epidemic continues.
- Health-care access is also an important factor in the fight to end AIDS. While the treatment exists to prevent further infection, 51 percent of people with HIV are not virally suppressed, according to the Centers for Disease Control and Prevention. A 2009 study found that people experiencing traumatic events, such as sexual assault, housing instability, unemployment, and loss of income, are less likely to adhere to treatment for HIV. Expanding Medicaid, making preventative care accessible, and lowering prescription drug costs could help reduce these barriers. Instead, critics point out that the Trump administration's efforts to repeal and replace Obamacare have done the opposite, increasing the uninsured rate for the first time since the ACA rollout.
- Speaking practically, AIDS researchers say implementation is an expensive challenge. "An end to the HIV/AIDS pandemic can be achieved only with provision of sustained and additional resources at the local, regional, national, and global levels," two researchers at the National Institute of Allergy and Infectious Diseases wrote in 2018. The Trump administration, however, has attempted to cut programs aimed at ending HIV; to appease anti-abortion groups, the Department of Health and Human Services also plans to end funding for fetal tissue research, which the Foundation for AIDS Research and other scientists say has been crucial in preventing HIV. (In something of a contradiction, Trump pledged his support for this agenda during the State of the Union, saying, "Let us work together to build a culture that cherishes innocent life.")
- Lastly, there's the administration's record on LGBTQ rights. HIV disproportionately affects African-American gay men and bisexual men, but a 2018 Politico investigation found that the Department of Health and Human Services has systematically dismantled protections for LGBTQ patients, rolling back regulations that ban discrimination based on sexual orientation in health care.