The grand gesture of commitment to an implausible health goal is a State of the Union tradition. Richard Nixon once declared a mission to “conquer this dread disease,” referring to all cancers. Barack Obama promised to “map the human brain,” an ambition that scientists could explain only by using further metaphors. (Obama later also announced a plan to cure cancers.)
On Tuesday night, Donald Trump championed ending AIDS in the United States. “My budget will ask Democrats and Republicans to make the needed commitment to eliminate the HIV epidemic in the United States within 10 years,” the president said. “Together, we will defeat AIDS in America and beyond.”
Leaked transcripts of the speech did not include “and beyond,” which was presumably ad-libbed. That would be a much bigger commitment.
In either case, the promise is not a question of a single line item in the U.S. budget. Eliminating AIDS would involve an overhaul of the health-care system. It would also require a much-needed rhetorical commitment from Trump himself.
In contrast to prior presidential vows, ending HIV transmission is possible and even plausible. Unlike cancers and Alzheimer’s and so many other vexing diseases, HIV is not a problem of investing in developing the necessary chemical or surgical approaches, or completely reorienting a human’s immune system.
Rather, treatment exists: Antiviral drugs can decrease the amount of HIV a person carries to effectively zero and prevent uninfected people from contracting HIV. Combine these with other long-known preventive practices, and at a basic science level, there is no reason HIV should continue to be spread.
Trump’s message is good, but Trump himself as its bearer is a contradiction that could end up undermining the cause. The barriers to ending AIDS have long been a lack of investment in outreach and access, alongside disenfranchisement from the medical system. Trump has contributed to these obstacles with racist, sexist, anti-transgender, anti-science rhetoric. Until now, his words have worked at almost every turn to fuel HIV’s spread.
Unlike so many other topics related to people’s health, ending HIV is not necessarily a partisan issue doomed to haunt the country indefinitely. George W. Bush started the President’s Emergency Plan for AIDS Relief, or PEPFAR, which orchestrated U.S federal agencies to provide care to millions of people around the world, ensuring a position of global leadership in preventing and treating AIDS. This work was continued under Obama.
Trump, however, repeatedly threatened to end PEPFAR when considering budget cuts. He eventually agreed to reauthorize it in December, but he has undermined HIV treatment and prevention at a policy level in other ways. At the moment, about half of Americans with HIV aren’t taking antiviral treatment, many because they simply can’t get it. Procuring the medications generally requires consistent access to health care, including the private insurance that can be purchased through the exchanges created by the Affordable Care Act. But the annihilation of the ACA was a central promise of Trump’s campaign; his administration has worked to malign and erode it by eliminating the requisite individual mandate, cutting the open-enrollment budget, and winnowing its time window.
People on Medicaid do have access to HIV medications, though many states have refused federal money to expand their Medicaid programs in order to protest the ACA, in line with Trump’s demonization of the law. Many of these are states where HIV is most common, concentrated in the southeastern United States. The Trump administration is fighting Medicaid expansion that would provide care for many of the people most in need of HIV treatment. The administration has also made multiple efforts to cut funds for Planned Parenthood, which offers HIV services.
To commit now to eradicating HIV would demand a reversal of course on all these policy fronts.
Beyond issues of access to treatment and preventive services, some of the people with HIV who aren’t receiving care don’t know the options that exist, or don’t trust doctors and scientists. The very act of seeking testing and treatment, even for people with excellent insurance, can itself be psychologically fraught. Trump’s anti-science rhetoric has ranged from deriding climate change to insinuating that vaccines cause neurological damage to saying people shouldn’t trust what they read or see or hear in “the media”—which is a primary way that people learn about medical advancements, distribution programs, and when and how to sign up for health insurance.
According to reporting by Politico, Trump’s HIV strategy will have health officials “target the U.S. communities with the most HIV infections.” But these are precisely the communities his rhetoric and policies have tended to alienate. HIV disproportionately spreads among racial minorities and people of stigmatized sexual orientations. Homosexual and bisexual men account for some 70 percent of new diagnoses, and by far the highest rates of transmission are among nonwhite people. Transmission between black and Latino homosexual men accounts for three times as much spread as transmission between white homosexual men. Trans communities and low-income communities are also disproportionately affected.
These are the demographics most disenfranchised from the medical system. Trump’s denigration of immigrants—which reportedly includes an assertion that immigrants from Haiti “all have AIDS” (White House officials have denied the president said this)—adds to sentiments and policies that lead noncitizens to lie low and avoid seeking treatment, and therefore risk contracting and spreading disease.
Eliminating HIV depends on a consistent stream of scientifically informed messaging that unites people, builds trust, and promotes understanding and facts and open-mindedness toward professionals—doctors, scientists, and journalists whose job is to learn and disseminate truth. This is a cause that depends on rhetoric aimed at bridging divides and destigmatization, not stoking fear and hatred. To have Trump now champion HIV prevention stands to exacerbate barriers to reaching the highest-risk communities who do not trust that he has their interests at heart.