Trump's policies threaten his 2019 vow to end HIV, experts say

WASHINGTON — During his 2019 State of the Union address, President Donald Trump laid out an ambitious goal: end HIV in the United States by 2030.

But six years later, his actions are actively undermining that effort, say people who have supported the Ending the HIV Epidemic initiative, and the administration is considering cuts to roughly $1.3 billion in prevention funding housed at the Centers for Disease Control and Prevention, according to two sources familiar with the discussions.

“The success of the “Ending the HIV Epidemic” initiative is in peril,” said Colleen Kelley, chair of the HIV Medicine Association’s board of directors, referring to the initiative launched by the first Trump administration. “Not only will we not end the HIV epidemic with the current administration’s policies, we could reverse these gains and go back to the dark days of the ’80s, when people died from HIV every day.”

Even before the threats of cuts, actions taken by the Trump administration in the last two months had put HIV services providers on their heels. Trump’s executive orders have essentially sought to eliminate transgender people from the federal government’s health programs and have targeted funding for programs that mention “diversity, equity and inclusion,” efforts advocates say have an outsize impact on the dramatic goal he set during his first term.

Several organizations that provide HIV testing and treatment services have had their federal grant funding threatened for violating the executive orders by serving trans people or highlighting those efforts in their programs’ names or descriptions. While those organizations continue to receive funding thanks to preliminary injunctions in lawsuits challenging the executive orders, the orders themselves foreshadow the direction the administration intends to go in policymaking.

The CDC has also stopped collecting data regarding trans people, including in HIV surveillance systems, and paused public awareness campaigns about HIV. And the administration has canceled at least 20 National Institutes of Health grants funding HIV research, including projects studying health disparities and stigma in HIV prevention care.

The irony is that Trump is essentially undercutting an initiative launched by his first administration, advocates say. Federal agencies have sent billions of dollars to state and local governments and health departments and local organizations to expand access to prevention and treatment resources.

The Ending the HIV Epidemic initiative “provided additional money — probably the first real increase to federal funding for HIV in years — because the president and his administration wanted to try to do something that would try to address the epidemic in the United States and drive down new infections,” said Jennifer Kates, director of global health and HIV Policy at KFF, a health policy organization.

The reversal of those policies, she said, is “going to make it harder to reach the goals the administration has set. It would mean a certain group of people would not be able to receive those services.”

Thanks to antiretroviral therapies, far fewer people are dying of AIDS today than during the height of the epidemic. About 8,000 people in the U.S. die every year from HIV-related illness, compared with the height of the epidemic in 1995, when about 50,000 people died.

Medications also prevent infection in people who may be at high risk. But the remaining challenge has been connecting with people disproportionately affected by HIV who are less likely to access services because of systemic racism, stigma and other barriers.

Key populations

Priority populations identified by the 2022-2025 National HIV/AIDS strategy include gay, bisexual and other men who have sex with men, Black and Latino men, Black women, trans women, people between the ages of 13 and 24 years and people who inject drugs. Many of those populations, particularly trans people, have been targeted by the administration, including through an executive order making it the policy of the federal government that “sexes are not changeable” and that it is a “false claim that males can identify as and thus become women and vice versa.”

HIV is prevalent among trans people; 14% of trans women have HIV. Black trans women are especially impacted, with 44 percent having HIV.

“I don’t know another condition that has such a disproportionate impact on marginalized communities,” said Oni Blackstock, a physician who helped lead the HIV response in New York City, with a focus on health equity.

“These policies are directly impacting our ability to end the HIV epidemic because they’re targeting all of the programs and research that is working towards ending the epidemic. … It’s all about sort of marginalizing and erasing certain groups. And by no surprises, [these] are the same groups that are affected disproportionately by HIV.”

At the heart of the Ending the HIV Epidemic initiative was a strategy to direct federal resources to parts of the country with the highest prevalence of HIV infections. It was designed to target limited federal resources to where they would have the most impact, setting the goal of reducing new HIV transmissions by 90% by 2030 through increased access to testing and pre-exposure prophylaxis (PrEP), which prevents HIV infection, rapidly linking people with new HIV diagnoses to treatment, public awareness campaigns and more.

Funding

Funding community health centers and local organizations that have built trust in their communities was a key part of the initiative.

Now those organizations worry that they will be forced to ignore certain populations in order to retain federal funding.

“We’re in a wait-and-see pattern for a lot of these programs right now,” said Carl Baloney Jr., CEO-elect of AIDS United, a nonprofit focused on ending the HIV epidemic in the U.S.

Grantees have received letters from the CDC and the Health Resources and Services Administration stating they must terminate any parts of their programs that conflict with the executive orders. But they haven’t received guidance about what that means.

Some organizations have removed language from their websites or stopped outreach to some populations for fear of losing significant federal funding.

It has created a chilling effect across the HIV-care continuum.

“It’s so unclear and so nebulous that I think folks are forced to be even more cautious than maybe even the law requires,” Baloney said.

Some organizations, including the San Francisco Community Health Center, had been informed that their grants were canceled.

The San Francisco group’s $400,000 CDC grant, awarded to connect adult trans women of color to HIV prevention services, was temporarily reinstated as part of an ongoing lawsuit, but the center had been told the funding was canceled in line with Trump’s executive “gender” executive order.

The CDC also terminated a $1.6 million grant for an HIV prevention program at St. John’s Community Health, a network of community health centers in Southern California, before an injunction blocked grant cancellations.

Organizations are also unsure how to interpret what DEI means, or whether they can continue outreach programming that seeks to connect trans people to HIV testing, treatment and prevention.

Organizations serving people with HIV are also awaiting an April 1 deadline for the CDC to renew prevention grants, with fears the money won’t come.

Adding to the confusion is the silence from the CDC due to an ongoing communications pause launched at the beginning of the Trump administration.

Some staff working with grantees on HIV work have been fired — likely part of department-wide cuts at the Department of Health and Human Services.

Data collection

The CDC has also stopped collecting data about trans people accessing HIV services.

While the initiative’s data dashboard previously tracked various HIV statistics for trans women, trans men or other gender identities, it now only includes men and women.

“That’s the whole underpinning of the Ending the HIV Epidemic initiative,” said Adriane Casalotti, chief of government and public affairs with the National Association of County and City Health Officials. “Let’s look at the data and figure out where the most impacted populations are and target our resources there. That work has been incredibly important and valuable.”

Now, without the CDC collecting that data, officials wonder if it’s a violation of the executive orders to collect it themselves so they know how best to use their limited resources.

The environment has also discouraged people from seeking care, Casalotti said.

The Trump administration had removed several government webpages mentioning trans people, including several related to HIV. The website for the initiative removed “transphobia” as a driver of potential HIV resurgence.

While a federal judge ordered the administration to reinstate the pages, many now have a notice at the top stating that it does not “reflect biological reality and therefore the Administration and this Department rejects it,” and some of the language around trans people is still missing.

It’s a sharp departure from the Biden administration, which aimed to improve health care for trans people in the U.S., including by increasing access to HIV care, though the former president also faced criticism for not going far enough.

“Some folks who would normally receive these services are experiencing fear or dropping out of care due to safety concerns about their identity,” Casalotti said.