Trump Pledged to End H.I.V. But His Policies Veer the Other Way.

WASHINGTON — In his State of the Union address, President Trump announced a bold plan to end the scourge of H.I.V. by 2030, a promise that seemed to fly in the face of two years of policies and proposals that go in the opposite direction and could undermine progress against the virus that causes AIDS.

In November, the Trump administration proposed a rule change that would make it more difficult for Medicare beneficiaries to get the medicines that treat H.I.V. infection and prevent the virus from spreading.

Mr. Trump has repeatedly urged Congress to repeal the expansion of Medicaid under the Affordable Care Act, even though Medicaid is the largest source of coverage for people with H.I.V. And he has promoted the sale of short-term health plans that skirt the Affordable Care Act, even though such plans usually exclude people with H.I.V.

To end the spread of the virus, federal health officials say they must reduce the stigma attached to gay men and transgender people who are at high risk so they will seek testing and treatment. But for two years the administration has tried to roll back legal protections for people in those groups.

Those opposing moves by the administration have AIDS activists baffled.

“The president’s announcement comes as a surprise, albeit a welcome surprise,” said Jennifer C. Pizer, the law and policy director at Lambda Legal, a gay rights group. “It represents an about-face on H.I.V. policy.”

The administration describes the plan to end the spread of H.I.V. as one of the most important public health initiatives in history. But the record shows a rather large gap between the administration’s words and deeds.

Since Medicare’s outpatient drug benefit began in 2006, the government has required prescription drug plans to cover “all or substantially all drugs” in six therapeutic classes, including antiretroviral medicines to treat H.I.V.

In November, the Trump administration proposed a new policy to cut costs for Medicare by reducing the number of drugs that must be made available to people with H.I.V.

The proposal would allow certain exceptions to the requirement for Medicare drug plans to cover all drugs in the six “protected classes.”

Insurers could require Medicare beneficiaries to get advance approval, or “prior authorization,” for H.I.V. drugs and could require them to try less expensive medications before using more costly ones, a practice known as step therapy.

People with H.I.V. and doctors have condemned the proposals.

Bruce Packett, the executive director of the American Academy of H.I.V. Medicine, representing doctors who care for H.I.V. patients, said the administration’s proposals “could be catastrophic” for Medicare patients with the virus, as well as for the president’s campaign to end the epidemic.

“At least 25 percent of all people living with H.I.V. who are in care in the United States rely on Medicare as their insurer,” Mr. Packett said.

Those patients are 65 or older or have disabilities and often have other chronic diseases or conditions, so doctors need access to the “full arsenal” of medicines to treat H.I.V., Mr. Packett said.

Many of the Medicare patients with H.I.V. are taking medicines for their other conditions, so doctors have to worry about drug interactions, Mr. Packett said. In addition, he said, some have drug-resistant strains of H.I.V., and different patients often respond to the same drug in different ways.

“It’s important that providers have access to all the available options” among drugs to treat H.I.V., he said.

Requirements for prior authorization and similar restrictions can delay the start of treatment. Studies show that a rapid start to therapy, within a week or even a day of diagnosis, produces better results for patients and reduces the likelihood that they will infect others while waiting for treatment.

“You can’t end H.I.V. with treatment and prevention if you put prior authorization and step therapy on H.I.V. drugs,” said Carl E. Schmid II, the deputy executive director of the AIDS Institute, a public policy and advocacy organization.

Trump administration officials say the proposal would allow Medicare to use tools widely employed by private insurers. But patients say a number of commercial insurers have been forced to change their drug benefits after they were found to discriminate against people with H.I.V.

Medicaid covers more than 40 percent of people with H.I.V. who are receiving care. Some, including people with disabilities, are also covered by Medicare. The expansion of Medicaid under the Affordable Care Act has contributed to a nationwide increase in coverage for people with the virus.

Congress rejected numerous proposals to repeal the Affordable Care Act in 2017. But in his budget last year, Mr. Trump again asked Congress to repeal the expansion, and he proposed $1.4 trillion in Medicaid savings over 10 years.

He would have given states a choice between lump-sum federal payments, known as block grants, and limits on the growth of per-capita Medicaid costs. Both options would squeeze funds available to combat the spread of H.I.V.

Alex M. Azar II, the secretary of health and human services, said the Trump administration’s campaign against H.I.V. would focus on 48 counties where about half of new infections occur. Eighteen of the counties are in states that have not expanded Medicaid: Florida, Georgia, North Carolina, Tennessee and Texas.

The administration has not said how it will help cover the cost of medications to prevent H.I.V. among uninsured people in those states. A daily drug regimen known as PrEP, for pre-exposure prophylaxis, helps block infection among people who do not have H.I.V. but are at high risk of getting it. The pills sell in pharmacies for an average cash price of more than $1,600 for a month’s supply, according to the drug price website GoodRx.

Mr. Trump has encouraged the sale of “short-term, limited-duration” insurance plans that are exempt from the coverage requirements of the Affordable Care Act and are much cheaper than plans that comply with the law.

White House officials called these plans “an attractive option for the nearly 30 million uninsured, or people with gaps in employment and those most hurt by rising premiums and a lack of affordable coverage.” The growth of the market for these plans “benefits society by allowing greater choice and lower-cost coverage,” a report issued last week by the White House said.

But the short-term plans often refuse to cover people with H.I.V. Some do not cover prescription drugs, which are essential in any effort to end the spread of H.I.V.

A typical question on an application for short-term insurance asks consumers if they have tested positive for H.I.V. or received treatment advice or medication for H.I.V. infection in the past five years.

In a recent study analyzing 38 short-term plans, the Kaiser Family Foundation found that people who said they had H.I.V. were rejected in every case.

Short-term insurance would generally not meet the needs of someone with H.I.V. because of the limits on benefits, particularly for prescription drugs, and high out-of-pocket costs, the Kaiser study said.

Describing their plan to end the epidemic, Trump administration officials said it was necessary to remove the stigma that surrounds H.I.V. so people would not be afraid to seek testing and treatment. Prejudice against gay people contributes to the stigma, they said.

The Centers for Disease Control and Prevention said the stigma often leads to discrimination, and as an example it pointed to the case of “a health care professional refusing to provide care or services to a person living with H.I.V.”

The agency’s website says that transgender people may be at higher risk for getting or transmitting H.I.V. One reason, it said, is that “many transgender people face stigma, discrimination, social rejection and exclusion that prevent them from fully participating in society, including accessing health care, education, employment and housing.”

But the Trump administration has stepped back from efforts to fight such discrimination.

Administration officials said last year that they were planning to roll back a rule issued by President Barack Obama that prevents doctors, hospitals and health insurance companies from discriminating against transgender people.

And the Justice Department has told courts that a civil rights law that bans job discrimination based on sex does not protect people who suffer discrimination because of their lesbian, gay or transgender status.

“If this administration wants to combat the spread of H.I.V., they need to immediately end their efforts to cut Medicaid funding, undermine the Affordable Care Act and license discrimination against the people who are most at risk,” said David Stacy, the chief lobbyist at the Human Rights Campaign, which presses for the rights of lesbian, gay, bisexual, transgender and queer people.