By Tim Fitzsimons
President Donald Trump’s announcement Tuesday of a new federal initiative to “eliminate the HIV epidemic in the United States within 10 years” has sparked both cautious optimism and flat-out skepticism from experts and advocates.
According to an overview released by the Department of Health and Human Services, the proposal overhauls the federal government’s HIV/AIDS plan and brings it more closely in line with cutting-edge models pioneered in places like New York City, San Francisco and Washington, D.C. HIV diagnoses there have fallen sharply, thanks to well-funded public health initiatives that quickly link HIV-positive people to treatment and refer at-risk individuals to take PrEP, or pre-exposure prophylaxis, to prevent them from being infected with HIV.
“The president sees a once-in-a-generation opportunity to end the epidemic, thanks to the most powerful HIV prevention and treatment tools in history, and new tools that allow us to pinpoint where HIV infections are spreading most rapidly,” Health Secretary Alex Azar said in a statement.
While veteran HIV/AIDS public health officials say it is indeed possible to end the epidemic with new tools, others say the devil is in the details — of which there are currently very few.
DETAILS OF THE PLAN
In a conference call with reporters Wednesday, HHS Assistant Health Secretary Adm. Brett Giroir outlined a four-point plan for driving down new HIV infections by 75 percent in five years and 90 percent by 2029: diagnose, treat, protect, respond.
‘We are going do diagnose all people as early as possible, we are going to treat the infection rapidly and effectively, we are going to protect those at highest risk, we are going to respond to any outbreaks with overwhelming force,” Giroir said.
These goals emphasize “biomedical interventions” — public health lingo for the new methods — beyond condoms, that officials hope can drive down new infections from 40,000 in 2017 to 4,000 by 2030.
“We now have the tools that, if applied, could have a major impact on our goal of ending the HIV epidemic in the U.S.,” said Dr. Anthony Fauci, head of the National Institute of Allergy and Infectious Diseases at the National Institutes of Health. “You could theoretically end the epidemic as we know it, and that is our goal, and the question is implementing it.”
Some of these tools are already working because cities and states have rolled them out on their own. Before the introduction of PrEP in 2012, the annual number of new diagnoses was roughly 50,000; now it’s closer to 40,000. And the Affordable Care Act has provided more people access to top-tier HIV drugs that can prevent a person living with HIV from transmitting the virus to their sexual partners, a paradigm named “undetectable = untransmittable” or TasP (treatment as prevention).
A fifth point provides for the creation of “a local HIV health force” in each of seven targeted states and 48 targeted counties, plus Washington, D.C., and San Juan, Puerto Rico. These teams would be the project managers “committed to the success of the initiative in each jurisdiction.”
The targeted focus is in response to the geographic disparities in the American HIV epidemic. In 2016 and 2017, more than 50 percent of all new infections occurred in D.C., San Juan, the 48 target counties and the seven target states — Missouri, Kentucky, Oklahoma, Arkansas, Mississippi, Alabama and South Carolina — according to information released by the HHS. The seven states shoulder a disproportionate burden of HIV diagnoses in rural areas.
The plan also calls for the Centers for AIDS Research, or CFARs, to play a greater role. These NIH-funded institutes, embedded within universities and medical schools across the country, research ways to better fight HIV by leveraging cutting-edge clinical research, behavioral science to improve adherence to medication, and local activist networks.
HOW IT MIGHT SUCCEED
The federal proposal is similar to one started in New York in June 2014. The state’s Ending the Epidemic plan’s goal is “to reduce the number of new HIV infections to just 750 (from an estimated 3,000) by 2020, and achieve the first-ever decrease in HIV prevalence in New York state.”
New York’s plan calls for finding all HIV-positive people and linking them with care, keeping them linked to health care so their virus remains suppressed and untransmittable to others, and also increasing prevention efforts for HIV-negative people by identifying and linking those at-risk to PrEP.
Four and a half years in, the plan is already having an impact. According to the Ending the Epidemic Dashboard, New York is nearly meeting its goals to increase PrEP use among Medicaid patients, to reduce the number of new infections, and to increase the average viral suppression of HIV-positive people.
New York’s plan is similar to the one implemented in Washington, D.C., where officials halved the HIV rate between 2012 and 2016 in part through a citywide effort to test every district resident and immediately link them to health care and HIV medications.
The federal plan proposes funding the initiative through the existing Ryan White HIV/AIDS program. Ryan White, which pays for the HIV medications and care for a half million people, is associated with high rates of viral suppression. Roughly 90 percent of Ryan White patients have an undetectable level of HIV in their blood, meaning they can’t transmit HIV to their sexual partners. Of the general HIV-positive population in the U.S., roughly 50 percent have undetectable levels of HIV.
It would also provide funnel funds to federally qualified health centers, such as New York City’s Callen-Lorde, which provides LGBTQ-oriented care to at-risk and low-income communities. Planned Parenthood, which provides HIV-prevention services to low income people, is barred from receiving this money because its clinics perform abortions.
In an interview with NBC News, Dr. Demetre Daskalakis, deputy commissioner for the Division of Disease Control at the New York City Department of Health and Mental Hygiene, noted the similarities between the proposed federal plan and New York’s plan.
“The idea that Ryan White [HIV/AIDS program] is a good scaffold on which to build this — it’s true, it’s a great idea,” Daskalakis said. “It’s in the right places, and it does correlate to prevalence.”
In addition, the federal program increases the federal government’s commitment to two extremely effective new HIV-prevention methods: preexposure prophylaxis (PrEP), and treatment as prevention (TasP). Both involve taking daily HIV medications, and both stop the spread of HIV between sexual partners almost 100 percent of the time. Condoms alone, on the other hand, stop HIV transmission roughly 80 percent of the time.
“The bottom line is that a lot of the interventions that the strategy is looking to implement are all biomedical strategies,” Daskalakis said, noting that biomedical strategies have been a major part of New York’s End the Epidemic plan.
In addition, Dr. Harris Goldstein, the associate dean for scientific resources at the Albert Einstein College of Medicine, which is New York City’s regional Center For AIDS Research, said he is encouraged by the proposal to increase funding for all 19 of the nation’s regional CFAR sites.
“Dr. Fauci has referred to us as the boots on the ground for HIV/AIDS in terms of translating the research advances into having an impact in the communities,” Goldstein said, noting that CFAR sites harness cutting-edge advances in HIV treatment, behavioral science to improve health outcomes, and preexisting local networks to improve treatment outcomes.
While Goldstein said his office has yet to learn details of the plan, he noted a conference call was planned for this week to outline details.
HOW IT COULD FAIL
In spite of the unity shown by federal public health officials, activists and Democratic leaders expressed skepticism that the president’s new proposal is offered in good faith.
Corey Johnson, who is speaker of the New York City Council and is HIV-positive, tweeted:
In January 2018, after a string of resignations, the White House fired everyone on the Presidential Advisory Council on HIV/AIDS, and the council has sat dormant since then. Last month, two members of the Air Force were discharged after disclosing their HIV status. And through proposed changes to Medicare, HIV-positive seniors may soon lose access to the newest, most effective, and least toxic treatments.
In a press release, House Speaker Nancy Pelosi, D-Calif., said “the president’s call for ending HIV transmission in America is interesting, but if he is serious about ending the HIV/AIDS crisis, he must end his assault on health care and the dignity of the LGBTQ community.”
The reason for the skepticism is because “you hear different things from different parts of this administration,” said Greg Millett, the vice president of amFAR and an author of President Barack Obama’s national HIV/AIDS strategy.
“We know that the people who are proposing this … these are all evidence-based public health people,” Millett said. And then on the other hand, efforts to remove HIV drugs from Medicare coverage and throw up barriers to Medicaid eligibility, “all of those work against this plan.”
Just a day after the president announced his plan to end HIV, the Department of Justice moved to shut down a Philadelphia safe consumption site for injection drug users. The city has one of the highest injection drug overdose rates in the country, and the site was an effort to reduce overdoses and HIV transmissions by providing naloxone and sterile needles.
The website dedicated to the new federal plan does not contain the word “transgender” and transgender women are at high risk of acquiring HIV. In the conference call, the health officials offered a gentleman’s promise not to discriminate against transgender people even if administration efforts to redefine gender and reduce trans legal recognition are successful.
The plan also contains no details about how to finance a huge surge in spending on extremely expensive HIV medications. Truvada, which is used for PrEP, has a list price of $1,700 per month.
Giroir said the HHS is “not able to provide specific budget numbers at this specific time,” but he added, “we are highly confident that the resources that are being provided in 2020 are sufficient.”
“Nowhere in this plan do I see anything about reducing the cost of PrEP,” James Krellenstein, an activist with PrEP4All, said.
Even in the absence of any details about how the plan will be funded, the plan overview ends on a fiscal note, saying “we can’t afford not to” end the HIV epidemic.
“Without this new intervention, new infections will continue and we face the very real possibility that they will increase, costing more lives and the U.S. government more than $200 billion in direct lifetime medical costs for HIV prevention and medication.”