The writers of the Trump administration’s “American Budget” for the coming fiscal year give themselves a pat on the back in advance, touting the plan on the front page as “Efficient, effective, accountable.” Just as cutting funding for effective tuberculosis programs led to resurgent TB infections and multidrug-resistant TB, this budget, by targeting effective public health programs and access to health care, will lay the ground for increases in new HIV infections and a resurgence of HIV-related illness and death.
Budget priorities that lead to these outcomes are inefficient, ineffective, and unconscionable. The plan lays out sweeping cuts to crucial public health services and policies that will impact the health of millions of Americans, and especially people with HIV.
The White House plan undermines our public health systems and policies in a manner that is dangerously disruptive to our hard-won progress toward ending the HIV epidemic. Through steady scientific progress, people living with HIV can expect normal or near-normal lifespans and not transmit the virus to others if they are diagnosed, in care, and receiving successful antiretroviral therapy that keeps the virus suppressed. People can avoid HIV infection by taking pre-exposure prophylaxis (PrEP), which requires medical supervision. To achieve the goals of the National HIV/AIDS Strategy, we must expand – not jettison – effective programs. The Trump budget marks an abrupt departure from these goals, increasing the odds that instead of receiving the services they need, people living with HIV will fall through the cracks.
By attacking the Patient Protection and Affordable Care Act, the budget plan undermines access to health care for people with HIV and millions more, with repercussions for access to HIV testing, PrEP, and HIV care, and treatment for substance use and mental health issues. After numerous attempts to repeal and sabotage the ACA, it is no surprise that dismantling the legislation – including Medicaid expansion – is one of the first priorities under Health and Human Services in the Trump budget plan. The plan would take us back to “junk insurance” with premiums but without protections. It would enable states to allow insurance offerings without preexisting conditions protections or essential health benefits such as prescription drugs or emergency care, and with lifetime caps on spending. Repealing the ACA would jeopardize coverage for as many as 20 million people who were newly insured under its provisions, including thousands with HIV.
While more than 40 percent of people living with HIV who are in care count on Medicaid for their health coverage, the White House plan challenges the most basic tenets of Medicaid’s safety net role, promoting work eligibility requirements and seeking to restrict access to medications. Medicaid helps ensure effective care for people with HIV by providing access to all antiretroviral treatments recommended by federal guidelines based on effectiveness and safety, rather than blindly restricting access based on cost. That a public program like Medicaid would deny HIV care and treatment to someone who is unable to work illustrates not only a fundamental lack of commitment to the program’s purpose, but a baffling failure to grasp that the HIV epidemic is a public health crisis that requires effective care for all persons with HIV to preserve their health and to stop transmission of the virus.
While obstructing access to routine health care, the plan also threatens programs that meet specific needs of people with HIV. It would eliminate two effective and efficient initiatives of the Ryan White HIV/AIDS program: the Special Projects of National Significance program and the AIDS Education and Training Centers. The Special Projects program advances and evaluates innovative service delivery models for challenges that include treating patients coinfected with HIV and hepatitis C and integrating medication for addiction treatment into HIV clinics. The AIDS Education and Training Centers program is critical for building and maintaining HIV medical provider capacity at a time when we already lack a sufficient workforce to care for the ever-increasing numbers of persons living with HIV.
Under Trump’s plan, domestic HIV prevention would be cut by $34.6 million, and the Centers for Disease Control and Prevention’s Global AIDS Program by $58 million. The Trump budget also would slash the CDC’s overall discretionary funding by $878 million, jeopardizing many effective public health programs that provide preventive care, screening, referrals, and linkage to treatment. And at a time when novel biomedical approaches to HIV treatment, prevention, cures, and implementation science are both promising and urgently needed, the plan would cut funding for the National Institute of Allergy and Infectious Diseases by $111 million.
The White House plan proposes $40 million to support a new CDC Elimination Initiative for intensive prevention, screening, treatment, and referral efforts to jointly address intersecting diseases including HIV, viral hepatitis, sexually transmitted infections, and TB, but the plan robs existing HIV prevention programs to pay for the new initiative, through budgetary sleight of hand that is neither efficient nor effective. The plan does acknowledge the growing opioid crisis with a proposed $10 billion in new funding directed toward addiction and mental health treatment and services, yet in that proposal makes no mention of the epidemics of HIV and hepatitis C that follow the spread of injection drug use, another missed opportunity for efficiency and effectiveness. Unraveling the fabric of programs that people with HIV and millions of other Americans count on, the White House budget plan would be damaging and costly if passed -- immediately for those whose lives urgently depend on reliable access to health care, and in the long run for all Americans.
Our dramatic progress toward improving the health and quality of life for people with HIV is deceptively and frighteningly fragile, depending as it does on continuous access to health care and medications, and public health programs that are already underfunded and often inadequate. Moreover, these cuts are guaranteed to widen existing health disparities, including the disproportionate rate of HIV among African-Americans, gay and bisexual men, trans persons, and persons living in the U.S. South.
This budget will be efficient and effective only in fueling the HIV epidemic, and it surely will not be accountable to taxpayers with HIV or a host of other serious medical conditions, whose health and lives hang in the balance. In pursuing this budget, the administration proves once again that ending the HIV epidemic is not a priority, nor are the lives of people with HIV.
Accountability for the public’s health and the ability to prevent the dangerous outcomes wrought by this budget now lies in the hands of Congress. Efficient, effective, accountable: These words do not describe this budget, but they do describe HIV advocacy. Once again, silence equals death and we must jam the phones and halls of Congress to ensure that our leaders feel their accountability acutely.
MELANIE THOMPSON, MD, is chair of the HIV Medicine Association and principal investigator of AIDS research at the Consortium of Atlanta.