President-elect Trump on global health and HIV

Secretary of State John Kerry hosts a high-level meeting on global AIDS with PEPFAR partners at the United Nations General Assembly in 2013.

Today is World AIDS Day. A new Republican administration convenes in January. So it’s a good time to look at what the next four years means for American-led global-health programs, particularly efforts to combat the HIV crisis. The U.S. and the world are watching.

Will President-elect Trump make changes to PEPFAR, the President’s Emergency Plan for AIDS Relief? The U.S. initiative is a multilateral global commitment to saving lives and achieving an AIDS-free future. The prospect of Trump making cuts to the program has many health experts fearful.

In a November 9 Council on Foreign Relations online letter, Laurie Garrett, senior fellow for global health, noted that the British journal Lancet created a website tracking the U.S. elections and its impact on global health.

“Terrific detail can be found there,” said Garret, about the website. “Though in fairness to Republicans it is clear the Lancet folks were not enamored” with Trump.

The signs are worrisome, according to Mitchell Warren, executive director of the AIDS Vaccine Advocacy Coalition, a New York-based organization founded in 1995 by nine HIV treatment activists.

“During the U.S. election campaign, plenty was said about emails and sexual harassment,” said Warren, in a November 25 article on (DW), the German broadcaster Deutsche Welle’s website. “But there was little or no talk on global health or HIV.”

President George W. Bush signed PEPFAR into law in 2003, with strong bipartisan support from the U.S. Congress.

“HIV/AIDS is one of the greatest medical challenges of our time, said President Bush, when signing the PEPFAR bill. “The legislation launches an emergency effort that will provide $15 billion over the next five years to fight AIDS abroad.”

Thirteen years later and many experts consider PEPFAR a success. However, there have been challenges. A studypublished in the May 2016 issue of Health Affairs found that abstinence programs in Sub-Saharan Africa have failed.

Despite roadblocks, PEPFAR’s achievements since 2003 have been dramatic, with more than:

  • 68.2 million people receiving HIV testing and counseling, including 14.7 million pregnant women,
  • 1 million babies born HIV-free,
  • 9.5 million men, women and children receiving life-saving antiretroviral treatment,
  • 8.9 million men receiving voluntary medical circumcision, and
  • 5.5 million orphans and vulnerable children receiving care and support.

Today, PEPFAR is a generous $57 billion global-health juggernaut. (Add the United States Leadership Against HIV/AIDS, Tuberculosis and Malaria Act, and total funding exceeds $72 billion.)

“Thanks to a spate of scientific advances, this decade could be the beginning of the end of the HIV/AIDS epidemic,” reported STAT News in July.

President Obama marks World AIDS Day in 2011 by announcing plans to boost U.S. efforts to fight AIDS at home and aboard.

President Obama continued to support PEPFAR, and, despite eight tough years of partisan wrangling on Capitol Hill, his administration pushed through many advances in global health and development. The Pentagon led an international military mobilization against Ebola, and the Obama administration strengthened the Global Health Security Initiative and launched the Global Health Security Agenda, which coordinates the global effort to standardize disease surveillance and response spelled out in the International Health Regulations.

For 2017, PEPFAR’s budget request is $5.2 billion. Will a President Trump, bolstered by renewed conservative GOP armor in both houses of Congress, maintain the initiative’s staggering momentum? It’s vital that he does, not only for the benefit of its recipients overseas, but for American workers as well.

Though estimates are scarce, PEPFAR employs–either directly or indirectly, in both the public and private sector–tens of thousands Americans.

The State Department implements the program. Key agency coordinators include the U.S. Agency for International Development, the Department of Health and Human Services, the Center for Disease Control and Prevention, the departments of defense, commerce, and labor, and the Peace Corps.

Add to that list the National Institutes of Health, the Health Resources and Services Administration, the Food and Drug Administration, and the Substance Abuse and Mental Health Services Administration–and decreases to PEPFAR’s labor requirements by Trump could impact scores of American workers.

However, some health experts choose to focus on small nuggets of hope in Trump and his Vice President-elect Mike Pence, the deeply conservative and devotedly religious Indiana governor.

“Politics is cyclical,” said Naomi Seiler, an associate research professor at George Washington University, at a World AIDS Day 2016 panel at GW’s Milken Institute School of Public Health.

Democrat or Republican, its normal for policies to be renegotiated, realigned and reaffirmed with every new presidential administration, said Seiler.

HIV/AIDS care delivery and awareness was an exception to the rule in the 1980s and early 90s, said panelist Dr. W. David Hardy, senior director at the Whitman Walker Clinic. But today, said Hardy, the American public is more accepting of the public health model championed by HIV/AIDS that’s shown that effective funding and resources can beget worthy results.

One panelist even finds optimism in Pence.

In 2015, when an HIV outbreak sprung seemingly out the blue among intravenous drug addicts in small, rural and poor Scott County, Indiana, Governor Pence, said Dr. Richard J. Wolitski, director of the Office of HIV/AIDS and Infectious Disease Policy, (eventually) responded admirably.

Pence’s first reaction to the endemic was to pray, according to an August 2016 article in the New York Times. But in short order, Pence approved a needle exchange program, along with drug therapy and aggressive outreach, slowing “the flood of new HIV cases to a trickle.”

But as the AIDS Vaccine Advocacy Coalition’s Warren indicated about the 2016 presidential campaign, there is little indication of what Trump will do about global health or HIV.

However, at an October 2015 press briefing in New Hampshire, when a college student asked Trump whether he would support PEPFAR, he seemed to suggest he wouldn’t make changes. The student, whose name was not revealed, began his question to Trump by saying how successful PEPFAR has been.

“Would you commit to doubling the number of people on treatment to 30 million by the year 2020?” asked the student.

Though candidate Trump did not particularly reference PEPFAR in his response, he mentioned AIDS and seemed to commit to PEPFAR in a general way. “Well, I like committing to all those things. Those are great things–Alzheimer and AIDS–but the answer is yes. I believe so strongly in that. And we are going to lead the way.

A clinic on the outskirts of Kampala, Uganda, that receives money from the United States through PEPFAR for AIDS prevention. (Photo: Rodney Muhumuza, Associated Press)

One year later, will President-elect Trump stick to his word?

Even as Trump’s views rotate toward conservative GOP ideology the closer we get to inauguration day, he has altered his positions on domestic healthcare a number of times, both pre- and post-election. In April, the Washington Postreported that Trump changed his position on abortion five times in just three days.

And what of the Affordable Care Act, or Obamacare, the health reform law that Republicans have demonized ever since it was enacted in 2010? Trump and his fellow 2016 GOP presidential candidates, together with Republicans in Congress, have made it clear that repealing the law will be one of their first initiatives in 2017. Now Trump is not so sure.

“Either Obamacare will be amended, or repealed and replaced,” he told CNNfour days after the November 8 election, acknowledging that it was Obama, who met with Trump in the Oval Office for 90 minutes, who encouraged him to reconsider. “I told him I will look at his suggestions, and out of respect, I will do that.”

If ACA is repealed, an estimated 22 million people, many of them poor and older, will lose their health insurance, according to a November 28 New York Times editorial. After his meeting with President Obama, Trump seems open to compromise. The key word is “seems.”

And if Trump so easily flips-flops on domestic healthcare policies like abortion and ACA, what can be expected on the global HIV crisis? Which brings us back to World AIDS Day.

Absent a crystal ball into Trump’s HIV/AIDS global plans, today is a day for action. Whether partnering with the ONE initiative to empower women to take action, or working with the International Medical Corps to relieve suffering, or volunteering with the CDC to rally a domestic response, World AIDS Day inspires small and large acts of hope every December 1, and throughout the year, for achieving an AIDS-free future.



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