President Donald Trump surprised many in his State of the Union address when he announced a bold goal of ending the HIV epidemic over the next decade.
It is rare to see HIV at the top of the headlines these days. For the past two years, virtually all of the communities most heavily affected by HIV have been under seemingly unending attack. Whether it is the denigration of people of color, incitement against immigrants, aggressive actions against transgender people, along with other LGBTQ people, and the shaming of women and others seeking to protect access to contraception and reproductive choice, the communities bearing the heaviest burden of HIV often have experienced open hostility from this administration.
So there was a sense of whiplash and not a little distrust when this unexpected announcement was made.
Unexpected, but still welcome. Now the focus turns to what is in the plan and how it is resourced.
As HHS Secretary Alex Azar testifies this week before Congress on the administration's budget priorities, we have an opportunity to better understand their plan. The administration is proposing significant increases in discretionary funding for HIV programs, with $291 million in funding for this initiative in the next fiscal year. This suggests a serious effort, but it cannot come at the expense of cuts to other HIV programs, or cuts to programs for other groups that would divide people with HIV from other deserving communities. Money is only part of the response, and policies must be aligned to keep us moving forward and not back.
I know a little about what it takes to end the HIV epidemic. I served as President Barack Obama's HIV/AIDS adviser and coordinated his efforts to produce our country's first comprehensive National HIV/AIDS Strategy, which was released in 2010, shortly after the enactment of the Affordable Care Act.
The strategy was updated in 2015, and the Trump administration is currently working on the next five-year update, presumably centered around their plan for ending the epidemic.
In some ways, the path to ending the HIV epidemic is quite simple. We need to identify all people with HIV, get them into care and onto treatment. If people are on treatment and virally suppressed, they can stay healthy and can't transmit infection to others sexually. We also need to make sure that effective pre-exposure prophylaxis, or PrEP, is available without hassles for all who need it, along with recommended screenings and clinical care.
Currently, only about one in 10 people for whom PrEP is recommended are accessing it. Post-exposure prophylaxis, or PEP, also has a role in certain circumstances, which allows people to stay HIV-free if they get quick access to medical care following a potential exposure and take a month-long course of treatment.
To do all of these simple things, however, care needs to be affordable and accessible, and we need to create climates of trust in which people feel safe seeking health care services. We need to invest in communities so that known community voices (including health care and social services providers) are serving as trusted entry points for accessing services. We need to counter HIV stigma and fight discrimination, and we need to stop criminal prosecutions against people with HIV.
While there is much to like about the Trump plan, the administration's actions are not fully consistent with achieving its success. After remaining stable for a period of many years, new HIV infections declined by 8 percent annually from 2010 to 2015. I credit the ACA with part of that success, yet the administration has been unrelentingly hostile to the law.
Several years ago, the Centers for Disease Control and Prevention estimated that only one in four people with HIV in the United States had achieved viral suppression. While still too low, they now estimate that half of all people with HIV have met this mark. The focus is shifting not to whether individuals have ever achieved viral suppression, but whether we can support people to stay on their treatment regimens and maintain durable suppression over time.
Again, what we need to do is quite simple. We need to make the care experience as hassle-free as possible, as every problem or glitch, whether it is a rude receptionist in a doctor's office, a long wait to get an appointment, an insurance plan denial, or an unexpected co-payment at a pharmacy counter, is a chance for the health system to fail in ways that lead people to stop treatment - and that in turn interferes with the durable viral suppression needed to end the epidemic.
A proposed policy change in Medicare would move us in the wrong direction. An estimated one in four people with HIV are covered by Medicare. Last year, the administration proposed to modify a special protection in Medicare Part D that requires drug plans to cover all or nearly all drugs in six classes for serious conditions such as cancer, mental illness, multiple sclerosis and HIV. This extra level of protection mandates that insurance plans cannot subject HIV antiretroviral medications to prior authorization.
The proposed changes would allow for the exclusion of new formulations of drugs which could limit access to promising long-acting HIV treatments that are under development, but not yet approved for use. If implemented, plans could newly require prior authorization and increase the hassle factor that causes interruptions in HIV treatment. Some plans may want to gain a reputation as a difficult plan for people with HIV, to avoid them as enrollees.
Moreover, prior authorization and step therapy (wherein a person has to first try one medication before getting approval to use another) are generally not clinically appropriate for managing HIV. If people with HIV are required to use a regimen that may have side effects or contribute to other health problems, their health could suffer. If individuals are forced to take medications that make it harder to adhere to daily treatment, they could develop resistance, which could limit their ability to use not only one drug, but whole classes of drugs or drug regimens. In addition to this serious personal cost, fostering resistance through short-sighted pharmacy denials has larger public health implications. These seemingly small changes could be extremely harmful.
Trump can build a legacy of leadership on HIV. As he and his team strive to take a leap forward toward ending the HIV epidemic over the next ten years, Secretary Azar should withdraw the proposed Medicare drug plan changes so as to not take a step back by introducing uncertainty and new access barriers to the critical HIV treatment provided by Medicare.
ABOUT THE WRITER
Jeffrey S. Crowley is the program director of infectious disease initiatives at the O'Neill Institute for National and Global Health Law at Georgetown Law. From 2009 to 2011, he served as the director of the White House Office of National AIDS Policy. While the O'Neill Institute receives financial support from Gilead Sciences, the company had no involvement in this op-ed.
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