President Joe Biden marked World AIDS Day yesterday by displaying the AIDS Memorial Quilt on the White House lawn — a historic first — and placing a massive red ribbon on the White House’s southern portico, an annual tradition since 2007. In his speech, Biden noted the over 40 million people still affected by HIV worldwide and he called on states to repeal their outdated HIV criminalization laws to help reduce anti-HIV stigma.
He also noted his administration’s efforts to end HIV/AIDS, including his reauthorization of PEPFAR (the President’s Emergency Plan on AIDS Relief), an African HIV-prevention program; the Food and Drug Administration’s relaxed guidelines allowing gay and bi men to donate blood; his protection of the Affordable Care Act (ACA) which requires insurers, Medicare and Medicaid coverage to pay for HIV treatments, medications, and preventative drugs like pre-exposure prophylactics (PrEP).
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But HIV advocates worry that these efforts could all be threatened by the incoming administration of President-elect Donald Trump.
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The first Trump administration had a mixed record on HIV
Trump’s four World AIDS Day proclamations never explicitly mentioned gay and bi men, and he allowed the Office of National AIDS Policy (an executive advisory task force) to fall apart by terminating all its members and failing to appoint a new director.
In his 2019 State of the Union Address, Trump launched the Ending HIV Epidemic (EHE) Initiative, a $291 million plan to reduce the number of new HIV infections by 75% by 2025 by targeting HIV prevention and treatment in the nation’s highest-risk areas. This plan included Ready, Set, PrEP, a program to give 200,000 uninsured Americans free annual access to daily PrEP.
However, the EHE has fallen far behind its goal. While Biden has continued the plan, between 2019 and 2022, the number of new HIV infections in the U.S. dropped from 35,100 to 31,800, a 9.4% decrease, according to HIV.gov.
In 2018, Trump also signed a five-year extension to PEPFAR, an African HIV-prevention program launched by George W. Bush in 2003 that has been hailed as a successful diplomatic and humanitarian effort. PEPFAR provides antiretroviral treatment for 14.6 million people and has been credited with saving over 25 million lives and preventing children of people with HIV from becoming orphans.
However, Republicans have begun to target PEPFAR, falsely claiming that it’s a “massive slush fund” for promoting abortion and LGBTQ+ advocacy. Additionally, Project 2025, the blueprint for Trump’s second presidency, seeks to reinstate the Mexico City Policy, (also known as the global gag rule), an executive order denying any U.S. funding for global health organizations that provide any information about abortions.
Slashing PEPFAR and reinstituting the gag rule could force international health providers, particularly ones providing reproductive health services to choose between losing funding of providing emergency sexual healthcare for those key populations in conflict and other crisis situations, according to John Plastow, the executive director of Frontline AIDS, the world’s largest partnership of civil society organizations working to end HIV and AIDS.
Trump’s pledge to repeal the Affordable Care Act will doom millions
Trump has also repeatedly pledged to repeal the ACA without any plan for its replacement. Doing so would leave an estimated 21.3 million people without any medical coverage. Without the ACA, young adults between the ages of 18 and 26 would no longer be allowed to stay on their parents’ insurance plan. Additionally, health insurers would be allowed to once again deny coverage to people with HIV and to refuse “essential benefits,” like specific prescription drugs, labs, and mental health services that provide comprehensive HIV treatment.
The ACA’s Medicaid expansion in several states covers healthcare costs for an estimated 40% of all Americans living with HIV. During his first presidency, Trump suggested $1.4 trillion in Medicaid cuts over 10 years by allowing states to choose between a lump-sum federal Medicaid payment (also known as a “block grant”) or a growth cap on their per-capita Medicaid costs. Both would essentially limit the program’s ability to cover HIV medication and treatment.
This year, Republicans have called for massive budget and staffing cuts in HIV care, according to the Bay Area Reporter, including between $500,000 and $800,000 for the Centers for Disease Control and Prevention, $214 million for the CDC’s HIV prevention programs (including the entire budget of EHE), $190 million from Ryan White HIV/AIDS Program, and $15 million from the Health and Human Services Secretary’s Minority HIV/AIDS Fund.
The Ryan White HIV/AIDS Program makes up 12% of the government funding for HIV/AIDS care, and an estimated 52% of all people diagnosed with HIV in the nation utilize the program. Trump’s first administration also proposed an 18% cut to the Department of Health and Human Services (HHS), which cite the program’s maintenance as one of its “highest priorities.”
“Although the funding levels in this bill are far from final and not likely to pass on the House floor, they represent a dangerous move by the House Republican majority to deprioritize support for people living with HIV, women, and people of reproductive age, people of color, low-income individuals, and the LGBTQ community,” Ernest Hopkins, senior strategist and adviser of the San Francisco AIDS Foundation, told the aforementioned publication.
Now that Republicans will have a slim majority in both Houses and Congress, it’s likely that they will try to advance such budgetary cuts. Slashing their budgets would have a trickle-down effect.
If all these people suddenly find themselves without insurance coverage, they’ll need to rely on state, city, and private programs to help pay for medication; but these smaller groups can’t possibly match the millions in funding provided by the federal government.
Some of state and local HIV programs receive financial support from the AIDS Drug Assistance Program (ADAP), a part of the federal government’s Ryan White HIV/AIDS program, which offers services to low-income people living with HIV.
But with a rush on ADAP services, patients with HIV may suddenly find themselves on waitlists before they can afford life-saving medication. This is especially concerning considering that people who receive late and inconsistent HIV treatment have worse health outcomes than those who get early and regular care.
In November 2019, the Trump administration proposed cutting costs for Medicare — the federal medical coverage for people over 65 and those with disabilities — by reducing the number of drugs that the program must make available to people with HIV. Doing so would allow insurers to require Medicare beneficiaries to first get advance approval for certain HIV drugs and possibly undergo “step therapy,” a process of trying less expensive medications before accessing more costly ones.
Such medication restrictions “could be catastrophic” for older HIV patients and Trump’s EHE initiative, Bruce Packett, the executive director of the American Academy of HIV Medicine, a group representing doctors who care for patients with HIV, told The New York Times.
Older patients with other disabilities and chronic diseases often take other medications, increasing the likelihood of possible negative drug interactions, Packett said. Furthermore, some patients have drug-resistant HIV strains or respond to certain medications differently. As such, doctors need access to quicker access to the “full arsenal” of medicines to properly treat HIV, he added.
Cadena and Marnina Miller, co-directors of the Positive WOmen’s Action Network-USA, told The Body, “We may need to set up some kind of Underground Railroad to get [HIV] meds across states for people who really need them.”
Elevating anti-LGBTQ+ voices and conspiracy theorists harm those most in need
In his first and most recent campaigns, Trump also elevated Republican voices that stoke hostility towards queer men, trans women, and people of color — those most at risk of contracting HIV. During his first term, he quietly started firing military servicemembers living with HIV. During his recent campaign, Trump and Republicans lied about legalized Haitian immigrants spreading HIV in Springfield, Ohio, something that public health officials said was untrue.
In May 2019, Trump announced a “conscience rule” pledging legal protection for medical professionals who cite religious beliefs as a pretext for refusing care to LGBTQ+ people. The 2024 Republican platform has repeated this pledge, increasing the likelihood that LGBTQ+ people might not seek HIV testing, medication or treatment for fear of healthcare discrimination.
It’s also unclear if a Trump administration official or a Republican-appointed judge would try to argue, as one has in the past, that forcing insurers and pharmacists to provide HIV prevention or treatment medications violates their religious consciousness.
Project 2025 calls for dismantling large parts of the federal government, including any deemed a “waste” of taxpayer funds; and Trump has nominated Robert F. Kennedy Jr., who has denied that HIV causes AIDS, to head the Department of Health. He has called for Dr. Mehmet Oz, a celebrity lifestyle influencer who has peddled quack cures, to head the Centers for Medicare and Medicaid. Trump has also called for Dr. Marty Makary to head the Food and Drug Administration and Dr. Janette Nesheiwat for surgeon general — both are frequent Fox News contributors.
Collectively, these appointees could dramatically change how these federal agencies operate and help execute Project 2025’s plan of purging any officials who try and resist Trump’s agenda.
Jeremiah Johnson, executive director of PrEP4All, said in a statement to Inside Health Policy that the new Trumop administration will create an uncertain and unpredictable time for federal HIV policy.
“Will he be the Donald Trump who initiated the Ending the HIV Epidemic initiative in 2019, or will he follow House Republican efforts to gut that same essential program?” Johnson asked. “Will he see himself as a champion of helping to develop and deliver biomedical interventions for infectious disease, as he did with COVID, or will he, with RFK Jr. poised to take a leadership role on healthcare in his administration, turn away from science?”
“And within all of this, how will (advocates) address the HIV-related needs of the communities that we know this administration will attack, including migrants and transgender populations?” he asked.
Jeremiah Johnson, executive director of the PrEP advocacy group PrEP4All, told The Body, “One of the worst things we could do right now is to either completely downplay how dangerous this coming era could be—or to overplay it to such a degree that we lose perspective on where we can actually protect ourselves and our community going forward.”
Cecilia Chung, a transgender advocate living with HIV who is senior adviser at the Transgender Law Center, reminded the aforementioned publication that constituents can still play a key role in the coming administration. In particular, she mentioned the upcoming 2025 AIDSWatch in March, an annual meetup in Washington D.C. in which people living with HIV visit the offices of their elected officials.
“We should continue to tell our stories and share with people first-person that there’s a human impact [to any policy changes],” she said.
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