President Trump, in his first term, urged Congress to spend more in the nation’s decades-long fight against HIV and AIDS. “We have made incredible strides — incredible,” the president said to applause during his State of the Union address six years ago. “Together we will defeat AIDS in America and beyond.”
In that speech, he set out one of the most ambitious health policy goals of his administration: End the HIV epidemic in the U.S. in 10 years.
That initiative may now stop five years early. President Trump is back in office with new priorities. The White House budget proposal would roll back next year’s federal HIV prevention funding to levels not seen since around 1987. Much of that funding typically flows to local public health agencies and nonprofits to test for infections, monitor for outbreaks and promote prevention.
No money is flowing at the moment. The administration this month froze at least $460 million for grants to local public health and nonprofits that were scheduled to start June 1.
The president’s reversal is paralyzing HIV prevention work nationwide, advocates, researchers and public health experts told Tradeoffs.
“Does this administration simply want HIV prevention activities to go away, and by extension, want additional HIV infections throughout America?” said Jeremiah Johnson, executive director of the advocacy group PrEP4All. “Because there's simply no explanation of what else this could possibly achieve.”
How the U.S. funds HIV prevention (for now)
The Centers for Disease Control and Prevention is the federal agency that oversees HIV prevention. It has been spending about $1 billion a year on those activities, including roughly $220 million for Trump’s first-term initiative.
The White House is now asking Congress to strip nearly $800 million from that spending. City and state budgets would be squeezed by the loss of those funds, much of which is sent to cities and states to pay for epidemiologists to track infections, for free HIV tests and self-testing kits, and for various types of prevention outreach.
Andrew Nixon, spokesman for the Department of Health and Human Services, said HIV prevention continues to be a high priority for the administration, and critical activities will continue under the new Administration for Healthy America.
The U.S. spends far more on HIV and AIDS treatment — largely through Medicare and Medicaid — than on HIV prevention, even before Trump’s proposed cuts. Public health and infectious disease experts say the nation could save by investing more to stop infections, which costs about $500,000 over a lifetime to treat.
Trump’s proposal would cut HIV prevention under the CDC by 75%, reducing spending to a level not seen since the U.S. launched its first AIDS public service announcement in the mid 1980s.
For anyone old enough to remember the early years of the HIV epidemic, prevention has come a long way. As it became clear the virus could spread by sex and contaminated needles, public health agencies recommended condoms and safe needle exchanges. It was, understandably, an imperfect defense.
“I went through this myself. You hear your whole adolescence and into young adulthood, the best way to not get HIV is to not have sex,” said John Brooks, an epidemiologist and doctor who has spent his career fighting the virus. “Nobody's a saint.”
It was, however, the best defense available for about a quarter of a century. That changed radically in 2012, when regulators approved a daily pill that can block an HIV infection. The treatment is known as PrEP, for pre-exposure prophylaxis.
Brooks, who retired last fall as medical director of the CDC’s HIV prevention division, described PrEP’s discovery with something like awe: “It was astonishing, the potency of this simple intervention.”
Trump’s big swing to end the HIV epidemic
PrEP is critical to Trump’s initiative to end the epidemic by 2030.
By 2019, as the initiative launched, PrEP had been on the market for years, but had failed to take off. Getting more people on this medication is a key strategy to halting the epidemic.
It’s also one of the biggest challenges for reaching the president’s target. The costs involved in taking the medication, including occasional lab work, and the stigma that persists around HIV keep many from talking to doctors about a prescription, say advocates. Some doctors and pharmacies don’t offer the drug, creating what are known as PrEP deserts.
Through last year, Congress has poured $2.3 billion into the president’ initiative, including extra funding to HIV hotspots for PrEP advertising, outreach and screening.
That money is critical if the nation wants to bring the virus under control, said Brett Giroir, one of the first-term Trump health officials who helped get the effort started. But the administration’s backing for the initiative’s ambitious target was crucial, too, he said. “Money without leadership is nothing. You're just throwing it away.”
PrEP use has increased nationwide, to roughly 30% of those who would benefit, up from 22% before the initiative got underway. But that’s still short of the 50% target to meet the initiative’s 2030 deadline for halting the epidemic. One analysis published this year by CDC researchers found no extra gains in PrEP use in places targeted by the initiative. But the authors cautioned that the pandemic disrupted the initiative’s early work, so impact of programs may not be visible yet.
Threats of funding cuts have already stopped some HIV prevention efforts
In Tulsa, Okla., the nonprofit organization called Health Outreach Prevention Education, or HOPE, has made progress in boosting PrEP use, but its successes take time.
HOPE staffs clinics and mobile vans that bring HIV tests and promote PrEP across the city and nearby rural areas — partially funded by the president’s initiative and other HIV prevention grants from the CDC.
Brad Sullivan is one of HOPE’s success stories. He had seen HOPE’s outreach staff around Tulsa over the years, he said, and knew he was overdue for HIV testing and PrEP. But it took his friends having a scare with a sexually transmitted infection to get him to finally talk to a HOPE staffer and start on PrEP.
Had HOPE’s program not existed he might not have gotten tested, Sullivan told Tradeoffs. He would feel too vulnerable to have a conversation about HIV at his primary care clinic. Sullivan is gay and 53. He grew up in rural Oklahoma and attended Christian college before he came out.
“You live with that fear of rejection from loved ones,” he said, “from friends, from people you may just be a casual acquaintance with.”
He didn’t feel that fear with HOPE. “You're going in there and you're talking with people that get it,” Sullivan said.
Hana Fields, HOPE’s outreach manager, said she hears ‘no’ often from people she talks with about PrEP, as she visits spots around the city.
Some tell her they are uninsured and fear they can’t afford the treatment. Others have never heard of it. Many say they can’t travel across town to HOPE’s clinic for the exam and tests they’d need to start the medication.
Despite repeated “no’s,” Fields and her team keep showing up time after time, to get the word out on PrEP and to build trust. Sometimes, eventually, it works, she said. “If you are there enough in a person's life, you will catch them on the day that they're ready to start taking action.”
Much of HOPE’s federal funding is now up in the air. The Trump administration froze the HIV prevention grants from the CDC that were scheduled to start this month.
The HOPE program was counting on that money, and now Taryn Norman, HOPE’s executive director, finds herself poring over the nonprofit’s finances, trying to figure out how long their cash will last.
The worst case scenario, Norman said, would force HOPE to stop some of its work and lay off staff.
Oklahoma last week advised HOPE to limit HIV prevention spending to necessities, Norman said, until the federal government makes it clear when it will release CDC grant funding. Public health agencies elsewhere have taken more aggressive steps. The Arizona Department of Health Services told organizations it funds with CDC grants to stop their HIV prevention work, such as helping people get PrEP prescriptions.
If CDC funding eventually comes through, the state will try to pick up where it left off, the agency said in an email to Tradeoffs, adding “The longer the delay in funding lasts, the harder it will be for organizations to bring services back.” Los Angeles County and North Carolina have also halted funding for local HIV prevention efforts.
Federal turmoil could squander investment, reverse gains
Threats of funding cuts are the latest in White House actions that, combined, would gut the nation’s defenses against HIV, say public health leaders and HIV prevention advocates.
Mass layoffs at the Health and Human Services Department included HIV prevention teams at the CDC — teams needed to do the analysis of HIV infections and PrEP use nationwide. Much of that work stopped with the layoffs, though the agency said this month it would rehire some people who do work on HIV and other sexually transmitted diseases.
Trump’s HIV initiative also poured money into studies of how best to increase PrEP use among high-risk groups, including transgender women, Black women and gay and bisexual men.
But several of those studies abruptly lost funding when the President issued executive orders to eliminate equity initiatives and policies. For studies of LGBTQ+ health alone, the administration terminated about $800 million in research, according to a recent lawsuit.
Congressional Republicans, meanwhile, are pushing ahead with plans for new Medicaid enrollment rules that would remove millions from that safety-net health insurance program. Medicaid coverage is one factor associated with higher use of PrEP, studies find.
“Any hope of ever ending the HIV epidemic is very much tied to a functioning Medicaid program,” said Amy Killelea, an assistant research professor at Georgetown University and public health law expert.
The upheaval also threatens to squander potential progress from a longer-lasting version of PrEP approved by the Food and Drug Administration this week.
The new drug, lenacapavir, is highly effective at stopping infection, as are existing drugs on the market. But other versions of PrEP must be taken daily or, at best, every two months, with schedules that have been hard for some people to maintain. A single dose of Lenacapavir protects against HIV infection for six months. Researchers’ estimates suggest having this sort of less-demanding option available can further reduce infections.
“It really does change things considerably by virtue of its long-acting effect,” said Jim Kublin, a principal scientist at the Fred Hutchinson Cancer Center who is working to develop an HIV vaccine. But the powerful new drug option will need formidable outreach to reach enough people to make a difference, he said, or “its eventual impact will be far inferior to the initial enthusiasm we may have had.”
Tradeoffs is an editorial partner of Side Effects Public Media. To learn more about Melanie Evan's reporting, you can listen to this podcast episode from Tradeoffs.
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Side Effects Public Media is a health reporting collaboration based at WFYI in Indianapolis. We partner with NPR stations across the Midwest and surrounding areas — including KBIA and KCUR in Missouri, Iowa Public Radio, Ideastream in Ohio and WFPL in Kentucky.
