An HIV Policy Expert Explains What Trump’s HIV Policy Might Look Like
It’s hard to know exactly what President-elect Trump has planned for his administration’s HIV policy because his website makes no mention of it — an alarming omission considering that there’s 1.2 million Americans and 36.7 million world citizens currently living with HIV. So we talked to Ben Plumley, Chief Executive Officer of Pangaea, an international HIV organization that works with funders and national governments to help at-risk populations — like men who have sex with men (MSM), drug users, sex workers, incarcerated populations, teenage girls and young women — get equitable access to HIV prevention, testing, treatment and care.
Although Pangea works internationally with international funders and governments, Plumley says, they promote evidence-based approaches to HIV reduction that scale to the community’s needs and value their human rights.
“Human-rights-based approaches are ones centered on giving people the tools to manage their own health. If you’re going to manage your health around HIV risk, you need to be as free as possible from the stigma associated with being [an at-risk population]. … If you persecute and criminalize behaviors and natures, then you drive the epidemic underground and you lose all hope of containing it. All it does is make it harder to reach people … harder to make information available on ways to minimize HIV infection. Apart from being morally wrong, it’s profoundly counterproductive.”
During our conversation, we focused on three areas: 1) how Trump’s nationalism might affect his global HIV policy, 2) his Vice President-elect Mike Pence and 3) his Secretaries of State and of Health and Human services, all of which could have an impact on the President’s Emergency Plan for AIDS Relief (PEPFAR), an international aid program created in 2003. It should also be added that Trump’s promise to repeal the Affordable Care Act could end access to HIV-medication for millions of people.
The following interview has been edited for clarity and length.
Trump’s “America First” approach
Ben Plumley: HIV knows no boundaries. So, HIV may be re-surging in parts of Africa, but it doesn’t mean that we are going to be immune from that.
I had the privilege to work with the late ambassador Richard Holbrooke — the guy who negotiated the Dayton agreement to end the Balkan Wars in the ‘90s — and he understood the importance of infectious disease as a national security issue. If we let HIV go unchecked, it will be destabilize countries. HIV targets the economically productive people in the prime of their years. If those people die or are incapacitated, we create generations of orphans, we don’t have people working in factories, generating incomes like we had wanted and we really run the risk of disrupting and destabilizing the concept of nation-states in many countries. And it’s not restricted purely to sub-Saharan Africa where you have vulnerable states. Infectious disease can come in and further destabilize them.
In my mind, HIV far from being the mass epidemic of the 20th century is one of the greatest challenges to the 21st century. It thrives on globalization. It thrives on the interconnectivity between societies and precisely because it plays to the most sensitive of human behaviors, it can be the hardest thing to tackle. And of course, unlike the infectious diseases we see coming out of Hollywood (films) where everyone dies in two or three days, you can be unaware of your HIV status for up to a decade, and that can mean that you can infect a number of people, you will be completely unaware of the threat to your own health. You may not know that you’re sick until your immune system has been severely compromised.
So in many ways, you can say that HIV is finely attuned to challenge the human experience, the whole human way of life. It’s really not, the HIV doesn’t suit soundbites. It’s a long-term issue that requires a long-term state strategy. Policy makers looking for quick fixes, the blunt truth is there is no quick fix when it comes to HIV.
Trump has said he would “stop sending foreign aid to countries that hate us” — presumably that applies to countries that currently receive PEPFAR funding, no?
We really don’t know. Throughout the course of the election campaign, a number of activist groups reached out to both campaigns to understand what their strategies were. We received absolutely no information and no response from the Trump campaign, so we have no information at all.
I think there are a couple of things that can be said. The first, slightly more positively, is PEPFAR was created under the presidency of George W. Bush, and in the countries in sub-Saharan Africa it generated very significant goodwill towards the United States. These are countries that are economically not very important but nonetheless remain allies of the United States. So you could argue that PEPFAR was very sound investment in preventing the spread of radical Islam or radical anti-Western attitudes in sub-Saharan Africa. And so I think that in any advocacy we have with the administration, we would want to show that investment in PEPFAR was a sound investment in U.S. security and U.S. reputation internationally.
On the other hand, we do know that far-right groups like the Heritage Foundation have been developing strategies really for the last few years, precisely at the opportunity when you have a a Republican Senate and House of Representatives and Presidency to change the very nature of the way development aid is provided so that you move away from what might be termed a liberal human rights-based approach and turning towards relying on faith-based organizations, anti-abortion priorities front and center, and which are anti-harm reduction, specifically against needles-sharing programs for drug-users.
Just an interesting footnote. Russia has been a country that has taken a very repressive strategy towards drug users and of course has seen huge rates of increase of HIV in those populations.
Vice President-elect Mike Pence
Let’s talk about Mike Pence. He’s anti-LGBT and voted to defund HIV/AIDS programs in his home state.
Pence is an interesting character because on the first glance he doesn’t look like an ally…. He has been extremely pro-gay conversion therapy. As you rightly said, he has refused to adopt and support evidence-based interventions for key populations when he was governor of Indiana. He was a supporter of PEPFAR, he voted for it. He certainly wanted to see more emphasis on the role of faith-based organizations, the importance of abstinence as a prevention strategy.
Do abstinence-only approaches help reduce HIV?
No. During the course of the last couple of years, there were a number of reviews done by the CDC that showed that abstinence-only strategies provided no benefit. That being said, if you understand abstinence to mean as part of a comprehensive prevention stratetgy along with condoms, PrEP and sexually reproductive health education, then it certainly has its role. But as an intervention on its own, it has absolutely no benefit whatsoever and that is proven in the literature.
How about faith-based initiatives? Lots of religious charities do HIV work, but do they come with strings attached for LGBT people?
My experience of the last 25 years in sub-Saharan Africa is that many faith-based organizations, particularly the Catholics and the Anglicans the Methodists and some of the other Protestants have, through their medical services, done extraordinary things when it comes to access of treatment. They have made access to treatment a priority regardless of where people come from. Now, of course, in Sub-Saharan Africa, a majority of the transmission is heterosexual, so that might have made things slightly easier for them, but they have certainly been at the forefront of providing access to treatment.
When it comes to prevention though, the issue is completely different, and opposition to condom distribution, support of abstinence-only education has been really problematic. The faith-based communities to a large degree have… we have really relied on them in terms of treatment and have not been able to engage them in any meaningful way on prevention. Perhaps that’s one of our big collective failures of the last 20 years.
A real concern for all of us is to make sure that the far-right religious preparations for development aid are really challenged in the Trump administration as it develops its overall strategy. Now, I’ve not heard any re-commitment to gay conversion therapy in any of this, but clearly a concern must be that with many of Trump’s supporters on the religious right supporting that approach we have to make sure that strategies that have been funded by the U.S. government, trying to bring in key populations and men who have sex with men, bringing them into HIV testing, into prevention, into care — that those aren’t threatened by a re-commitment to gay conversion therapy.
Pence ended up with an HIV outbreak among intravenous drug users in his home state. That doesn’t bode well for his approach, doesn’t?
But the story of Indiana is also one that he was forced to come around and understand that evidence-based interventions had to be used when you have a crisis. The administration (eventually) allowed for the use of needle exchange in the so-called hot spot areas. They were supposedly used for a limited time only, but define limited in the context of an HIV outbreak. There’s no getting away from this. This happened under his watch and it happened because his administration did not value the importance of evidence-based intervention to reduce HIV infections with injection drug use.
And I think one of the things we need to engage with the Vice President on is his understanding of what it takes to be part of government. He’s been a governor in Indiana so he has experience of having to make tough decisions in tough environments so none of this to demean or detract at all from what is really not an encouraging record on the issues of concern to us, but I think our job is to engage with him and engage with him as someone who has had experience of government and who has to balance values with evidence. This is something we need to watch and watch very closely.
Trump’s secretaries who oversee federal HIV/AIDS programs
We know that Price is anti-abortion, once voted to block U.S. funding for a needle-sharing program and is a member of a medical group (the Association of American Physicians and Surgeons) that doesn’t think that HIV causes AIDS, though we don’t know if Price personally shares that view. What do we know about his approaches to HIV?
Price is important because of investments in ADAP (the AIDS Drug Assistance Program, a program that provides FDA-approved medications to low-income people living with HIV) and Ryan White (the Ryan White CARE Act, the largest federally funded program in the U.S. for people living with HIV and AIDS). I think the big concern domestic HIV-groups have would be a significant reduction in funding for those programs which will mean that people who rely on the government for their anti-retrovirals may well be at risk of having those lost. So a key priority for domestic HIV-groups is really to press him in understanding how he will uphold ADAP and Ryan White.
Certainly in terms of prevention, I think people are gearing themselves up for an extended debate over the utility of PrEP. Again if you’re dealing with particular faith-based groups that see abstinence as the only method of HIV-prevention, we really run the risk of there being a major dis-investment in PrEP programs which are funded by federal agencies. So as well keeping an eye on making sure that treatment is invested in, perhaps the biggest risk is limiting the availability of PrEP in federal programs. Yet again, it’s going to be an issue of those who can afford it have access to it.
Is there anything else we should be keeping our eye on?
PEPFAR is going to sit under the auspices of the Secretary of State (Exxon CEO, Rex Tillerson). So we are obviously concerned about the implications of the Secretary of State for global AIDS response. So far we don’t know much information about the new guy. When we were looking at Mitt Romney and Senator (Bob) Corker, these were all people we thought we could do business with.
Unfortunately we’re in a wait-and-watch scenario. We’ve got to be prepared to fight very assertively for the rights-based and evidence-based approaches and at the heart of those respecting the rights and dignity of gay men. I think we’ve just got to be prepared. I think it is absolute foolishness for us to think that Trump will be too busy building his wall to be worried about global AIDS and LGBT rights. I think he has a lot of allies in his party and very closely aligned with his administration for whom these are indeed major issues. And while he himself seems not to be so bothered, we really have to be on top of what this means for public policy.