Despite extraordinary achievements in addressing the 35-year-old HIV crisis in the U.S., the future of billions of dollars in federal support funds for people living with and at risk for the virus could be in jeopardy when a Republican Congress and president are sworn-in this January.
That money is a lifeline for approximately 1.2 million Americans as well as a funding source for prevention initiatives which are helping to reduce new infections.
How the new GOP controlled government will fund and address HIV in the U.S., and with international aid, is unclear.
"It's a little bit hard to know exactly what a Trump administration will do," said William McColl, health policy director at the Washington D.C.-based AIDS United. "There's very little information about what particularly Trump believes about HIV."
Key among the issues, said McColl: The future of the Affordable Care Act and the funding of the Ryan White CARE Act.
"We know they are going to move forward on repealing the ACA," said McColl. "That's not very helpful to people living with HIV."
Republicans, including President-elect Donald Trump, campaigned on a platform to repeal the ACA. That could result in millions of recently insured Americans being dumped off insurance rolls. So far the GOP has not produced any solid plans on what they would replace the law with, although Trump himself has said he would be interested in retaining some aspects of the law, such as the pre-existing conditions coverage rule. That requires insurers to provide insurance to a person regardless of a pre-existing condition, such as HIV infection.
"They're not going to have the teeth to enforce that, or the premiums will be so high it won't be worth spending the money," McColl said of potential conservative alternatives to the ACA.
Also casting a shadow over the conversation — the role of Vice President-elect Mike Pence. The former Indiana governor and congressman has a long history of antipathy, if not outright hostility to LGBT people and HIV issues in particular. His campaign website from his successful 2000 bid for Congress contained the following statement on HIV:
"Congress should support the reauthorization of the Ryan White CARE Act only after completion of an audit to ensure that federal dollars were no longer being given to organizations that celebrate and encourage the types of behaviors that facilitate the spreading of the HIV virus. Resources should be directed toward those institutions which provide assistance to those seeking to change their sexual behavior."
In other words, Pence wanted to fund reparative therapy for people who engaged in same sexual behavior. Pence also was sitting as governor when the largest outbreak of needle borne HIV happened. Months into the crisis, which ultimately resulted in over 180 new cases of HIV in a community that had traditionally reported five cases a year, Pence finally approved a needle exchange program — after much "prayer," as national media outlets reported.
Trump has announced Pence will oversee the administration's domestic policy agenda. While Pence's call for full funding for the Ryan White CARE Act, which provides the majority of public HIV care dollars in the U.S., is notable to a point, the current GOP Congress has passed legislation cutting Ryan White funding. Right now there are two separate funding bills providing dramatically different cuts to programming including elimination of Title X family planning dollars.
President Barack Obama had sought $2.3 billion for the program.
If significant cuts, or outright elimination, of Ryan White funding happens, it could have a devastating impact on Michigan's HIV efforts, state officials said.
Last fiscal year, Michigan appropriated millions for HIV prevention and care services including drugs, said Jennifer Eisner, spokeswoman for Michigan Department of Health and Human Services. Thirty-five percent of the funding, $18.7 million, comes in from Ryan White funding from the feds. That funding has remained "flat for the past several years."
The state puts up $9 million in state budget dollars in required matching funds to access the federal dollars. That money comes from the Michigan Health Fund Initiative. That fund was targeted in 2013 by former GOP national committeeman and former State Rep. Dave Agema, R-Grandville. Agema proposed eliminating the fund — the sole source of Michigan's HIV funding match dollars — and shifting the funds to support airport upkeep. Agema is a retired airline pilot.
The remainder of that funding is expended in the AIDS Drug Assistance Program. ADAP accounts for $21.5 million in spending, of which $12.5 million is obtained through federal appropriation. The remainder of the cash is garnered through drug rebates provided by pharmaceutical companies providing HIV medications.
"State funding alone would not be sufficient to cover the current HIV Care expenditures," Eisner said. "With the tremendous advances in HIV care, life expectancy of those living with HIV will continue to increase requiring continued and increased funding overtime."
The Michigan Legislature is highly unlikely to appropriate more dollars to address HIV in the state.
McColl said he is more hopeful that the Ryan White program could be spared significant cuts or reductions — although it has already been hit by budget deal sequestration cuts which have held the budget stagnant.
"We do hear a fairly strong commitment to Ryan White programs," McColl said. However, the GOP has nationally indicated a distaste for "single disease programs," he said.
Sean Strub, a longtime HIV advocate and executive director of the Sero Project, said what will happen in addressing the epidemic under a Trump administration remains unclear, other than basic suppositions.
"The short answer is that I don't know what the impact of a Trump administration will be on HIV generally, other than the assumption we are all making about less funding, more hostile environment, dangerous and repressive new initiatives," he said in an email.
But he said national efforts to modernize HIV-specific criminal laws on a state by state basis have been met with bipartisan support. He said he expects that the growing political involvement of people living with HIV will play a crucial role in protecting HIV funding on federal and state levels and addressing HIV criminal laws.
"We've already seen such a tremendous upswing in the engagement of PLHIV (People Living with HIV/AIDS) in the political processes, as evidenced by the increased number of people participating in AIDSWatch, turnout for HIV is Not a Crime conference, interest in and growth of networks of PLHIV," Strub said. "The heightened threat of a Trump administration will only make that engagement so much more critical."
