Trump's plan to end HIV transmission requires gaining the trust of the people he's trying to help

By | March 24, 2019

In the middle of Washington, D.C.’s H Street Corridor, between a cellphone shop and a wine bar, lies a building where passersby can see only their reflections when they try to peer through the windows — protecting the privacy of people within. The name of the health and advocacy organization, HIPS, is spelled out in pink, outlined in part by a human body’s silhouette.

Many of the people who enter HIPS have engaged in sex work and drug use, are homeless or transgender, and come to sit away from the cold for a while with a cup of coffee or a snack. They can do laundry, shower, or use the Internet. They also can obtain addiction treatment, pick up clean needles and condoms, or receive medication to prevent and treat infectious diseases, including HIV.

HIPS is just 1.3 miles away from the Capitol where, over the course of the next year, Congress will decide whether to meet President Trump’s request for $ 931 million toward the goal of ending HIV transmission in a decade. Organizations like HIPS show the difficulty of serving people who could benefit most from additional funding — they often are the hardest to reach and have nowhere else to turn.

HIPS staff even drive a van packed with supplies to neighborhoods throughout the city. Alexandra Bradley, the HIPS mobile services manager, said that too often the people they serve are dismissed by outsiders as “undesirable and disposable.”

“It’s a gross way to look at fellow community members and certainly doesn’t respect the humanity or the pathways to where people get where they are,” she said. “There are folks from a lot of different backgrounds who contract HIV, but I’m not sure that everybody is looked at the same way as our clients are.”

Advocates for HIV patients and many Democrats have welcomed Trump’s funding request to bolster the work on the ground, but many remain deeply skeptical of the administration, particularly because of its record on LGBT rights. Trump’s budget also calls for cuts to Medicaid, the government program that pays for poor people to have prescription drugs that treat and prevent HIV. The funding request for the HIV initiative assumes no changes to Medicaid, administration officials said, but proponents of extending Medicaid say it could be a huge help in the fight.

“I certainly appreciate the number, but I don’t appreciate what they are doing,” said Del. Eleanor Holmes Norton, D-D.C. “You don’t put a number out there with one hand and literally snap it back with the other.”

Trump officials have stressed that they want community organizations like HIPS to drive the work, with the federal government ready as a partner to assist.

“We need to earn people’s trust, I understand that,” said Dr. Brett Giroir, the assistant secretary for health. “We are prepared to do that.”

The Trump administration’s plan, rolled out in recent weeks, is to reduce HIV transmission by 75 percent in five years and by 90 percent in 10 years. Washington is one of the its “hot spots” for HIV reduction, but it already has extensive on-the-ground programs that have yielded results.

An estimated 13,000 people, or 1.9 percent of the population, are HIV-positive. It’s a high rate compared to other parts of the U.S., but it’s also a drop from its 3 percent peak less than a decade ago. The Trump administration will have to expand some of the lessons that Washington and HIPS have learned to other cities and neighborhoods to have success, despite the cultural and political differences.

To be sure, Trump administration officials have already taken positions not traditionally associated with Republicans. Health and Human Services Secretary Alex Azar has sanctioned the use of needle exchanges; Dr. Jerome Adams, the surgeon general, once persuaded then-Gov. Mike Pence to adopt needle exchanges in Indiana during an HIV outbreak. And Dr. Robert Redfield, the Centers for Disease Control and Prevention director, is an AIDS researcher whom Azar has credited with “making all of this happen.”

The officials frequently call stigma the “enemy of public health” and refer to addictions involving intravenous drugs, which cause 10 percent of HIV transmissions, as a disease rather than as a moral failing.

“My goal is to help people, to make them healthier and improve their quality of life,” Giroir said. “I don’t care about anything else. And nobody here cares about anything else except doing the right thing … If you have the opportunity to eliminate a disease, I mean really eliminate a disease, it’s not just an opportunity, I think it’s a moral obligation to do so.”

But critics see mixed messages. Redfield took a controversial position supporting mandatory HIV testing during the AIDS epidemic in the 1980s. Azar has defended the Trump administration’s move to cut off funds from organizations like Planned Parenthood that help pay for HIV testing. The Department of Justice sued to block a nonprofit organization in Philadelphia from opening a facility where drug users could inject heroin and illicit fentanyl under medical supervision. City health officials supported the move to reduce overdose deaths and curb HIV.

The administration faces a difficult battle. Its HIV initiative focuses on getting people onto medication, but people with HIV are at risk of getting infected avoid the medical system for a lot of reasons. They fear being judged by a doctor, are uninsured, or don’t have transportation, housing, or a place to store medication if they can get it.

A study of transgender women in New York found the side effects of prevention drugs were debilitating and that patients grew overwhelmed with taking another pill alongside hormone therapy. People who get HIV through illegal activity particularly worry about what might happen to them if they seek treatment. That’s why organizations like HIPS advocate for decriminalizing sex work and loosening drug laws to improve public health.

“The constant cycle in and out of arrest and incarceration is a serious public health issue in every single way possible: in terms of housing, in terms of financial stability, in terms of safety,” Bradley said.

The D.C. government and organizations like HIPS view it as essential to address those kinds of social factors, as well as to have the freedom to try new approaches to reducing HIV transmission. More than 694,000 people live in the District, but Congress has the power to override the laws here, and it’s happened with HIV efforts before.

For almost a decade, Congress banned D.C. from using city funds to run a needle exchange program, worrying about enabling more drug use or making the problem worse. The opposite happened when the ban was lifted: From 2007 to 2017, new HIV infections tied to drug use plunged from 150 cases to just 7 cases.

“I can point to people who died because the Congress kept us from doing needle exchange,” Holmes Norton said. “That was a life and death — or to put more bluntly — a death rider, or amendment, that was put on the District of Columbia.”

D.C. made a lot of other changes to reduce HIV infections. It created a program through which people who test positive get care, even if they don’t have coverage. It partnered beginning in 2010 with the federal government’s National Institute of Allergy and Infectious Diseases to study HIV and improve prevention, testing, and treatment.

The city runs a campaign on buses known as “U=U,” or “undetectable equals untransmittable,” to tell people that if they take medications to suppress HIV, then they can’t transmit it to others. A team of minority, gay, bisexual, and transgender health workers teach residents about HIV medications.

In 2017, 368 more people were diagnosed with HIV in D.C. That’s far from where it was in 2007, when 1,362 people were newly diagnosed with HIV.

“We’ve got the numbers to show this can work,” said Michael Kharfen, who oversees the efforts for D.C.’s health department. “So here’s an example right here in [the federal government’s] backyard that tells you that there is a community committed to ending this epidemic.”

After hearing from Trump’s health officials, he believes they’re committed, too.

“I see this as genuine,” he said. “I truly do.”