donald trump stannds at podium, Pelosi and pence visible behind him.
President Donald Trump proposed an initiative to eliminate HIV transmission by 2030 during his 2019 State of the Union address. Screenshot courtesy of WhiteHouse.gov

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By Yen Duong, Rose Hoban and Taylor Knopf

In his State of the Union Address Tuesday night, President Donald Trump vowed to end the transmission of HIV infections in the United States by 2030.

“My budget will ask Democrats and Republicans to make the needed commitment to eliminate the HIV epidemic in 10 years,” Trump said during his Tuesday address. “We have made incredible strides. Together we will defeat AIDS in America and beyond.”

If the Trump administration intends to make that happen, then southern states are likely to be high on the list of those places receiving federal attention.

In 2017, people from the South made up more than half of all the new HIV diagnoses in the country, while North Carolina had the 6th highest number of new HIV infections in the nation. Three Southern states – Florida, Georgia and Louisiana – have the highest rates of infection in the country.

In 2017, 52 percent of new HIV diagnoses were made in southern states. Data, map courtesy: Centers for Disease Control and Prevention

And while welcoming the news of the initiative, local advocates said there’s some level of skepticism about significant action coming from an administration that has pursued policies they see as hostile to some members of their communities.

Mecklenburg targeted

“Most infections are now highly concentrated in certain geographic hotspots,” wrote Health and Human Services Sec. Alex Azar in a blog post that went live late Tuesday. “New infections are highly concentrated among men having sex with men; minorities, especially African Americans, Hispanics/Latinos, and American Indians and Alaska Natives; and those who live in the southern United States.”

At the center of the plan is a strategy to target 48 counties in the U.S. with the highest rates of HIV; one of those is Mecklenburg County. According to Azar’s blog post, targeting will result in additional federal funds for each of the “hotspots,” enhanced data analysis of patterns of spread, and targeted prevention and treatment.

At the end of 2018, 6,792 people in the county were living with HIV, said Matthew Jenkins, who manages HIV/STD community services for the county health department.

Graphic from Alex Azar’s blog post about Pres. Trump’s “Ending the HIV Epidemic: A Plan for America” shows the regions targeted by the administration in an attempt to reduce new infections by 75 percent in five years and by 90 percent within a decade.

Jenkins also pointed out that syphilis cases more than doubled between 2013 and 2017, from 107 to 251 cases diagnosed per year.

“Sometimes we talk about HIV and we don’t mention syphilis, [but] HIV and STIs go hand in hand,” Jenkins said.

In Charlotte, steps to fight HIV infections have been underway with the “Getting to Zero Mecklenburg” plan, which started in 2018 but unlike Trump’s plan has no set target date.

The Mecklenburg plan to eliminate new HIV infections includes offering education, free testing and PrEP, a medication that, taken daily, has been shown to prevent HIV transmission, to uninsured and low-income HIV-negative people.

The Mecklenburg health department pays six providers to provide medical services to high-risk people, who then receive the prescription for free through a medication assistance program, Jenkins said.

In contrast to other parts of the U.S. where transmission tends to be higher in urban areas, in the South, 23 percent of new cases are identified in suburban or rural areas. So, the department will also expand to Gaston, Cabarrus, Union and Anson counties using state funds.

“Treatment as prevention” is the final pillar of the Mecklenburg plan, Jenkins said.

“Once an individual has been diagnosed with HIV, the earlier we can get them in and linked to care and started on treatment, the better,” Jenkins said. Once they’re treated, they’re less likely to spread the virus.

While Mecklenburg’s rate stands out, overall, North Carolina had 1,315 new HIV infections in 2017, and there were a total of 35,045 people living with HIV in the state, including those diagnosed elsewhere.

Data, graph courtesy: Centers for Disease Control and Prevention

African-American and Latino men who have sex with men have the highest rates of new HIV infections in North Carolina in 2017, with rates of 2,150 per 100,000 and 830 per 100,000 respectively while, newly diagnosed HIV infections among injection drug users in North Carolina are predominantly among white males.

Among women, African-Americans have the highest rate, with 17.1 per 100,000 newly diagnosed in 2017.

Skeptical partners

“If we’re going to tackle the HIV epidemic, we have to center this work in the communities that are facing the highest rates of new transmission, and that’s African- American communities, LatinX communities, with gay and bisexual young men and in the trans community,” said Lee Storrow, head of the North Carolina AIDS Action Network. “All of those are communities that Donald Trump and his administration have attacked and stigmatized in other public policy issues that they’ve worked on for the last two years.”

Instead, the Trump administration needs to support the LGBTQ community and people of color, “if we have any hope of ending new HIV transmissions by 2030,” Storrow wrote in a statement.

Storrow also said that state lawmakers should take the president’s challenge to end HIV seriously and expand Medicaid, which would expand access to treatment as prevention, as well as provide medications for HIV and hepatitis C patients.

In addition to policies around gay and transgender communities, the administration has been viewed skeptically in the HIV advocacy community because of disarray on the President’s Advisory Council on HIV and AIDS. Six of the council’s 25 members resigned early in Trump’s tenure in office, and at the end of 2017, the rest were dismissed by the administration. Throughout 2018, the council had no members at all until two new chairs were appointed just before the new year.

U.S Surgeon General Jerome Adams was the health director in Indiana when a large outbreak of HIV driven by injection drug use occurred in a southern county. Adams told health officials in Raleigh recently that while heeding the science is important, it’s key for public health leaders to take a community’s culture and wishes into account when making public health interventions. Photo credit: Rose Hoban

In December, an announcement in the Federal Register noted that a full meeting of the PACHA would take place this March, with briefings for “new Council members.”

Street cred

Despite skepticism from advocates, some members of the Trump administration have considerable credibility when it comes to reducing HIV transmission. Prominent among them is U.S. Surgeon General Jerome Adams who served as the state health commissioner of Indiana during the infamous Scott County HIV outbreak, which started in 2011 and was attributed primarily to people who were injecting drugs and sharing needles and syringes. The outbreak spiraled out of control with a total of 215 new HIV diagnoses before public health leaders were able to step in in 2015 to arrest the spread.

Adams spoke in Raleigh last month and told public health leaders they need to work with their local communities to optimize syringe exchange programs to prevent the spread of HIV and hepatitis C.

While he worked with the Centers for Disease Control and Prevention and other experts to get the Scott County outbreak under control, Adams told North Carolina health directors, “I put my butt on the line to get a syringe exchange program approved so that we could stop the HIV outbreak.”

Adams said that it was just as important for him to drive from Indianapolis and spend time out in the rural county where the outbreak was happening. There, he met with local businessmen, faith leaders and the sheriff, and listened to their concerns before he shared the research behind needle exchanges and other harm reduction strategies.

Robust harm reduction measures have resulted in significant drops in HIV rates among drug users in Europe and Canada, such as syringe exchanges and drug consumption rooms. Both promote safe injection habits and the use of clean supplies.

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