Safer Solutions: Is It Time to Defund HIV Prevention?
One early casualty of the Trump administration’s efforts to shrink the federal government was funding for USAID, a global program whose work includes supporting HIV prevention and treatment efforts abroad. Additionally, the U.S. President’s Emergency Plan for AIDS Relief—known as PEPFAR—is struggling to survive after massive cuts to the once-popular bipartisan initiative. Now rumors are growing that the administration will pivot its America First approach internally, weighing funding cuts for domestic HIV prevention programs. Taken together, these moves put Americans at greater risk—and are likely to cost more money than they save over the long term.
Why are treatment and prevention important?
In the 44 years since HIV entered medical awareness, it has gone from an untreatable, fatal harbinger of acquired immunodeficiency syndrome (AIDS) to a preventable chronic illness. While this transition is unquestioningly a medical success, there is more work to be done. In 2022, almost 32,000 Americans became infected with HIV, and, in total, about 1.2 million Americans are currently living with HIV. Unfortunately, up to 46 percent of those are not receiving routine care and about 13 percent are unaware of their diagnosis. Not only is this treatment gap a problem for these individuals’ health, but it also represents a challenge to prevention efforts.
If taken as prescribed, modern HIV medications can suppress the virus to levels undetectable by standard lab tests. This is critically important because being undetectable not only improves health—it also means that the virus cannot be spread to others in the community, colloquially known as U=U, or undetectable equals untransmittable. This means that consistent access to HIV medication is a key element of preventing new HIV cases. In other words, HIV treatment is also a form of prevention.
For people without HIV, the gold standard for preventing infections is pre-exposure prophylaxis, commonly known as PrEP. When taken as prescribed, PrEP is 99 percent effective at preventing HIV infection from sex and 74 percent effective for preventing infection from injection drug use—the two primary ways people acquire HIV. Ensuring that people who could benefit from PrEP can access it is key to preventing new HIV infections. In fact, studies have shown that higher rates of PrEP usage among people who need it are associated with fewer HIV diagnoses.
Cuts will cost us
The administration’s proposed cuts to HIV prevention and treatment are ironic, given that such programs were a priority during President Donald J. Trump’s first term. In his 2019 State of the Union address, Trump announced the Ending the HIV Epidemic in the United States (EHE) plan with the goal of decreasing new infections by 75 percent by 2025 and 90 percent by 2030. EHE increased funding for HIV-related programs—programs that the Trump administration is now rumored to be putting on the chopping block.
Although slashing domestic HIV funding is being framed as a cost-saving measure, years of data provide evidence of taxpayer savings. Moreover, although evaluating progress toward the EHE goals is tricky because HIV data lags by several years (the most current data on PrEP usage and new HIV diagnoses is from 2022 and 2023, respectively), we can say confidently that we are making progress toward ending the HIV epidemic. But we may not reach the EHE goals on the ambitious timeline laid out by the president during his former administration.
The possibility of not reaching the EHE timeline targets is not a reason to back down from its goals, however. When it comes to eliminating infectious diseases, progress is almost always slow. Consider the fact that only two infections, smallpox and rinderpest, have ever been eradicated and, despite active efforts since 1988, polio is still not eradicated worldwide. Not to mention the resurgence of measles due to decreased vaccination rates. That said, we are making real progress on HIV. PrEP usage has increased and estimated new HIV infections are declining. What we are doing is working.
Of course, progress always has costs; but, so does inaction. The United States spends 67 percent of federal HIV funding ($28.7 billion annually) on medical care for people living with HIV. Medical care, which is mandatory spending through Medicare and Medicaid, is also the main driver of growth in HIV-related spending. Furthermore, federal spending on HIV is less than 1 percent of the overall federal budget, and only 3 percent ($1.1 billion) of HIV funding is spent on prevention efforts. But funding prevention efforts is money well spent, as most prevention programs that have been evaluated are cost-effective, even if they are expensive. For HIV, specifically, money spent on prevention pays dividends compared to money spent on continued care.
Federal budget and spending decisions are never straightforward. When it comes to HIV, we cannot afford to step away from prevention efforts. Although funding HIV-related programs might not feel as urgent as it once did, a probable rebound of the virus would affect everyone. Simply put, defunding prevention represents a departure from making America healthy again.