With the transition underway from President Trump to President-elect Joe Biden, advocates in the fight against HIV/AIDS are at a crossroads on whether to hold firm or seek a change in plans as the Department of Health & Human Services is floating an updated National AIDS Strategy that would carry over into the next administration.

The decision on the way forward carries high stakes for people in the LGBTQ community, who continue to become infected at higher rates. As documented by the draft 87-page document made public on Tuesday, gay and bisexual men make up 67 percent of new infections. In new data, the draft report also finds 14 percent of transgender women have HIV, including 44 percent of Black transgender women.

A key component of the draft document, the first update on the National AIDS Strategy since the Obama administration in 2015, is the Trump administration’s plan to end the domestic HIV epidemic by 2030. The cross-agency, PrEP-centric initiative was one of a few policies during the Trump administration that stood out as beneficial to the LGBTQ community, despite an overall anti-LGBTQ record. 

“The HIV Plan covers the entire country, has a broader focus across federal departments and agencies beyond HHS and all sectors of society, and addresses the integration of several key components that are vital to our collective work, including stigma, discrimination and social determinants of health,” the draft report says in the introduction.

Carl Schmid, executive director of the HIV+Hepatitis Policy Institute, said in a statement the updated draft strategy makes additional commitments on the uptake of PrEP, eliminating stigma and addressing disparities in priority populations.

“It is also reassuring to see an emphasis on the integration of efforts related to the syndemics of viral hepatitis, sexually transmitted infections, substance use and mental health along with a focus on stigma and discrimination and the social determinants of health,” Schmid said.

As part of the draft review process, which is set to last until Dec. 14, HHS asks interested parties to submit comments in consideration for the final report. The final report is expected to come out in mid-January 2021, an HHS spokesperson told the Washington Blade. 

In contrast, Biden has campaigned on beating HIV by 2025, although the strategy isn’t as thorough as the plan developed by HHS during the current administration. In his World AIDS Day statement on Tuesday, Biden fleshed out his vision by saying he plans to reinstate the Office of National AIDS Policy, release a new comprehensive National Strategy on HIV/AIDS, and expand support for global programs like the President’s Emergency Plan for AIDS Relief, or PEPFAR, and the Global Fund to Fight AIDS, Tuberculosis & Malaria.

“An AIDS-free generation is not only imaginable, it is within our reach,” Biden said. “And under a Biden-Harris administration, America’s response to the HIV/AIDS epidemic in this moment will match their unparalleled example.”

It remains to be seen whether the Biden plan builds off the Trump plan, including the draft National AIDS Strategy, or scraps those efforts in favor of a new plan. A Biden transition spokesperson referred the Washington Blade to the Biden campaign’s health plan and the president-elect’s statement on World AIDS Day in response to a request to comment.

As proposed by the Trump administration, the National AIDS Strategy breaks down current numbers for HIV/AIDS in the United States, observing the number of new infections, including 36,400 in 2018, has become stable since the 1980s. That stabilization, the report says, has opened the door to combat the disease with renewed focus and coordinated development of the HIV plan, which seeks a 75 percent reduction in new HIV infections by 2025 and a 90 percent reduction by 2030. 

The draft report indicates gay and bisexual men, Black gay and bisexual men continue to face the brunt of HIV/AIDS. The prevalence of HIV is more than 150 times higher in gay, bisexual, and other men who have sex with men and in transgender women than straight men and women.

Gay, bisexual and other men who have sex with men are “the population most affected by HIV in the United States” and make up 61.7 percent of the estimated 1.2 million people with HIV in the United States and 67 percent of the new infections, the draft report says.

Within this group of men who have sex with men, Black men are most severely affected by HIV, accounting for 26 percent of new HIV infections in the United States and 39 percent of new infections among all gay and bisexual men, while Latino men are also heavily afflicted and make up 22 percent of new HIV infections and 33 percent of new infections among gay and bisexual men, the draft report says.

For the first time, the draft report also includes data on transgender women, finding an estimated 14 percent have HIV. Broken down by race, an estimated 44 percent of Black transgender women, 26 percent of Latina transgender women, and 7 percent of white transgender women have HIV. Among the 3 million HIV testing events reported to CDC in 2017, the percentage of transgender people who received a new HIV diagnosis was three times the national average.

With regard to whether or not this plan will carry over into the Biden administration, Schmid said advocates in the fight against HIV/AIDS are in a wait-and-see mode until the transition team announces nominees for the chief health officials for the next administration.

“We’re anxiously awaiting who’s going to be the secretary and who’s going to be the head of CDC and all those agencies because a lot of the leadership was really dedicated and very vocal on HIV and I hope that will continue until the next administration,” Schmid said.

Schmid said he thinks the framework established under the Trump administration is “spot on,” but also was hopeful about the Biden administration because of the president-elect’s commitment to the Affordable Care Act, Medicaid and LGBTQ non-discrimination in health care.

“My hope is that the Biden administration will continue and ramp up this initiative,” Schmid said. “It’s sound, it’s targeted, it’s exactly what we want and it’s exactly what other countries are doing as well. I think they will have some welcome policy changes that could help speed implementation. Biden has already said he wants to end HIV by 2025 and we need to hold him accountable to that.”

Late last month, the Act Now: End AIDS Coalition announced it has reached out to the Biden transition team for a meeting on several concerns related to the federal Ending the HIV Epidemic: A Plan for America initiative. A community-driven policy paper from the coalition highlighted the need for transparency with the HIV community and when allocating resources from the federal government against the disease. 

Edric Figueroa, an Act Now: End AIDS Coalition coalition spokesperson, said the team met with the Biden campaign in September, but hasn’t obtained any explicit commitment or a meeting despite the initial request and a follow-up last week.

Meanwhile, advocates in the global fight against HIV/AIDS are pushing hard for Biden to make new commitments to PEPFAR, which distributes anti-viral drugs to countries heavily afflicted by HIV, including countries in Africa. Trump had repeatedly sought drastic cuts to global AIDS programs, including PEPFAR, although Congress continued to fund the program at existing levels.

The Center for Health & Gender Equity is calling on the incoming Biden administration to make a massive $1 billion investment in PEPFAR in the DREAMS program, the first HIV prevention program aimed at adolescent girls and young women.

CHANGE President Serra Sippel said in a statement the investment “is not only the right thing to do, it is the smart thing to do because it contributes to the overall health and well-being of communities and countries.” 

“CHANGE has consistently heard from young women who are service providers and advocates in Malawi, Tanzania and Zimbabwe, that more resources are needed to ensure that adolescent girls and young women are at the table to design and implement programs and expand DREAMS to more communities,” Sippel said.

If the next administration were to build on the Trump domestic plan, time is running out for Congress to issue the next layer of funding for that. The White House has sought $450 million beyond existing levels for the second year of funding for the plan to end HIV, but Congress has yet to appropriate funds for that or anything else for fiscal year 2021.

Counterintuitively, the Democratic-controlled House, faced with budget caps, declined to provide the additional money for HIV, while the Republican-controlled Senate has proposed legislation that would provide $207 million. It remains to be seen what if any kind of agreement Congress will make on this money before funding for the government writ large expires on Dec. 11.

One issue that appears to have been decided going forward is the reinstatement of the Office of National AIDS Policy at the White House. The position was vacant for the entirety of the Trump administration, but Biden pledged to reinstate the position as part of his World AIDS Day statement.

Early on during the Trump years, six members of PACHA resigned in protest largely over Trump’s refusal to fill the role, saying it demonstrated his lack of commitment to fighting AIDS.

Schmid was undecided when asked by the Blade whether the addition of the White House czar would be helpful in coordinating the fight against HIV/AIDS, or just added bureaucracy.

“It all depends,” Schmid said. “It does provide a central, pivotal focus at the White House for HIV. So, I do think it’s important, and it shows the commitment to HIV.”