The Trump administration’s cuts to the Department of Health and Human Services make the dream of ending the HIV epidemic more unattainable than it has been in years, and public health experts warn it also marks an escalation of the president’s attacks on trans people.
The administration began its drastic overhaul of the HHS last month, which included department secretary Robert F. Kennedy Jr. axing key agencies and federal grants dedicated to HIV prevention, treatment and research. Several initiatives, including funding for HIV services aimed at low-income people and people of color, are set to be eliminated next year, according to a draft HHS budget.
HIV rates have fallen steadily in the United States since the introduction of the preventive medication PrEP, also known as pre-exposure prophylaxis, in 2012. PrEP has the ability to almost completely reduce the risk of HIV transmission, and anti-retroviral medications are able to render the virus undetectable in those living with HIV. Still, almost two-thirds of the 1.2 million people who could benefit from preventive medication are not taking it.
Most of the modern infrastructure for HIV treatment and prevention has been built by and for cisgender white men, while people of color and other LGBTQ+ people often do not have access to the care they need. Trans people make up 0.3% of the United States population, yet they account for 2% of new HIV diagnoses. The World Health Organization estimates that globally, trans people are 13 times more likely to have an HIV diagnosis compared to their cisgender peers. Black and Latina trans women in the U.S. make up the largest share of new HIV infections among trans people overall, according to a study conducted from 2019 to 2021.
The HHS cuts will affect whether trans people can access social safety net programs and exacerbate existing barriers to care for HIV, public health experts say. Trans people already report higher levels of discrimination in health care settings, as well as increased stigma and a lack of health insurance.
Medicaid is the largest insurer of people living with HIV, and roughly 276,000 trans people access health care through that system.
The Centers for Medicare and Medicaid Services proposed a rule last month that would make it more difficult for low-income people to get insurance from plans covered by the Affordable Care Act — and proposed that gender-affirming care would no longer be covered as an essential health benefit, a move that could drive up medical costs for hundreds of thousands of trans Americans.
“I know people are stockpiling not just HIV meds but also gender-affirming care meds. It’s sad, but something that people have to do,” said Yves Chu, an HIV advocate in San Francisco. “This is life or death. I don’t want to see another AIDS epidemic in my lifetime, but it looks as though this administration is willing to let people die.”
“As a transmasculine HIV-positive person, I do feel almost doubly under attack,” he added.
HHS did not immediately respond to HuffPost’s request for comment.
Some of the Ryan White HIV/AIDS programs, which provide direct support for people living with HIV, are completely eliminated in the draft HHS budget for next year.
Under the Biden administration, which adopted a more holistic approach to fighting the HIV epidemic, programs were urged to use the funds to help transgender people living with HIV access gender-affirming hormone therapy, mental health services and housing assistance.
But a Trump official recently issued a letter reversing those recommendations, criticizing the strategy as a “radical ideological agenda.” The letter clarifies that Ryan White programs will be more narrowly tailored to prevention and treatment.
Experts are concerned outreach efforts specifically geared toward trans people could disappear.
“It means that free testing events, or opportunities to get PrEP … all those different tools that we have are going to be minimized and eliminated depending on where you are in the country and what levels of access and transportation needs you have,” said Tori Cooper, director of strategic outreach and training at Human Rights Campaign. “People are going to die, and people are going to be sick when they don’t have to be.”
Cooper was the first Black trans woman to be appointed to the Presidential Advisory Council on HIV/AIDS under President Joe Biden. PACHA, which President Bill Clinton formed in 1995, is a council of experts who offer recommendations and policy advice to the HHS secretary and the director of the White House’s Office of National AIDS Policy. Cooper’s goal when she was appointed was “to be a voice for trans people, gender-nonbinary people and gender-expansive people.” Over the last four years, the council has made recommendations to HHS to have the private sector include more trans people in research, to remove anti-trans riders from HIV funding bills and to ensure that health care providers who receive federal funding are trained in meeting the needs of trans people.
“Technically, I’m still on PACHA,” Cooper said, but, “any second now, we’re looking forward to being terminated by the Trump administration.”
An HHS spokesperson told Reuters earlier this month that the department was going to end the volunteer service of the current council members and had no timeline for replacing them.
Research on the specific challenges to HIV prevention among trans women, trans men and gender nonconforming people has only started in the last five years, meaning experts are still figuring out the most effective strategies and programs to get medication in the hands of people most in need.
Much of the research so far has relied on Centers for Disease Control and Prevention data on trans people and communities with high rates of HIV. That data was already sparse before President Donald Trump returned to office, and his administration has wiped dozens of web pages, studies and data sets that make any mention of gender.
In addition, the administration has canceled dozens of federal grants from the National Institutes of Health, the research arm of HHS. Nearly 29% of terminated grants involved research into HIV and AIDS, according to an unofficial database kept by academics tracking the cuts.
A new study from the University of Michigan shed light on the effectiveness of trans-inclusive HIV research. It found that when trans people had access to gender-affirming hormone therapy in the form of primary care, they had a 37% lower chance of getting HIV and a 44% lower chance of having the virus detectable in blood samples.
“Preventing HIV and optimizing HIV care are not ‘one size fits all’ in public health,” wrote study author Sari Reisner, an associate professor of epidemiology at the university. “We need tailored approaches that address the lived experiences and priorities of trans people, such as integrated models of care that incorporate gender care with HIV prevention and care services.”
Another grant for Reisner’s newest study about HIV prevention among trans gay men, an underreported but growing community at risk of HIV, is among those that have been terminated.
Scientific progress is all but impossible without access to existing data and other resources.
“Research is what helped put PrEP on the market and make it such a valuable tool in preventing HIV diagnoses and transmissions,” Cooper said.
With many research grants on pause, public health advocates expect HIV disparities within trans communities to grow even further.
“There’s a data and surveillance gap,” Chu said, noting that trans men are often left out of HIV research. “There are no [sexual orientation and gender identity] data-gathering standards for us, so it means that oftentimes transmasculine people are overlooked.”
With so much uncertainty at the federal level on the horizon, protecting access to HIV prevention and treatment will increasingly fall to the states.
Illinois recently implemented a standing order to allow residents to get PrEP directly from a pharmacist and without a prescription. The program, PrEP 4 Illinois, is modeled after the nationwide campaign, PrEP4ALL, championed by Biden to get the medication to low-income people, trans people and people of color. Maryland passed legislation in February to repeal its antiquated criminal penalties for individuals who knowingly or attempted to transfer HIV. The law had been used to charge people for spitting on or biting others, even though HIV does not spread through saliva.
Mandisa Moore-O’Neal, the executive director of the Center for HIV Law and Policy, said laws to decriminalize HIV status are important because trans people and communities of color are more likely to be targeted and harassed by law enforcement. One report found that nearly 27% of trans people experienced physical force from police. Across the board, people of all backgrounds are more likely to face higher criminal penalties due to their HIV status.
“We now have a larger group of people with less access to resources because almost everything has been defunded — except law enforcement. Criminalization is likely to increase because of the ongoing war on trans folks, on people who are Black, on immigrants, on people living with HIV,” Moore-O’Neal said. “Public health experts have begun sounding the alarm about what such deep cuts to HIV research and treatment may mean more broadly.”
Trump has tried to significantly roll back civil rights protections for trans Americans in all aspects of life, but especially by restricting access to gender-affirming care. Earlier this month, Attorney General Pam Bondi issued a memo instructing the Justice Department to investigate doctors who provide gender-affirming care for minors, and the White House tried to sow doubt into the efficacy of gender-affirming care altogether.
Cooper said the administration’s early emphasis on targeting trans people and people living with HIV should concern everyone.
“I believe these attacks are an entry way,” Cooper said. “Angela Davis has a quote something to the effect of ‘They come for me in the morning. They’re going to come for you in the night.’ What I believe is that trans communities are essentially a test to see just how far they can go. If they can regulate trans people’s lives, who are tax-paying citizens, then next they can go after different groups.”