Trump-Pence budget would weaken response to outbreaks of infectious disease

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If the Trump-Pence budget released earlier this week had been in place just a few short years ago, the level of public health in Austin, Ind., would likely now mirror that of a country in sub-Saharan Africa, where rates of HIV transmission and infection are high and there are little to no public health prevention services available.

In 2015, Austin, which is located in rural Scott County, was hit with a devastating outbreak of HIV that will cost taxpayers at least $180 million to treat. At its height, then-President Obama was receiving daily updates on attempts to contain the epidemic, which began in November 2014 when the first of 181 HIV diagnoses were made throughout a 12-month period. For context, a total of five cases of HIV had been diagnosed in all of Scott County during the previous decade.

{mosads}Four months after the initial HIV diagnosis, then-Gov. Mike Pence declared a public health emergency, and the U.S. Centers for Disease Control and Prevention oversaw a contact tracing investigation to find — as quickly as possible — anyone who had had sexual contact or shared intravenous needles with the first 11 people who had been diagnosed with HIV.


The labor-intensive process, which is described in detail in a New England Journal of Medicine article about the HIV outbreak, required a team of experienced epidemiologists who were trained in conducting sensitive interviews about highly personal behavior. Through these interviews, investigators identified 536 people who might have been exposed to HIV. They located 468 of them and administered HIV tests on the spot.

If the Trump-Pence budget had been in place, this work would not have been possible. The proposed budget would cut CDC funding by $1 billion, or 9 percent, and the cuts specifically target programs that respond to outbreaks of infectious disease, such as HIV. (The Trump-Pence budget would also cut the CDC’s HIV, hepatitis, sexually-transmitted disease, and tuberculosis prevention by 17 percent).

As a result of the CDC’s contact tracing efforts, an additional 170 people with HIV were identified, and they required immediate medical care. The Midwest AIDS Education and Training Center, one of many such centers around the country that are funded by the Ryan White HIV/AIDS Program, took the lead in connecting these people with healthcare providers. The center also provided in-depth training in HIV care to doctors and other clinicians who had never before treated anyone with HIV, which is a complicated chronic disease that impacts treatment for other, more common, chronic conditions such as diabetes, cardiovascular disease, and hypertension.

If the Trump-Pence budget had been in place, this work would not have been possible, as the Trump-Pence budget proposes total elimination of every AIDS Education and Training Center in the country.

Treatment of HIV is medically-intensive. Fortunately, just weeks after the first case of HIV was diagnosed, as the authors of the NEJM article write, the state of Indiana had “fortuitously” accepted the Medicaid expansion offered by the Affordable Care Act (ACA). This new availability of health insurance to people who had, for the most part, been uninsured, “helped to ensure health care coverage in the largely uninsured and impoverished community that was affected by the outbreak and facilitated the immediate enrollment, coverage, and access to critical health care services, including HIV treatment.”

If the Trump-Pence budget had been in place, this treatment would not have been given. The budget proposes a massive cut in Medicaid services which, when coupled with passage of the American Health Care Act, would almost surely result in a loss of health insurance — and access to care — for those now being treated for HIV.

People with HIV have disproportionately benefited from state Medicaid expansions. Before passage of the ACA, 36 percent of people living with HIV obtained their health insurance through Medicaid; after passage of the ACA that number rose to 42 percent. Meanwhile, the rate of no insurance among people with HIV fell from 22 percent to 15 percent.

The most amazing thing about the Indiana HIV outbreak — which rapidly spread through a loosely connected network of opioid addicts who were sharing needles — was the public response to it. It required coordination among federal, state, and county agencies.

It required sophisticated training for healthcare providers. It required extensive lobbying of Pence by federal and state officials, who needed the then-governor to back a new state law in Indiana that would legalize needle exchange programs. It required a massive effort to put public health, education, and prevention resources in place where there had been none previously.

Indeed, just one year before the first HIV diagnosis, the only healthcare provider in Scott County that offered free HIV testing and substance abuse treatment was a Planned Parenthood clinic that was forced to close after Indiana lawmakers voted to defund it.

The second most amazing thing about the Indiana HIV outbreak is how quickly lawmakers like Pence seem to have forgotten about it. The CDC has identified 220 counties in 26 states with conditions that make them just as vulnerable to an eruption of HIV as Scott County was: pervasive opioid addiction among impoverished rural residents where there is no access to sterile needle exchanges or treatment for addiction and limited access to basic healthcare and HIV prevention services.

Imagine if the public had turned its back on the residents of Austin as HIV made its way through the population? Imagine if HIV had been allowed to progress among those newly infected without any treatment? Imagine what Austin would look like now?

Well, that’s easy. Austin now has an HIV prevalence rate of approximately four percent, which is comparable to that found Nigeria and Cameroon, where HIV spreads among poor people who have limited access to treatment or prevention services. Unlike Nigeria and Cameroon, however, when a major public health crisis struck Austin, its residents enjoyed the benefit of a coordinated local, state, and federal response to HIV that continues today.

The Trump-Pence budget is a radical rejection of the social compact that has sustained the United States for 50 years. Its proposed gutting of Medicaid would end the provision of health insurance for millions of poor people that has been in place Lyndon Johnson’s War on Poverty in 1965. Its cuts to the Children’s Health Insurance Program and general welfare programs that help people living in poverty pay for food would decimate the social safety net.

It casts our most vulnerable people aside and leaves them to fend for themselves without the resources they need to succeed. If enacted, vast swaths of our country would look more like a developing nation than our own.

Sean Cahill, Ph.D., is Director of Health Policy Research at the Fenway Institute, a group that advocates for the LGBT community, people living with HIV/AIDS and the larger community. 

The views expressed by contributors are their own and are not the views of The Hill.

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