Can the U.S. end the HIV epidemic in a decade, as Trump pledged?

President Trump confirmed Tuesday that his administration will attempt to end the HIV epidemic in the United States within the next decade — but experts have warned that’s a harder task than his simple pledge suggests.

Trump’s decision to emphasize the pledge in his State of the Union address, as Politico first reported this weekend, triggered excitement among public health experts who know that with adequate funding for medications and other scientific tools that great inroads could be made in at least reducing the number of infections that occur in the country each year. In 2017, nearly 39,000 Americans contracted HIV.

“Together, we will defeat AIDS in America — and beyond,” Trump told the dignitaries assembled in the House for the State of the Union.

But he offered no details of how his administration hoped to achieve the goal, beyond saying that his budget would ask for funding for the endeavor.

“There were high expectations that the president would use this opportunity to announce something bold on HIV in the U.S.,” said Jen Kates, vice president and director of global health and HIV policy at the Kaiser Family Foundation.

“While getting anything into the [State of the Union] is always an achievement and important, this announcement had few details. There was no detail on funding, for example, or the specific components of what might be done,” she said.  “Without this detail, it is hard to say what this will mean for truly making a difference on HIV.”

Experts STAT spoke to before the speech predicted the administration would roll out further details of its plan in coming days. One of those experts, Carl Schmid, the newly appointed co-chair of the Presidental Advisory Council on HIV/AIDS (PACHA), expanded on the plan in a press release lauding the announcement.

Schmid, who is deputy director of the AIDS Institute, said the policy the administration will roll out will include provisions to increase access to antiretroviral medications for people living with HIV. It will also include provisions aimed at helping prevent of transmission in communities with the highest rates of HIV and where additional resources are most needed. He said the initiative will also include a scaling up of HIV testing.

“Under the President’s proposal, the number of new infections can eventually be reduced to zero,” Schmid said.

.@POTUS just announced our commitment to ending the #HIV epidemic in America—one of the most important public health initiatives in American history. We have right data, the right tools, and the right leadership to accomplish this. #SOTU pic.twitter.com/pJGyzSlYJr

— Secretary Alex Azar (@SecAzar) February 6, 2019

Senior health officials in the administration — Health and Human Services Secretary Alex Azar; Dr. Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases; and Dr. Robert Redfield, director of the Centers for Disease Control and Prevention — reportedly have been involved in devising the policy. Fauci and Redfield are leaders in the field of HIV/AIDS research and treatment.

Redfield may have sowed the seed of the plan when he took the helm of the CDC last spring. In his first address to the Atlanta-based agency’s staff, he raised the possibility of stopping HIV transmission in the U.S., saying the current tools could get the job done in a matter of a few years if they were effectively applied.

Though HIV/AIDS is not an issue that has seemingly preoccupied the president — the disease has not featured in his Twitter feed — there is reason to believe Trump likes the idea of notching a history-making health accomplishment during his presidency.

Philanthropist Bill Gates revealed in an interview with STAT last spring that Trump reacted with excitement when Gates urged him to put his administration’s support behind the quest for a universal influenza vaccine — insisting on getting Food and Drug Administration Commissioner Scott Gottlieb on the phone to ask if he thought the goal was achievable. But there’s no suggestion that Trump has pursued the idea in the intervening months.

Science doesn’t yet know how to design a flu vaccine that can protect against all strains of the virus. But there is evidence to support the idea that HIV transmission can be stopped.

Highly effective antiretroviral drugs, when taken properly, can drive down the amount of virus in an infected person’s body to undetectable levels. Studies have shown that when people who are HIV-positive reach that state of viral suppression, they do not transmit the virus to others. The phenomenon has become known by the mnemonic U=U — undetectable equals untransmissible.

Another tool is known as PrEP — pre-exposure prophylaxis. When taken by people who are at high risk of contracting HIV, antiretroviral drugs can substantially lower their chances of becoming infected. PrEP reduces the risk of contracting HIV from an infected partner by 95 percent; if the partner is virally suppressed, the risk of infection is lower still.

These and other tools — such as programs to provide injection drug users with clean syringes — can be highly effective, studies have shown. But applying them isn’t always easy.

Using the antiretroviral drugs to maximum advantage requires everyone who has HIV to know their status. But of the estimated 1.1 million people in the United States who are infected with the virus, it’s estimated that 15 percent are unaware of that fact — and therefore are not on treatment.

And only about half of people on antiretroviral drugs are virally suppressed, noted Kates, who said that for transmission to be halted, that figure would need to be at about 90 percent. “It’s just not enough at 50 percent,” she said.

Another concern has been the cost of the drugs, which can be prohibitive for people without health insurance, and even for some with insurance because of copays. Without insurance, PrEP can cost upward of $1,500 a month — though there may be a break in sight, noted PACHA’s Schmid, but he stressed that for the purposes of this interview, he was speaking on behalf of the AIDS Institute.

In late November, the U.S. Preventive Services Task Force — an independent expert body that makes recommendations about preventive health services that ought to be offered to Americans — issued a draft recommendation about PrEP. The task force gave the regimen a Grade A rating, which if formalized later this year would mean that health insurance plans would have to offer PrEP without copays.

That won’t help people without insurance. Kates said new federal funding to help pay for PrEP will need to be found. “I don’t think money is the only thing needed. But without new investments, it would be hard to see how the scale up or something more intensive could happen,” she said.

Targeting efforts at the communities that have the highest need will be crucial if an effort to end transmission is to succeed, said Brian Mustanski, director of the Institute for Sexual and Gender Minority Health and Wellbeing at Northwestern University Feinberg School of Medicine.

“Every 44 minutes, a 13- to 29-year-old gay or bisexual man in the U.S. gets diagnosed with HIV. These diagnoses are disproportionally among young men of color — the only group in the U.S. to show increases in the rate of annual diagnoses,” Mustanski said in a statement. “Any plan to end HIV transmission in the U.S. must center on the needs of young gay and bisexual men of color in order to be successful.”

These infections are largely concentrated in some southern states, where stigma may be high and access to preventive health services is not as great as in centers like New York City or San Francisco.

Connecting people infected with the virus and people at high risk of contracting it to health services will be critical to the success of this effort, Kates said: “That would be a key part of trying to do this.”