During Tuesday night’s State of the Union address, President Donald Trump pledged to end new HIV transmissions within a decade, and lauded the “incredible strides” made by the United States in recent years to curtail the infectious disease.

“Together, we will defeat AIDS in America and beyond,” Trump told the audience assembled in the House.

While new HIV infections have consistently fallen since the 1980s — when there were more than 130,000 new infections per year — the president’s message stood in stark contrast to the realities of injection drug use in 2018.

Last year alone, the nation witnessed HIV clusters linked to injection use around the country, including cases in Cincinnati, North Seattle, West Virginia, and Montana, as well as a larger outbreak in Lawrence and Lowell, Massachusetts, last spring, where the federal government was called in to investigate.

“HIV still takes advantage of stigma and social marginalization to spread.”

Even more recently, public health officials reported a cluster of HIV cases last week among people who inject drugs in Boston, and nearby Worcester, Massachusetts.

“The goal to eliminate HIV transmission is laudable,” said Dan Ciccarone, a professor of family and community medicine at the University of California, San Francisco. “It is doable by 2030, but not without much more attention to the ‘hidden pockets’ of transmission.” Ciccarone pointed to HIV’s spread among people who inject drugs as one of those.

“HIV still takes advantage of stigma and social marginalization to spread,” he added.

According to Alex Azar, the Secretary of the U.S. Department of Health & Human Services, the administration’s plan to stem the HIV epidemic will focus its efforts on the 48 counties where about half of new HIV infections occur. Those specific efforts will involve diagnosing patients early and treating them with antiretroviral drugs, so that they aren’t at risk of transmitting HIV to sexual partners. Other efforts will make Pre-exposure Prophylaxis (PrEP), a daily pill that prevents HIV infection, more accessible to people at risk for HIV.

By expanding access to antiretroviral drugs and PrEP to everyone who needs it, “you can theoretically end the epidemic as we know it,” said Dr. Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases during a press briefing Wednesday. “The question is implementing it,” he concluded.

The bulk of new HIV infections aren’t acquired by needle sharing. Of the new cases diagnosed in 2017, just 6 percent, or 2,389 cases, were linked to injection drug use, according to the U.S. Centers for Disease Control and Prevention (CDC). Still, it’s an area of disease transmission the administration will have to consider if they plan to wipe out HIV by their projected deadline.


Regina LaBelle, who worked in the White House Office of National Drug Control Policy during the Obama administration, said that ending new HIV transmissions by 2030 is “doable,” but only if the Affordable Care Act (ACA) and Medicaid expansion continue to be supported.

While LaBelle stressed that there are committed employees at the CDC working on the issue, the Trump administration has repeatedly tried to repeal the ACA, including challenging it in court.

LaBelle also pointed to the administration’s failure to embrace clean needle exchanges, an evidence-based method for stopping the spread of infectious diseases such as HIV and hepatitis C.

While Surgeon General Jerome Adams has publicly supported syringe exchange, both the White House’s national drug control strategy and the president’s commission report on opioids failed to mention syringe exchange.

Considering how cheap and effective needle exchanges are, that’s a big gap, according to LaBelle. “Syringe exchanges are not the only solution, but they’re a really important outreach tool that can be used to get marginalized populations access to the treatment they need,” she said.

As it stands, a federal statute bans the use of federal funds for syringes. “They could do an amazing thing by overturning that,” Labelle said. “A lot of these syringe exchanges are bootstrap operations. Every dollar matters.”

Ciccarone also advocated for prescribing PrEP to active drug users, which he said is rarely done in the United States, and increasing access to medication-assisted drug treatment, such as buprenorphine, which he called the “most valuable tool” we have for addressing the opioid crisis. Meanwhile, that crisis continues unabated. In 2017, nearly 70 percent of the nation’s more than 70,000 drug overdose deaths were attributed to opioids.

“It’s time to question the structural barriers to this valuable tool,” Ciccarone said. “We still do not have adequate amounts or equitable spread of substance treatment.”

Since the dual crises of HIV and drug use are intertwined, the Trump administration can’t necessarily solve one while neglecting the other. In the meantime, the outbreaks will likely continue.

“It’s great that you want to end the HIV epidemic, but where are the resources?” says Dr. Alysse Wurcel, an infectious disease physician at Tufts Medical Center. “Without them, it’s an empty statement.”