A top Trump health official leading the charge on the administration’s effort to end the HIV epidemic by 2030 said Thursday he’s “totally confident” about achieving the ambitious goal.
Robert Redfield, director of Centers for Disease Control & Prevention, made the remarks during an exclusive interview with the Washington Blade on the initiative and the continued stigma facing the LGBT community in health settings.
President Trump announced the initiative during his State of the Union address, pledging to seek resources to end the HIV/AIDS epidemic by 2030. The subsequent budget request to Congress sought $300 million for the first year of the initiative (while simultaneously seeking cuts to Medicare and Medicaid, programs on which many people with HIV rely).
Top health officials within the administration, Redfield said, developed the initiative and submitted the proposal to Secretary of Health & Human Services Alex Azar, who in turn submitted the plan to Trump in time for his State of the Union address.
“We presented that initiative to our secretary of health, who has fully embraced it as one of his major priorities,” Redfield said. “He was successful in presenting this to the president, who was also very committed and engaged, but I don’t know the actual process of how words get into his speech.”
Although the administration is also seeking to roll back the Affordable Care Act and to cut Medicare and Medicaid, Redfield said he doesn’t think changes to other health programs will affect the main HIV initiative.
“At least for individuals who are at risk for HIV infection or who have HIV infection, these persons will get access to the medical and preventive care independent of other issues they may come about related to the broader health care issues of our nation,” Redfield said.
Redfield, who worked as a medical researcher at the Walter Reed Army Medical Center at the height of the HIV/AIDS epidemic in the 1980s, also marveled at the advancements in treatment and prevention that he said enables the plan to beat HIV/AIDS by 2030.
“[I was] involved in the first trial to ever use AZT, and I remember how ecstatic we all were when we increased survival from 10 months to 26 months,” Redfield said. “Who would believe today that when you’re 20 years old and you get HIV, you can expect to live between the age of 70 and 75?”
Read the full interview below:
Washington Blade: Now that the budget request is out, how confident are you the administration can achieve President Trump’s goal of ending new HIV infections by 2030?
Robert Redfield: I’m totally confident that we’re going to succeed. And, again, I just want to clarify the goal is to end the HIV epidemic by 2030, and so, what that technically means is to bring new infections down to less than one per 100,000, so that would be less than 3,000. Obviously, we would like to do all the way down to zero, but the goal is to end the AIDS epidemic in America by decreasing new infections below 1 infection per 100,000 group of people.
Blade: The president announced the initiative during his State of the Union address. What was the process like to make sure those words would be included in the speech?
Redfield: Well, I really don’t know that process as much other than I can say that this was a very thoughtful initiative that was put together by key principals from CDC, NIH, HRSA, the Indian Health Services, the assistant secretary of health, who really did work together for months to look in detail whether we felt that the targeted initiative, a highly focused initiative could meet the goal of bringing the HIV epidemic to an end.
Once we were confident among ourselves that, as you know well, Chris, we had the tools, whether it’s successful treatment to get people diagnosed and treated, virally suppressed, so not only they can live a full life, but also, importantly, that if you’re virally suppressed that…you would no longer be able to transmit, and if you could couple that with getting people at risk for HIV infections in comprehensive prevention programs, including PrEP, that the epidemic would come to an end.
And the question was how would we do that. And when we looked at the new infections in America that have stabilized around 40,000 and just spotted the infections where they occurred, we noticed that over half the infections were in 48 counties and D.C. and San Juan — which is just 50 jurisdictions out of over 3,000, so immediately if you look at that map, everyone said, “Wait a minute. This is highly focused. We can do this.”
It’s also highly focused, as you know, demographically that most of the new infections that we’re seeing are in men who have sex with men, and not just men who have sex with men, but African-American and Latino men, and not just African-American and Latino men, but men that are between the ages of 25 and 34. So it’s very geographically focused and it’s very demographically focused.
So we came together with an initiative, which we all believed was no longer aspirational, but was practical. We presented that initiative to our secretary of health, who has fully embraced it as one of his major priorities. He was successful in presenting this to the president, who was also very committed and engaged, but I don’t know the actual process of how words get into his speech. Clearly, I do know how the secretary became very committed and made this one of the major objectives of his tenure as secretary and he presented it to the president. He wanted to make it one of the major initiatives of his presidency.
Blade: The president’s budget request calls for $300 million for the initiative. Will future requests seek similar resources, or was that a one-time request?
Redfield: As you know the president’s budget request, as you said, nearly $300 million, $291 million. That was the budget that the experts within the department, the agencies that I mentioned, thought that we needed in Year One.
This is a multi-year initiative, and people can anticipate that there’ll be additional requests in a second, third, fourth and fifth year. And people can anticipate that those resources obviously will be — requested will be significantly greater than the resources that were in the president’s budget for 2020.
Blade: The budget also requests an $845 billion cut to Medicare and seeks to roll back Medicaid as it was expanded under the Affordable Care Act. Could the administration achieve the 2030 goal if Congress agrees to the cuts as well?
Redfield: You know, Chris, that’s outside my expertise other than to say that I am confident, as are the other leaders, confident that within the president’s HIV initiative, we will have the resources needed to make sure that all — I’m going to keep saying that “all,” because people when I say “all,” they say but what about these people? I say all people with HIV infection we will work to get diagnosed, engaged in care and on retroviral therapy and virally suppressed.
And we did our current calculations with a five-year budget outline and eventually, as you know, it’s a 10-year program, but we did outline the first five years. We did it assuming that there was no significant change in expanded Medicaid and any change in services. The second thing we did is [ensure] all people at risk for HIV infection would get access to comprehensive prevention strategy, including PrEP.
So, at least for individuals who are at risk for HIV infection or who have HIV infection, these persons will get access to the medical and preventive care independent of other issues they may come about related to the broader health care issues of our nation.
Blade: You were working on HIV/AIDS drug development at the height of the epidemic in the 1980s and 90s. How would you compare HIV/AIDS treatment at that time to what we have now?
Redfield: You know, it’s really been a gift to watch the power of science apply. When I started as an HIV physician in 1983, many of my patients had a limited life expectancy. I learned as a physician just to try to take care of them to the best of my ability, but all too often, that ended in death way too prematurely. [I was] involved in the first trial to ever use AZT, and I remember how ecstatic we all were when we increased survival from 10 months to 26 months. Who would believe today that when you’re 20 years old and you get HIV, you can expect to live between the age of 70 and 75?
When we originally had therapy, as you know, and went through single lymphocyte, dual lymphocyte, then eventually the protease inhibitors came and we had many patients that were taking 20, 30, 35 pills a day, three times a day, significant toxicity, major side effects and frequently at the end of the day, half the patients developed resistance and therapy failed.
There was a time actually when I was involved in Baltimore after I left the military that I was considered one of the doctors of last resort. People would come with multi-drug resistance virus, resistant to three or four classes of drugs. We would try to do the best and keep their T-cell count from falling and just do the best we could.
Today, the therapy we have is single pill or two pills once a day. I like to use the term it’s pretty bulletproof, meaning the drugs really work and the virus really doesn’t have the ability to escape them the way it did in the old days. Drug resistance is no longer a real threat, particularly with some of the major drugs that are used today. The side effects now on these drugs are really minimal, close to the side effects of water. So today we have really very simple, very successful, very easy-to-take therapy that has minimum side effects, limited toxicity so that people can expect to take them for 20, 30, 40 or 50 years and can expect being able to have a high quality of life.
You know, and you follow this close, there’s even advancements in therapy that are coming beyond that in terms of some of the long-acting therapies, long-acting injectables. It probably won’t be long to some people who don’t even like taking a pill a day to be given an alternative option to take some type of injection, or even people are looking at long-acting implants that will be able to basically provide the treatment that they need.
It’s clear that we will need chronic anti-retroviral therapy to maintain viral suppression. I do think therapy strategies continue to be worked on, science is working hard trying to find ways we can cure HIV infection. I think those days will come. We’ve seen several cases already, but I think you’ll see strategies develop that are actually more applicable.
So, I think it’s just an amazing testament to the power of science and I’d like to say it to you: A big part of it was obviously the investment and the science that was done in the private sector, but probably the most important investment was the courage of the young men and women and persons in the community that had the courage to participate in the clinical research.
So that we actually went from a day when most people with HIV infection kind of looked at a difficult clinical course that too often ended in premature death and today we’re looking at actual lifetime, we’re even looking at the ability to tell young people that are HIV infected, we can actually not only help you live a natural lifetime, we can actually make it so you’re no longer infectious to those you care about or those you have sexual relationships with. And who would have believed that?
Again, I know you reach out to a large community, a lot of credit goes to the community, the early community that had the courage to participate in clinical research.
Blade: Why has HIV/AIDS been such a personal priority for you?
Redfield: You know, that’s an interesting question because it really, really has. It wasn’t initially because of any insight. I was asked…my job in the military was to look at infectious diseases…that were viral that might be transmitted by blood, or sexually transmitted diseases. Rapidly, obliviously, it was clear that HIV fit into that group.
When I started prior to the understanding of the cause, taking care of the men and women that were in the military with HIV infection at a time when we didn’t know what it was, I’ll tell you the truth, they rapidly became my friends. It was a real challenge. I went into infectious disease rather than oncology because I didn’t think I could deal with my patients dying all the time. I eventually ended up with HIV [care] and becoming a dominant provider of HIV care.
Really, until I became CDC director last year, I cared for many, many, many patients and I say initially because I got to see it and I really did believe that, systemically, science could do this. I worked with really good scientists, I got to be part of the team that originally proved the causation between AIDS and HIV. I got to work on some of the earlier therapies as you mentioned. I saw incremental improvement, then it got applied to individual lives and made a difference.
I could still remember very clearly the last patient that I had that missed out on protease inhibitors…If she could have just lived another six weeks, she’d probably be alive today. But I think it was that. And I saw science making a difference. I think that’s why now I want to see those tools I would never believed even 10 years ago, we wouldn’t have been able to dream to end the AIDS epidemic, the fact those tools today, we have them. I think many of us for years were hoping there’d be a historical effort in the United States to do this, and we’re just honored and appreciative that President Trump has chosen to use this as a major initiative, Secretary Azar, and say let’s apply that science and let’s get this thing to the finish.
Blade: Let’s go back to the plan. There’s concern that it addressed the biomedical aspects of HIV/AIDS, but ignores the social determinants of health. What assurances can you make homophobia and transphobia won’t be a factor in seeking to treat HIV patients?
Redfield: Chris, this is a critical, critical point. Succeeding in ending the HIV/AIDS epidemic in America is not limited to the biomedical success. I think the first thing I will say is I feel very strongly that stigma in all its forms are the enemy of the public health. That’s obviously even more critical in the drug overdose, drug use, drug misuse epidemic that were dealing with. I think it’s clear that many of the people that haven’t gotten access to diagnosis or have been linked to care and stay in care, or haven’t gotten access to comprehensive prevention strategies, many of these reasons that has not happened are defined in what you highlight as factors that are really social determinants of health.
One thing I’ll say about this initiative: It’s not a top-down initiative. Each of these jurisdictions are going to have to come up with a different plan and we said it clearly: It’s a plan that’s for the community, by the community, in the community. I will say the community is going to be the most critical lynchpin of this plan because many of us public health leaders, or many of the academic leaders, probably aren’t the critical experts to understand what it is that community needs to get diagnosed in certain communities, or what it is they need linked to care.
I’ll be the first to say that housing is part of the medical issue. I’ll be first to say that there are a number of social determinants, so the community is going to be critical, and groups like your paper are going to be important because probably the most critical group that can help this program be successful is the persons who actually become HIV-infected in the first couple years.
I think we need to…have a detailed, what I call a social autopsy to understand what was it that didn’t work so this individual didn’t get access to the prevention efforts that we know work. What was it that made this individual’s sexual partner not get access to HIV treatment so they could be virally suppressed and undetectable? It really is building the trust and partnership with the community to be a part of this initiative. When I say this is our initiative from CDC, or our initiative from the U.S. government, it’s our initiative for the entire HIV community to finally bring an end to the HIV epidemic as we know it.
And the only thing that will prevent it is if we don’t get the full participation of the community, which I’m confident we will as we move forward and build the trust of the community that we’re serious about making sure the community does get — all people can get access to effective therapy, all people in the community can access to comprehensive strategies.
Blade: You talked about stigma being contrary to the interest of public health. Do you think that stigma based on homophobia and transphobia still persists in medicine and do you think the military’s transgender policy, the ban, which is framed as a broad-based medical policy, is evidence of stigma based on transphobia?
Redfield: What I can say is that I do believe that stigma still exists in the HIV epidemic, and particularly, you see it in transgender persons and having clinical settings that people feel comfortable accessing. We clearly see it in men who have sex with men, particularly the African-American and Latino men that have highly religious structures that have seemed to reinforce stigma.
We’ve also seen it, Chris, in one of the areas that I’ve seen in some of the surveys we’ve done about men who have sex with men about their own feeling about themselves. There is sadly still self-stigmatization that people have that we need to get rid of. People need to feel proud of who they are and not feel that they’re stigmatized either internally or externally, so it’s still there.
I will tell you, it’s nothing compared to trying to confront the stigma dealing with drug misuse and drug use, but it’s there and needs to be confronted and it needs to be peeled away so it doesn’t impact individuals from gaining access to the care and treatment and prevention services that they deserve to have free access to.
Blade: And is the military’s transgender policy an example of that?
Redfield: I really am not going to comment directly on that. I think that what the military’s decisions are — from a public health point of view we need to embrace transgender persons so that they can get access to care and treatment prevention services that they need, and I think you’ll see this initiative accomplish that. We need to embrace men who have sex with men that feel stigmatized so that they can be in clinical settings.
The one thing I will say that’s important that we need the community, all too often we develop these clinical programs where the illness is for the patients to come to us on our terms. I’ve challenged the community and I’ve reached out and I’ll continue to reach for the community to develop innovative ways to provide care and treatment and prevention services to the community where they are and I think, again, central to this, is the importance that stigma has no place in our efforts to bring an end to the AIDS epidemic and the president’s initiative.