A new rule announced Tuesday by the U.S. Department of Health and Human Services will allow HIV positive patients to receive organs from HIV positive donors, a move that will expand the pool of available organs and reduce wait times.

“This rule removes unnecessary barriers to kidney and liver transplants, expanding the organ donor pool and improving outcomes for transplant recipients with HIV,” said HHS Secretary Xavier Becerra in a statement.

The agency noted that the final rule also aims to combat stigma and health inequities associated with HIV.

“Research shows that kidney and liver transplants between donors and recipients with HIV can be performed safely and effectively,” Assistant Secretary for Health Rachel Levine added. “This policy change reflects our commitment to following the evidence and updating our approaches as we learn more. By removing research requirements where they are no longer needed, we can help more people with HIV access life-saving transplants.”

HHS notes that the rule applies to kidney and liver transplants, which correspond with the areas in which the evidence from biomedical research is the most “robust.”

Donald Trump’s return to the White House promises to shake up Washington in ways not seen even during the norm-shattering Trump 1.0 years: on the table are blueprints for radically reforming the federal civil service into a more partisan institution where loyalty is prized at the expense of expertise and competence; off the table, among other things, are anti-discrimination protections that had long bolstered the rights and welfare of LGBTQ federal government employees.

Washington proudly boasts, per-capita, the highest LGBTQ population of any city in any state in America. Ninety-two percent of the city’s 678,000+ residents voted for Vice President Kamala Harris. So, according to exit polls, did 86 percent of LGBTQ voters.

Many of D.C.’s LGBTQ residents who work for the federal government find themselves, now, at an unenviable crossroads. Some stood to lose their jobs regardless of who won in November because they serve in higher-ranking “political” roles that typically turn over administration-to-administration, but more are “career” employees with experience serving with both parties in charge of the White House.

Many find themselves choosing whether to wade into a hyperlocal job market that is, at the moment, competitive for job seekers — or continue, if they can, working under institutions run by Republicans who have vowed to destroy them (or at least shake them up, whatever that will mean).

The Washington Blade has spoken with LGBTQ employees in the federal government who worry about the welfare of gay, queer, and trans colleagues they plan to leave behind for jobs in the private sector. They share a deep concern, too, for the LGBTQ Americans who, they believe, will suffer harmful consequences of policy and governance under the incoming administration.

A lesbian attorney for the U.S. Department of Justice and a gay senior official for the U.S. Department of Commerce spoke anonymously with the Blade to share experiences and observations at their respective agencies.

Do you expect to be working elsewhere when Trump 2.0 begins in January

[Justice Department]: I plan to leave shortly after the inauguration.

[Commerce Department]: I hope to be working elsewhere by the next term. The job market is incredibly competitive, but that’s because the Biden administration hired the best and brightest public servants that represent every community in America. It’s particularly important that companies and nonprofits seek out the great early/mid-career staff from the administration. Many finished college remotely during the pandemic, to then immediately serve their country. They have exceptional work experience, but can be at a hiring disadvantage behind their classmates who immediately entered the workforce.

Would you be (or might you be) allowed to continue in your role under the next administration if you wished to do so?

[Justice]: Probably not.

Under the next administration, if you were allowed to continue in your role or serve in a different position at your agency or perhaps work elsewhere in the federal government, would you? Why or why not?

[Justice]: No—risk of doxing is too high; did it once before and not interested in doing it again.

[Commerce]: I would not work in the Trump administration, even if allowed. To work for someone who believes in retribution over public service would violate the oath I took to my country and the Constitution he refuses to respect. I look forward to doing what queer people have done for all of American history: shining brightly in the face of hate and being a success in spite of every attempt to shame.

What can you tell me about the post-election turnover at your agency that you’ve seen so far or expect to see in the coming months, as compared to that which you might have experienced during previous transitions?

[Justice]: I expect to see many more people leave than in any previous admin change.

[Commerce]: Experienced career staff who survived the first Trump years are burned out and leaving. This is a horrible loss for the American people who are losing the dedicated subject matter experts who do the hard work of making their lives easier, safer, and healthier. So many of them work for the federal government because of how it can be used to help people in big ways. They’re horrified to think of all the people, especially minorities, women, and queer people, will, instead, be targeted. They don’t want to be a part of that. They can’t live with that.

Are any of your LGBTQ colleagues staying in their jobs? If so, what can you share about the reasons you’ve heard for their decision to stay?

[Justice]: Yes; many will stay because they don’t have the luxury of leaving without a job lined up. 

What are some of your biggest concerns specific to how your agency might be run under the Trump 2.0 regime?

[Justice]: They will dismantle the civil rights division at DOJ or completely shift its focus. 

[Commerce]: I’m horrified at how data may be weaponized against vulnerable people.  So much work has been done to help communities by building close-knit relationships with leaders across the countries. Will all these programs focused on supporting the most vulnerable and underserved among us be turned on them to identify easy targets to victimize? 

Broadly speaking, what concerns do you have about the rights, safety, and wellbeing of LGBTQ folks who will remain in the civil service post-January, or those who might join the federal government’s civilian workforce after Trump takes over?

[Justice]: LGBTQ+ people will be at greater risk of doxing; bathroom flexibilities will disappear; harassment will go unchecked.

[Commerce]: We are barely out of the shadow of the Lavender Scare, where thousands of queer American public servants were harassed, humiliated, and often fired in shame. It starts with removing Pride flags, then the photos of our partners on our desks, and then we’re escorted from the building for being security risks. LGBTQ Americans are the soldiers, and scientists, and civil servants and should never, ever have to worry if their mere existence could suddenly cost them their security clearance, their career path, or their safety.

How do you think staff turnover at your agency will impact its work under the next administration? 

[Justice]: Staff turnover will severely undermine DOJ’s work and protecting the rule of law. 

If, ultimately, a disproportionate number of LGBTQ workers leave for jobs in the private sector, are you concerned about harms that might result from the loss of voices representing the community in the federal government and/or in your agency specifically?

[Justice]: Re: loss of voices, yes. The federal government cannot function as effectively when it doesn’t reflect the public it serves.

Recent years have seen major inroads in the fight against HIV, including through the development of new preventative medicines that have become more affordable and accessible thanks in part to government interventions like the Affordable Care Act’s federal health insurance coverage and cost-sharing mandates.

Over the past four years under the Biden-Harris administration and U.S. Health and Human Services Secretary Xavier Becerra, health policy has focused to a significant extent on health equity, including for LGB and trans or gender diverse populations.

President-elect Donald Trump’s record from his first administration, plans laid out in the Heritage Foundation’s Project 2025 governing blueprint, and the policies championed by voices closest to him offer a roadmap for how the federal government is likely to approach public health issues important for the LGBTQ community in the second term.

Speaking about these matters with the Washington Blade earlier this month were two experts from the Human Rights Campaign, Torrian Baskerville, who serves as director of HIV and health equity, and Matthew Rose, the organization’s senior public policy advocate.

Appointments  

The discussion happened before Trump’s nomination of Robert F. Kennedy Jr. to serve as HHS secretary, Dave Weldon for director of the Centers for Disease Control and Prevention, and Marty Makary to lead the Food and Drug Administration.

“HHS will be very important for us,” Rose said. “Who they put at the Office of Civil Rights at HHS will be incredibly important for us. The assistant secretary for health has, under Democratic administrations, and in Republican administrations, been a champion for us, sometimes” like Trump 1.0’s Assistant Secretary for Health Admiral Brett Giroir, who “did what he could for us.”

He continued, “This is the first time that CDC requires, will require, a Senate-confirmed person, and so that is going to be something to watch. I’m not as concerned about NIH always, unless they find someone really, really crazy to take over. FDA is a worry because it could change just how we view drugs and drug regulations and how those get approved.”

Rose added that he is “always watching OMB, because the people who make the budget decide how money gets spent” and it remains unclear whether the new administration will see a new director of the Office of National AIDS Policy.

Concerns

“I know a lot of people, particularly LGBTQ folks, who are like, ‘oh, shit. We are in trouble,'” Baskerville told the Blade. “And what does that mean for my care? What does that mean for” people who are saying, “I’m a Black trans woman who’s living with HIV — these proposals that folks are talking about, particularly out of Project 2025 and Trump, and the rhetoric — how does that impact me?”

“While we are desiring and hoping for the best,” Baskerville said, “the reality is that things that we have seen, at least the rhetoric, hasn’t been hopeful. And so we’re just hoping that there are guardrails in place that help to maintain and control as best as possible some of the things that may be going on.”

He added, “As a community, we’re really just thinking like it’s going to be a shit show, but what does that mean for us? How do we persevere through and what do we need to do to hold him accountable, hold his administration accountable, and continue the fight of advocacy?”

Baskerville said his biggest concern is “safety” and the ways in which the “Trump administration is going to challenge folks’ ability to feel safe” whether based on their immigration status or gender or sexual identity.

“Trump, in his rhetoric, has emboldened folks with different ideals and opinions to really lean into some of the hatred and the bigotry and the things that challenge and impose difficulties on folks’ safety,” he said. “If folks aren’t feeling safe at home, if they’re not feeling safe in their communities, they’re not going to access any of the health care, or any of the other things, and feel like they’re empowered to do that.”

In the case Braidwood v. Becerra, the Biden-Harris administration has defended the principle that the U.S. Preventive Services Task Force can make coverage determinations about preventatives like pre-exposure prophylaxis (PrEP), which is taken to reduce the risk of HIV transmission.

Under the next Trump administration, “We’re actually very concerned about the government reversing its role,” Rose said, which could jeopardize coverage mandates for contraceptives, too. “Changing the position on Braidwood is pretty quick and easy for them to do. They can pull out of that pretty fast.”

“It’s a whole sweep,” he said. “Like, the argument is that the U.S. Preventive Services Task Force is not an assigned body and voted on and thus they should not have prescribing authority to set standards, and that whole piece has been sent back to the district court” from the U.S. Court of Appeals for the Fifth Circuit.

“Nobody wants to pay for preventative medicine, is what they are trying to say,” Rose explained. “And that the government doesn’t have a right to tell us what the preventive medicine is. And then they asked [for the court to strike down] the whole ACA, which was just fantastical. But it’s still an active case, and we don’t know what’s going to happen if the U.S. government switches its position on it. I imagine that state attorneys general, who have been tracking the case, would step in, but we’ll have to see what their capacity looks like.”

“Our argument has always been that if you want to have your religion, that’s fine, but you don’t get to use government dollars to discriminate,” Rose said. “And if you want to have the government plan, and you want a government support, you can’t discriminate against people. If you wanted to set up your own private system, that’s on you, but you don’t get to take public dollars and do that with them.”

With respect to PrEP as well as other public health matters, Rose noted some other reasons for concern — including “some things in Project 2025” that indicate there will be “greater deference to all things like religious exemptions and conscience clauses and whatnot,” though he said it is unclear how far the next administration would be able to take this.

Trump 1.0

“Some of their biggest health people aren’t all anti-PrEP,” Rose said. “The HIV community has continuously reminded Republicans that Donald Trump did create the Ending the HIV Epidemic initiative that has helped move the needle. And so there is some promise there. They aren’t all full-on, like, anti-PrEP all the time, but they are wary of it.”

He added that while officials in Trump 1.0 were not “the biggest fans of the CDC,” they were “fighting so many other battles” that they were unable to substantially reorient the public health agency.

“They didn’t go back to some of the regressive years of, like, no promo homo, where you could not talk about gay people or anything that made gay life seem like a good thing,” Rose said.

“There were more Bush people back then,” he said, a lot of whom “still have the legacy of doing PEPFAR with the president,” like Giroir, who “worked on pediatric AIDS as part of his career, and so he was willing to push for some things that we wouldn’t have seen otherwise.”

Rose added that “that’s how he” and longtime National Institute of Allergy and Infectious Diseases Director Anthony Fauci “got together and worked to create, with the Trump people, the Ending the HIV Epidemic initiative.”

“At the same time, those same people who said, ‘wow, these HIV numbers are really bad and we should do something about it’ we’re like, ‘but we hate all these LGBTQ people and their health, and so we’re not going to have any non-discrimination [rules], and we don’t care if we kick them off their health care, and we don’t care if they’re invisible in society,” Rose said.

This is a problem, he said because “given where the epidemic has always been in the community, it’s hard to end the HIV epidemic without talking about LGBTQ people and the resources that we use in the community, and the lives that we live, and the lives that we have.”

“And so, it ends up being this weird place of like, you have these religious, fundamentalist nationalists who want one thing; you have these quasi-public health people who are like, ‘oh, the private sector can help;’ and you have these government people who are like, ‘we’re not spending any new money,'” Rose said.

“I will say that, despite his saying he was supportive, every budget produced by [Trump] when he was in office decimated funding for the CDC and HRSA and HHS in all of the HIV line items,” Rose said. “So, he didn’t wholesale eliminate anything, but he shaved those things down to bare bones.”

Timing

Asked whether the FDA under Trump would be likely to consider rolling back the expanded guidelines on blood donation for men who have sex with men, Rose said no.

“One, it’s very small potatoes for them,” he said. Plus, “because it was done through formal rule making, it would take a lot of effort to roll it back” and the guidelines — while they are substantially better than the categorical ban on blood donation by gay and bisexual men that persisted for decades — are not exactly perfect.

At HRC, Rose said, “we would say [the policy is] still not in a perfect place, because it still requires a level of deferment that is not the same for heterosexuals who engage in the same sexual activity, where data could just tell you and you’re going to test the blood anyway.”

More broadly, Rose said, “I think about what levers can they pull when. Like, dismantling the Affordable Care Act is going to take a while. He has ‘concepts of a plan,’ but until he gets rid of concepts and actually has a plan, no one’s buying that.”

The proposal for “block granting Medicaid” is also unlikely, Rose said. “Medicaid is one of the largest payers of HIV services, both for treatment and prevention, because there’s just a lot of low-income people on Medicaid and the poverty tracks are similar to the HIV tracks. So changes to the Medicaid program, I worry about like things like work requirements, which they’ll try again. That will happen faster than block granting.”

Timing-wise, Rose said, “For health, there’s just a lot of regulation to get through” so, “we’ll have less acute pain than some of the immigration stuff” where the administration will “hit the ground running on day one.”

At the same time, he added, for people living with HIV who are in mixed-status families, or who are undocumented, there will be a “chilling effect” that “will happen really soon, or could happen really soon,” which is “something I worry about the most, right away.”

PrEP

Changes to America’s healthcare governance come as the outgoing administration has pushed to expand access to preventative medicine for reducing the risk of HIV transmission, which follow major advancements in drug discovery.

“There is a new version that Gilead Sciences is putting up, lenacapavir,” Rose said, which is administered twice per year with a subcutaneous self-injector. The drug ” will have a different name when it comes to market, just like cabotegravir became Apretude,” he said.

“The coverage determination that the administration just released last month covers all PrEP products,” Rose said. “It happens to cover all three of them right now. Technically, it’s just a clarification of the existing rule already.”

He continued, “The ACA already required that you provide any Grade-A rated, preventative service at a zero cost sharing. And this clarification just says, ‘Hey, you were supposed to be doing this. We heard some of you aren’t doing this. If you want to sell in the marketplace, you have to do this.’ We saw the same [thing] with contraceptives also had to have this clarification.”

PrEP enjoys the rare distinction of being a drug regimen that is covered along with preventative services like mammograms, Rose added.

“In the early days of PrEP, we made the case to insurance companies that they should cover it,” he said, because “from a financial standpoint, at the time it was $16,000 a year for Truvada, which now has gone down with the generic. It’s around $18,000 for Descovy, but that is still cheaper than the overall cost of [HIV] treatment a year, which is, you’re looking at $62,000 plus additional medical expenses and costs.”

“Without guidance from the government, it was kind of a free range and the insurance companies said, ‘well, we’re going to put in prior authorizations to cost-control this,'” Rose added.

Baskerville detailed how HRC will continue to serve populations impacted by HIV.

“One of our biggest initiatives around wellness and action is our HIV self-testing kit program, understanding that there is a group of communities who will not go into a brick and mortar house and get tested,” he said. “And so providing them with another option” is important, and so on this initiative “we partner with seven community-based organizations across the U.S. mainland, and Puerto Rico, to distribute testing kits throughout the country.”

“In that partnership we have also worked with CVS Health,” Baskerville added. “What’s different with our program than other self-testing kit programs is that all of our partners also work to do a follow-up, so a navigation piece, once they distribute a testing kit, following up with them to see one, have they taken the test? If they have not taken the test, figuring out what barriers are in place, to get them to take the test and addressing those barriers. And then if they have taken the test, figuring out what their result was, and then connecting them to either care, if it was a reactive test, or connecting them to PrEP services if it was non-reactive.”

Baskerville continued, “We also have our leadership development program where we work with different populations over a course of six months to educate them around health equity, HIV, to then empower them to go into their communities, to help them be spokespeople and be advocates for HIV and help their community get the services that they need. This year, we particularly work with Black, sexually minoritized men living with HIV at the intersection of mental health, understanding that post-coming out of COVID, there have been a lot of issues with mental health things and depression and anxiety among populations.”

Additionally, “we have our public education sexual health platform, which is our My Body My Health” portal, Baskerville said, “where we provide all sex-positive, body-positive sexual health education as well as resources.”

“We’re currently developing what we call an HIV service provider index, and that is to assess service providers and their quality of service provision as it relates to providing HIV services to individuals, particularly Black and Latin LGBTQ community folks,” he said. “And so we’re utilizing that because we hear stories all the time around folks going to their providers and being denied PrEP or being told they can only get one particular version of PrEP when they want something different. It should be completed and developed by the end of February 2025, with implementation expected to happen kind around May – June.”

“We are constantly working with our federal partners to ensure that community’s perspective and the voice of community is is a part of the conversations when they’re thinking through policies and procedures,” Baskerville said.