Pres. Trump’s HIV/AIDS Record: A Look Back & Ahead

Mark Masselli (00:04)
The CDC reports. New HIV infections fell by 19% from 2018 to 2022, but there's been a 12% increase in
infections among Latino people. We've just marked World AIDS Day, which reminds us all that this fight
continues.

Dr. Vincent Guilamo-Ramos (00:22)
The Latino community has had actually a worsening situation in terms of HIV prevention and treatment, and
that's gone largely invisible. It's not received much recognition, and certainly when we have in fact, raised the
alarm, which over the past 10 years we've been trying to do that we haven't had much success in terms of
specific action steps.

Margaret Flinter (00:44)
Our guests today are Dr. Vincent Guilamo-Ramos, executive Director of the Institute for Policy Solutions at the
Johns Hopkins School of Nursing, and Dr. Marwan Haddad, medical Director of the Center for Key Populations
at Community Health Center Inc. and the Moses/Weitzman Health System.

Dr. Marwan Haddad (01:00)
Ready, set Prep, I think was a great program to sort of access. I I'm actually worried for the next four years
because we know we're hearing about potential decrease in funding and, and whenever we need to sort of start
to scale up programs that's gonna take funding, in, in terms of us doing that.

Margaret (01:23)
This is Conversations on Healthcare.

Mark (01:34)
Well, Vincent and Marwan, welcome to both of you to Conversations on Healthcare.

Marwan and Vincent (01:40)
Thank you.

Mark (01:41)
Yeah. Well, let's start with Vincent. You've written a piece in the New England Journal of Medicine titled the
US Latino HIV Crisis ending in Era of Invisibility. I'm wondering if you could just share with our audience your
concerns that you expressed in the article.

Vincent (01:58)
So thank you mark for that question. you know, I wanna start by saying that I think as a nation that we have had
tremendous success in ending. HIV would be unfair of me not to acknowledge that. because of that success and
because we have a national ending the HIV initiative, much of our messaging has been around progress. And
that's a good thing. It's really has motivated us, all of us, to continue working, to making HIV something that is
no longer what it was historically. Having said that, because of that positive messaging, what's been invisible is
that all communities have not benefited equally. And in fact, some for our purposes today and what's written in
the New England Journal of Medicine Paper, the Latino community has had actually a worsening situation in
terms of HIV prevention and treatment. And that's gone largely invisible. It's not received much recognition, and
certainly when we have in fact, raised the alarm, which over the past 10 years we've been trying to do that we
haven't had much success in terms of specific action steps. So that's really more what the paper's about. It's
really arguing that if we are, in fact, as a nation going to end HIV, that we've gotta lean in and make sure that
everyone, including the Latino community, is benefiting from all the progress that we've made.

Margaret (03:20)
Well, Vincent, thank you for highlighting that. And I, I think 2022 was the first year that new HIV infections
and Latino men who have sex with men outpace those in all other racial and ethnic groups. So we're, we're now
two years passed this news. CDC has allocated, I think, about $975 million recently for HIV prevention. Do you
think there's been enough of a public response from all quarters on this particular issue of the increase in Latino
population?

Vincent (03:51)
So, Margaret, thank you. That's a great question. And you know, and an honest answer would be to simply state
again, what I shared about, there's been tremendous progress. I don't wanna convey to anyone listening or
viewing that as a nation, there's not a lot that we should be proud of. At the same time, there's more work that

needs to happen. And in fact I think, you know, while we're talking about the New England Journal of Medicine
paper, the truth is that we've been raising the alarm for quite some time for over a decade. We published in 2020
a paper in the American Journal of Public Health, where we not only documented that since 2010, there have
been increases in new HIV infections in Latinos, we forecasted that if we didn't do something back when we
published the A JPH paper, the American Journal of Public Health Paper in 2020, that we would arrive at this
point. And so, Margaret, you're right, this is very troublesome because this most recent data that was released by
the CDC in May of this past year, it actually reported that Latino men that have sex with men are, are the
number one group in terms of new infections across the board. That's something that was not the case in the
past. And even more troublesome, is that when we look at younger Latino, MSM so ages 24 to 35, we see a 95%
increase in new infections between 2010 and the most recent data in 2022, we know what to do. We've actually
done it. We've made significant progress as a nation. The question is, are we willing to lean in and apply those
same techniques, those same tools, those same best practices to ending HIV in the Latino community?

Mark (05:34)
Well, to do that, we're gonna clearly need more equitable funding. And you've raised that right, for the Latino
specific HIV research. What's that look like? You know, as you sort of pa paint a picture, new administrations
come in. what would you say the dollar amounts are or the types of questions that would be answered in the, in
in this funding?

Vincent (05:57)
It's great question Mark. I, I would say there's a couple things that we highlight in the New England Journal of
Medicine paper. First is raising the visibility. And so, again, thank you for the opportunity to talk about the
Latino community on this, on this particular podcast. You know, we need a multi-sectorial approach. We need
everyone involved from media to pharma, to universities, the healthcare sector, public health government. We
need significant investments and more investments that are in alignment with the specific needs of the Latino
community. What I'm fearful of is that if we do make some shifts in addressing the Latino community needs, it
doesn't mean that I'm advocating that we reduce sort of funding in other places, other communities as well need
support. We need additional resources. We need to engage the Latino community in meaningful ways. We can't
resolve this without really embracing the communities that are most impacted. We need to redesign our public
health and our healthcare approaches so that they're better in alignment with the needs of the Latino community.
That means bilingual and bi-cultural healthcare providers. That means integrating clinical and social care. That
means moving care into settings where Latinos are. We also need to address the structural drivers that are
shaping the lives of Latinos and realize that when we have sort of messages of anti-immigrant sentiment, when
we exclusively focus on the border, which obviously is something very important, but not the only issue that we
as a Latino community are facing, that that doesn't help us to make it so that every single Latino in need of HIV
prevention and treatment feels welcomed and able to benefit from those services. And then Mark, finally, your
question, which is about research implementation science, and really taking the tools that we have developed,
we have done a lot in terms of discovery. We need to take the things that we know that work and figure out
through research how we can implement them in ways that the Latino community can benefit.

Margaret (07:58)
Well, thank you Vincent for that. I wanna come back at some point to some more of the specifics about what
you would be recommending based on your research. But I wanna turn to Marwan for a second. Marwan, we of
course, know you so well. You've led up the HIV efforts as family physician, HIV specialist, head of the Center
for Key Populations at CHC and the Moses Weitzman Health System. But as a colleague, let's ask you a general
question. Where are we in the overall effort to prevent HIV and cure aids?

Marwan (08:29)
Oh, thanks Margaret, for that question. And, and, you know, I wanna sort of reiterate what Vincent said that we
have as a country made major strides in, in sort of to, towards getting to the point where we hopefully will end
the HIV epidemic. however, when we look in the context of the initiative, the ending, the HIV national ending,
the HIV epidemic initiative, the goal that they outlined there is that we, that we need to get to 75% reduction of
new HIV infections by 2025 and 90% reduction of new infections by 2030. And I think, or I believe we're not
gonna come close to meeting these goals as it stands today. While we have made major strides in this, we're not
gonna meet those, those lofty goals of getting down to where we need to, to sort of, to achieve those percentage
decreases. We have extremely effective strategies, though, right? We've got the tools to do it. We have the tools
to end the new infections today. We're just not reaching those who can benefit the most from these
interventions. and those who are acquiring HIV now, right? So every year, despite the fact that we've decreased
the new infection rates, we're still getting 36 to 37 new infections each year. And when we look at who's getting
infected, 70% of these new infections are among black and Hispanic individuals 70%. And the majority are

among gay, bisexual and other men who have sex with men with the next populations getting infected, being
black women, and then black men and Hispanic men. And so we have the prep, prep pre-exposure prophylaxis
that prevents new infections, right? This is medication that's taken before HIV exposure and that can stop
acquiring the, the acquisition of HIV by over 99%. We also have HIV treatment as prevention, or what we call
undetectable equals, uh untransmittable Which is when we identify people with HIV, we engage them in care
get them on HIV medication and get the virus in their blood to undetectable levels, then they cannot transmit
this virus to their sexual partners, period. So these are incredibly, incredibly effective tools. So we have it,
however, we only have over a third of people who can benefit from prep have been prescribed prep. And if we
break that down to what sort of Vincent was saying in terms of race and ethnicity lines, only about 13% of
blacks and 24 4% of Hispanics can benefit from prep have received it compared to 94% of whites. And we think
about this, 70% of new infections are among black and Hispanics. And so we're not really reaching the, the
people we need to reach when it comes to prevention. Similarly, when we look at people with HIV who are
virally suppressed, only two thirds are in our nation. That means that one in three individuals with HIV currently
are out there, either not engaged in treatment or not on, on, on virally suppressive medication, and they can
continue to transmit the virus to others. We can stop this. We have these extremely effective tools. We just have
to get them to the people who need them the most.

Mark (11:39)
Vincent, Marwan laid out some of the shortcomings that we have, but there is also some good news, right? The
US Department of Health and Human Services states that HIV incidents among people aged 13 and older has
declined 21% in, but it's targeted in jurisdictions receiving funding from the ending of the HIV epidemic
program compared to 12% in the nation overall. and, and actually the implications are pretty significant, 5
billion in savings o over the lifetime due to the 9,500 fewer HIV infections. I'm just wondering, there's a lot of
noise out there. I'm wondering if this message is getting through to people.

Vincent (12:25)
Sure. So, thanks for, excuse me, mark that, that question, and, you know, the, the answer is is, is mixed. And on
one hand, I completely agree that as a nation, we've had tremendous progress. Most people living with HIV are
aware of their status. Increasingly, we have been able to link people to care. We have very effective treatments,
as Marin was saying, increasingly easier to, to actually dose and to take and longer acting. We have more and
more ability to prevent new acquisition of HIV. We have reduced you know, stigma in society. And certainly
there still is stigma, but nothing like it had been in the past. There's a lot to be excited about, mark. And so I
wanna be clear, That the HIV epidemic has been very effective, and it's pretty straightforward in some ways. it
has very predictable results. You know, you identified jurisdictions that have the highest rates of new infections
where there's a preponderance of people living with HIV, and you focus on those areas, and if you do the things
that align services with the people, you get positive results. That that is all true. I think the thing that is
challenging, and what I want to come back to is that despite us having all these tools, and, you know, Mara did
such a nice job at using prep as an example, we have Inequitable Healthcare and Health in our nation. And, you
know, I don't wanna move us off of HIV, but I do feel it's important to put this in a broader context. In June of
this past year, the National Academies of Science Engineering and Medicine released a 20 year follow up to the
unequal treatment report. That report, as you guys remember in 2003, was a landmark report. It said that we are
a nation that has huge inequities, inequities being unjust, unfair, negative outcomes that are a function of how
we practice and our policies and the way that care is set up. Well, we went back and I served on that committee,
and one of the things that was really surprising to me was that 20 years have passed. And as a nation, we have
made very little progress in terms of eliminating those inequities. And that's also true of HIV. And so what we
see is that while we are in fact making progress, we still have huge challenges. And those challenges, as Marin
said, are concentrated inserting groups. for today, I'm advocating for the Latino community, but let's be clear,
you know, we're not out of the woods in terms of African Americans, in terms of transgender communities, in
terms of people who use substances. We have a lot of work to do.

Margaret (15:05)
That is certainly a, a clarion call. And I, you know, this might be a question for both of you, but Marwan, let me
start with you on this. Certainly we understand there are calls for community engaged approach, and maybe
similar to what was used during the National EM impact vaccination campaign, which is fresh in people's
memories. It was very recent. Maybe take us through why that worked and how, how that might help us here.
And certainly Marwan is giving you a chance to start knowing your deep familiarity with mobile health units
and going where the patients are. but Vincent, I know you have a lot of experience in this area as well. So
Marwan, do you wanna start maybe?

Marwan (15:45)
Sure. Thank you, Margaret, for that. So, I mean, I think, I think sort of what we've been alluding to sort of all
along is that we need to really re-look at how we're delivering care and who is actually currently receiving the
care. And, and I think we need to come up with more innovative approaches to how we reach the people who
most, most desperately need to be reached, right? And so we sort of saw that with COVID. We saw that with
sort of empo and, and we were able like to sort of mass mobilize and get out there. And, you know, you
mentioned the mobile health van and you know, how, how excited I am about mobile health as well as street
medicine. Because in many ways it's, it's that last sort of frontier we always talk about, you know meeting
people where they're at. But even when we use those terms, we're still saying that those people, meeting them
where they're at still have to come to us, right? They still have to walk to the brick and mortar sites. And that's
not really meaning where people are at, right? We need to get out there, get out onto the streets, get to the, I
don't know, the barbershops, get to the, the stores. Maybe it's the Walmarts, you know maybe it's the
pharmacies. It's really thinking outside the box and going beyond just simply the brick and mortar sites to be
able to get to the people that we need to get to. It's the messaging, it's the social messaging people need to see
themselves reflected in, in who's delivering the message. We need to, to regain the trust of the public, right? I
think over the number of years, and through CID we have lost the, the, the trust of the public in many ways. And
so we need to figure out how we message this back again. and so we need to invest the money in these new
innovative models. We need to invest the money back in terms of the social me messaging and the education.
And we also need to prop up our workforce that's going to look like the people we're trying to reach. and we
know that if people see themselves in the workforce from every level, right? From, from administrators and, and
doctors and nurse practitioners down to the medical assistants and, and the front desk staff, were answering the
phones. People need to see that they are reflected in who they are. And that is true for, for black and Hispanic as
well as for gay and straight and trans and non-binary. It, it, we need to sort of prop that up. And I think we have
that infrastructure we, we've done it right. We were able to do it with COVID and with M-Pox. We just need to
start doing it now with more, more sort of targeted with HIV prevention and treatment.

Margaret (18:20)
Vincent, do you wanna add anything to that?

Vincent (18:22)
So just really briefly, I'll say Marwan did a fantastic job at really helping us to think about community
engagement and broadening the conversation. I would maybe just reinforce and build on what Marwan shared
by saying that meaningful community engagement is really elevating the community members to being equal
partners in the design and in the delivery of healthcare. It means not a top-down approach, not a health system
that is prescribing, but really a true partnership where those that are most impacted, affected key stakeholders
get to work together to think about how they can proceed collectively in ways that they can address the issue for
our purposes, HIV

Mark (19:01)
You know Vincent, Marwan mentioned social messaging in, in the last answer you were talking about stigma.
And I want to pull the thread on that, because a Latino advocate told CNN that feeling uncomfortable sharing
information with relatives or others is one of the main barriers faced that those at risk of getting HIV and those
living with HIV and she cited the strong religious influences in the community. And I'm just wondering if you
can elaborate on that and sort of talk about the challenges that this specific population has, but it also may be
something that's been shared by other populations as well, and how do we address it? And you've been talking
about raising the, the, the visibility of, of individuals making sure their voice is heard. But, but tell us a little
more.

Vincent (19:52)
So Mark, thanks for that question. Such an important issue. Stigma. HIV stigma is still persist and is certainly a
factor that impacts people, including Latinos at risk in living with HIV. there was a recent MMWR actually a
couple of years ago, that looked at Latinos living with HIV and their experiences in healthcare, and there were
some troublesome results. and so I'm intentionally Mark focusing on the sort of systems of care and less on the
individuals, but I'll come back to that because what they reported was that they had experiences when they were
receiving care that were pretty distressing, you know, feeling like people were judgmental their healthcare
providers you know, all of us not pointing fingers at any one group at all of us not feeling welcomed in the
clinic, feeling like they were being talked down to feeling like you know, they were in a setting where their best
interests were not really at the forefront of how care was delivered. Now, these are perceptions, I'm not
suggesting that they're objective facts, but the fact that Latinos living with HIV felt that way, certainly drives
their behavior. And if they're feeling, any of us feel like when we go someplace, we're not welcomed. We feel

judged. We feel like we're being talked down to, we're mistreated, and we're not gonna go back and we're gonna
be more ashamed of being able to talk about who we are. And, you know, HIV for the most part today is about
sex and drugs. And those are topics that we need to figure out way, a way as a nation to sort of grapple and talk
about. So, yes, mark, at the level of individuals, there can be stigma and shame, but it's also embedded in our
institutions in broader society. And we need to think about all of that and being able to you know, make routine
sexual health a normal part of our society de-stigmatize people that are using drugs, and think about ways that
we can help them to recover. These are big problems that we face as a nation, and they're not isolated situations.

Margaret (21:58)
Well, after several decades, I would hope that we had made more progress than we seem to have, but we will
stay with the fight. Marwan, you're the former chair of the HIV Medicine Association. It created a guide for
what President-elect Trump did on these issues during his first term. There's some notable achievements
including ready, set, prep the program to provide HIV prevention medication donated by pharmaceutical
company to people who don't have prescription drug coverage. would you like to opine on how you're thinking
about the next four years and what we might see?

Marwan (22:32)
Yeah. so definitely you know, at at the HIV Medicine Association which is part of the Infectious Diseases side
of America, we definitely sort of advocated for a number of principles in particular, right? That we, we, we
thought we needed to sort of highlight that truly to end the HIV epidemic as the Trump administration has sort
of kicked off that national initiative. And that really included ensuring, you know, healthcare access for all equal
access you know, equitable access, addressing social determinants of health, meeting people where they are, as
we talked about, and funding innovative care models, addressing the mental health and substance use epidemics
that we're in. As well as, as Vincent said, talking not only about drugs, but also about sex and ensuring that
sexual health and education happens and uh as well as looking at prescription prices, right? Fair prescription
prices uh from some of those. And, and while the ready set prep, I think was a great program to sort of access I,
I'm actually worried for the next four years because we know we're hearing about potential decrease in funding
and, and whenever we need to sort of start to scale up programs that's gonna take funding, uh in, in terms of us
doing that. And so the, the, we need to continue to look at funding innovative models as we talked about and
really looking at different places that people are doing fairly well. We can get them in, get them and then maybe
see them once or twice a year And yet, and so that we, we don't necessarily need to see them six times a year,
whereas others, we need to sort of scale up and, and put in more resources to be able to see individuals who are
struggling more often. we need to sort of really approach this in a endemic fashion. So what we mean by
endemics is there, you know, parallel epidemics that are occurring at the same time that, that that intersect and
worsen each other, especially in the context of, of, of social determinants of health that work against the
epidemics. And so when we talk about the HIV endemic, we're talking about the substance use epidemic, the
mental health epidemic, the such, the STI epidemic and the viral hepatitis epidemic. And there's been, there's
been progress in trying to break down those silos to be able to sort of read a look at funding, uh sort of parallel
programs so that way we can integrate it more. And as you know, I'm a huge advocate of integrating care across
the board, because that's how we're gonna get to where we need to get to. Uh in terms of handling the HIV
epidemic and getting ahead of it as well as these other epidemics we have to address housing, transportation,
food insecurity that we know are most vulnerable, are struggling with, which is why they're not making it in and
engaging in care and staying in care. We need to uh welcome and as sort of Vincent sort of started speaking to
our LGB and our transgender and non-binary communities are women, our racial and ethnic minorities, we need
to really think about ways to sort of expand those. And when we're thinking about prep, we're talking about
ready, set, prep, we know that, that we need a national prep program. And so we're hoping to advocate, but that
needs funding and what we need mean by the National Prep Program. We know that the Ryan White Program,
right, has been an extremely successful program in terms of engaging people with HIV and getting them in care.
So when we look at how well the Ryan White Program that's funded by the federal government does, we are
over 90% virally suppressed in the Ryan White Programs compared to 66% nationally. Right? So it does really
well. And so I think the National Prep Program is set up to not only cover medications, which, by the way, one
of the most effective medications is now generic. So you can really go generic and, and and use that cost saving
to fund the other, the other wraparound services, right? You need to cover the visits for, for pre-exposure
prophylaxis, you need to cover the, the testing, the HIV tests and the, and the gonorrhea and chlamydia and
syphilis testing. You need to cover the prep navigators and the outreach uh you know, sort of workers and the,
and the, and our peer navigators and our community health workers, those are the, those individuals are gonna
keep these, uh patients getting them in care and keep keeping them in care. And so, I think while we are starting
to do some work in advancement, we need to continue to sort of funnel in money and not cut money towards all
these programming for us to be able to really, truly get to ending the HIV epidemic.

Mark (27:16)
Marwan, and I, you, you sort of use the words vulnerable and progress. And I note that the International AIDS
Conference highlighted promising results and the safety of long-acting antiretroviral medication for HIV
prevention and pregnancy. Fill us a little more on on what's happening in that area.

Marwan (27:36)
Oh, yes, thank you for that question. This is extremely exciting. So this is so this was Purpose one and Purpose
two studies that were done. The one that you're referring to specifically was Purpose One study that really
engaged cisgender women, including they did not exclude anybody who was pregnant. So during that, that
study, there was probably around 500 or so pregnancies during that study. And this was a a, a, a medication
called Lenacapavir, which is a subcutaneous injection that is done every six months, twice a year, only
subcutaneous injection that showed zero new infections Wow. In this, in this cohort. and, and the purpose too,
looked at men of sex with men, transgender women, as well as trans men and non, and gender non-binary as
well. And that showed a 96% efficacy as again, with two subcutaneous shots a year. And so it, it, and, and that
sh was even superior to the current medications that we have for prep, which is, are extremely effective as well.
Right? So, so you can imagine how we can, if we can scale this up of, of two subcutaneous shots, right? So, uh
and, and get it to the people that need it. And, and we would drop the infection rates dramatically. The issue
here, right, again, is cost And how we're gonna scale this up and get, get these shots to, to our to our, to our
patients.

Margaret (29:10)
Well, thank you for ending on that note of progress and Dr. Vincent Guilamo-Ramos, Dr. Marwan Haddad.
Thank you both for joining us today. Thank you to our audience for being here. A reminder to be sure and
subscribe to our videos on YouTube. Find us on Facebook and X with our account name, CHC Radio. As
always, go online to chcradio.com to sign up for emails, and please share your thoughts and comments about
this program. Take care, be well. Vincent and Marwan, again, thank you for all the great work that you do.

(29:45)
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