The Impact of the 2020 Election on HIV and Related Issues

With less than one week to go until the November 3^rd elections, the HIV world is considering the potential for change, not only at the top of the ticket, but also at the Congressional and State levels as well. Interestingly, the impact on official policy at the national level has largely taken place within the context of responding to HIV community calls to end the HIV epidemic by 2025. To best prepare, the HIV community has been working to update documents in advance of a potential White House transition, assuming that Democratic challenger Joe Biden wins, particularly in the era and context of Black Live Matter and COVID-19.

Most recently, the Act Now End AIDS coalition rereleased an updated Executive Summary to the community-driven policy paper ‘Ending the HIV Epidemic in the US’, calling on the next presidential administration to center human rights in the national HIV response and to recommit to ending HIV by 2025. The Federal AIDS Policy Partnership, an umbrella organization for HIV groups doing work in Washington, has also begun its process of writing a transition document as well. The Academy is involved in these conversations at all levels.

In June, former Vice President Biden’s campaign released responses to a questionnaire from a coalition of HIV organizations. The candidate pledged, “I will update and implement the Obama-Biden Administration’s comprehensive National HIV/AIDS Strategy. I have long fought for access to treatment for people with HIV/AIDS and funding for HIV/AIDS research, and I helped pass and expand the Global AIDS program (PEPFAR). As President, I will re-commit to ending the HIV/AIDS epidemic by 2025.” President Trump’s campaign did not respond to the question. However, the Administration has previously announced “Ending the HIV Epidemic: A Plan for America” (EHE), a plan that seeks to end the HIV epidemic by 2030.

The EHE plan was accompanied by initial funding increases for Fiscal Year 2020 and presumably the Administration would maintain continuity. However, analysts have noted that there is a discontinuity between the Administration’s plans to end the epidemic and support for the Supreme Court to strike down the Affordable Care Act which the plan assumes will remain in place and static to reach its goals. Additionally, President Trump on October 20^th threatened to withhold funding from Democratic led cities that he has deemed “anarchist jurisdictions.” The Department of Health and Human Services (HHS) created a list that included funding for EHE as well as funding in other key areas such as fighting the opioid epidemic.

One interesting aspect of the election is that almost all of the top-level people who are in positions related to HIV policy have achieved national profiles as a result of the COVID-19 response. Many of them have worked for both Republican and Democratic administrations prior to this year. An odd aspect of the COVID-19 response has been how often President Trump has clashed with his own administration staff about the response including at times the Director of the National Institute of Allergy and Infectious Diseases (NIAID), Dr. Anthony Fauci, who is recognized as the nation’s top expert on infectious disease. At the beginning of the month, Dr. Fauci repudiated a campaign ad that appeared to take his complimentary words about health care workers and apply them to the President. Since then the President has attacked Dr. Fauci during the final Presidential debate. Other advisors such as United States Global AIDS Coordinator Dr. Deborah Birx, the response coordinator for White House Coronavirus Task Force and Centers for Disease Control and Prevention Director, Dr. Robert Redfield, have been disparaged by the White House in the last several months.

The negative talk from the President has led to speculation that these advisors could be changed even if President Trump wins reelection. In particular, a new Executive Order released on October 26, would allow the President to create a new class of “policy-making” civil servant positions that could then be hired or fired at will. Such a reclassification has the potential to apply to Dr. Fauci, possibly enabling the President to remove him following the election. Drs. Birx and Redfield are in political positions and could be let go at any time.

Of course, if Joe Biden were to win most of the high-level political positions relating to HIV would change over. In fact, it’s possible that Biden would also restore the position of the Director of Office of National AIDS Policy, a position that the Trump Administration abandoned in the second year of his Presidency. Without speculating on specific names, many of the Biden advisors on health policy were part of the Obama administration’s – and some even part of the Clinton administration’s – efforts to pass health care reform. As such, it would not be surprising for Dr. Fauci, a very familiar figure to all of them were to stay, at least for a short time.

In the meantime, there are 35 Senate seats, every House seat, 11 Gubernatorial races and multiple state legislative seats on the ballot as well. In the Senate, there are 12 Democratic and 23 Republican held seats that are up for reelection. According to the Cook Report, all Dems are in solid D races with the exception of Gary Peters (MI) who is in a seat that leans towards Democrats (Lean D) and Doug Jones (AL) in a seat that “Leans R”. Republican seats are more mixed with the races of Senators McSally (AZ) and Gardner (CO) leaning towards Democrats and Loeffler (GA), Perdue (GA), Ernst (IA), Collins (ME), Daines (MT), Tillis (NC) and Graham (SC) in tossup seats with three additional seats, Sullivan (AK), an open seat in Kansas and Cornyn (TX) Lean R.

The Cook report notes 60 competitive races in the Lean D, Toss Up and Lean R categories with the Democrats likely to retain their House majority. There are only two competitive governors races. Montana’s Dem Gov (Steve Bullock) is running for Senate so that’s an open race and rated a toss-up, while Republican Governor Parson in Missouri is in a Lean R seat. Otherwise all Ds and Rs up for reelection are in either Likely or Solid territory for their parties. Finally, state legislatures seem to be competitive this year in a way that they have not been before. Texas, North Carolina, Pennsylvania, Minnesota, Michigan and Iowa have been cited as potential changes, while Wisconsin, Ohio, Florida and Georgia seem likely to maintain and even increase Republican majorities. One important reason to keep an eye on the states is that following the release of the 2020 census, all states will redistrict for the U.S. House and state legislatures potentially affecting who will control various HIV processes.

With many states creating their own plans to end HIV and the intersection of key epidemics including COVID-19, hepatitis, the opioid overdose crisis, endocarditis, homelessness and more, the health care stakes of this election continue to grow. As a result, the message from HIV advocates across the country has never been clearer to vote.