Pete Buttigieg Explains His HIV Policy Ideas

HIV advocates have long requested that presidential candidates share their HIV policy plans, though they haven’t always gotten a response. But things have begun to change, and six of the top 2020 Democratic nominee hopefuls responded to an HIV-focused survey from ACT Now: End AIDS Coalition. The survey was sent to every major presidential candidate, including President Trump. So far, responses have been returned from several Democratic candidates. A summary of responses can be found here. Here's what Pete Buttigieg had to say.

Plus: Earlier this year, the Trump administration introduced their plan for ending the HIV epidemic in the United States by 2030. While the HIV community welcomes the increased financial resources and attention being paid to HIV by the administration, we also understand that to end the HIV epidemic we must address the social determinants of health and inequities that have led to a high-burden of transmission for HIV, STDs, and associated illnesses within vulnerable populations. Please describe what you would do to increase access to HIV prevention and treatment services, and outline your approach for addressing the social determinants of health and promoting racial justice. 

Buttigieg: My administration will undertake a truly comprehensive approach to ending the epidemic. That starts with leadership from the White House. I will revitalize the White House Office of National AIDS Policy (ONAP) — which was shut down by the current administration — to assure that all health (and related social) policy has an HIV lens. Within the first six months, ONAP will develop a revised National HIV/AIDS Strategy that truly embraces all elements of what it takes to end the epidemic.

The core principles of such a strategy are simple. First, everyone with HIV should be in treatment so they can lead longer and higher quality lives and so they won’t transmit HIV, since we know that U=U (undetectable equals untransmittable). Second, we must make sure that PrEP (and other primary prevention interventions) is readily accessible to all who are at risk and need it. Third, we must assure that all at risk for HIV — men who have sex with men, transpeople, injection drug users, women, people of color — have restored to them the civil rights protections to which they are legally entitled and receive health care in settings that are culturally competent. And fourth, we must address the stigma and other social determinants (poverty, lower income, housing insecurity, etc.) that often make accessing preventive and care services more challenging.   

As part of my overall plans for health equity, I will support increased funding for public health infrastructure, and the creation of and investment in Health Equity Zones to support local, multi-sector community solutions to reduce health disparities, including disparities related to HIV.  The answers to the questions below will provide more details that are specific to HIV treatment and prevention.  

2. U.S. HIV research investments have saved millions of lives, prevented countless new transmissions of the virus and placed us on a potential path to end the HIV epidemic. Do you support increasing dedicated HIV research funding to promote treatment advances, prevention efforts, and attempts to identify a vaccine and a cure? What, if any, changes to the current HIV prevention and research funding levels would you propose?

I support increased funding for HIV/AIDS research. The nation’s investment in biomedical and behavioral research through the NIH has resulted in groundbreaking advances in the treatment and prevention of HIV infection. Nonetheless, the epidemic is far from over, and it is critical to continue to build on the success of this research and to address the scientific gaps and challenges that remain. In the past, funding for AIDS research represented approximately 10% of the total budget of NIH, and AIDS research received about 10% of any funding increases. However, over the past five years funding for NIH has increased significantly while AIDS research funding has received none of the overall NIH increase. This is despite the fact that the NIH Office of AIDS Research has highlighted important scientific needs that require a 15% increase in funding.   

I support this increase in NIH research funding to begin to restore lost ground and to address the scientific priorities NIH has identified, including research on complications and coinfections such as cancer, TB, and neurologic complications; better, less toxic and less expensive treatments; research to better understand the differences in how HIV progresses in men and women; more effective prevention methods; and ultimately the development of vaccines and a cure that are affordable and available around the world. ​I will ensure that NIH research continues to focus on improving the health of all populations, including sexual and gender minorities, and communities of color, that have often excluded from research.​ I will also support research into new contraceptive methods that are simple, reversible, and effective for HIV/STI prevention. 

3. The opioid and HIV epidemics are two of the most pressing public health challenges of our time and they are increasingly intertwined. With 41,000 new cases of hepatitis C in the United States in 2016, of which, up to 70% occurred among people who use drugs, injection drug use is continuing to be a major factor fueling the domestic HIV epidemic. Do you support the use of federal funds to implement evidence-based substance misuse prevention and treatment strategies, including federal funding for the syringes provided at syringe exchange programs, to help address opioid addiction? What will your strategy be to extend medication to combat overdoses (i.e. naloxone) and medication-assisted treatment (MAT) to reach everyone experiencing opioid disorders? 

We cannot think about ending the AIDS epidemic without addressing directly the substance use disorder (SUD) epidemic in the United States. While opioids have fueled the immediate epidemic of overdose deaths and new HIV infections as a result of needle sharing, we should treat this as a SUD epidemic — whether through opioids, fentanyl or methamphetamine. The HIV outbreak in Scott County, IN was just the tip of the iceberg in terms of communities at risk. I saw at close range the price that is paid by not having comprehensive harm reduction and SUD treatment services. 

Among the key steps to addressing this joint epidemic are: community based substance use prevention programs that address the social and community determinants of SUD, appropriate monitoring of prescribing practices of clinicians, employing a full range of harm reduction services, including removing restrictions on use of federal funds for syringe services programs, broad availability of naloxone for overdose reversal — including distribution to users through syringe services programs and community availability on the same level as Automated External Defibrillators (AEDs), access to comprehensive health care services from SUD disorder treatment that includes MAT and treatment for hepatitis C by assuring broader adoption of Medicaid expansion and through existing networks of safety-net providers, and a recognition that we also need to more broadly invest in social support services that should surround MAT, akin to the services available for people living with HIV under the Ryan White program. I am especially concerned about the availability of MAT in rural communities where it can be very hard to find a provider who prescribes MAT. We must reexamine the waiver process that restricts prescribing MAT (while there are no restrictions on who can prescribe opioids) and expand prescribing more systematically among physician assistants and nurse practitioners. Finally, we must also address the stigma of SUD. Not unlike the stigma associated with HIV, this results in people afraid to seek care or not receiving the respectful treatment they need and deserve.  I have also made a strong commitment to strengthening our health system’s ability to address mental health issues. The LGBTQ community has demonstrated greater need for mental health services which, if unaddressed, increases risk for HIV. And we know that a strong, integrated, and comprehensive mental health component is needed as part of any response to substance use disorders.  

4. The Ryan White HIV/AIDS Program provides care and treatment for people living with HIV in the United States who are uninsured or underinsured and has demonstrated its success at linking and retaining people in care, improving both individual health outcomes for enrollees and a reduction in new HIV transmissions. Do you support increased funding for the Ryan White Program and for networks of people living with HIV that provide peer support and combat stigma? What changes, if any, would you make to the program and its funding? 

The Ryan White Program is the linchpin of our nation’s response to AIDS. Even as the number of uninsured has declined, the programs and benefits provided under Ryan White are central to a comprehensive approach to care and treatment of HIV. In addition to addressing gaps in insurance coverage — whether actual coverage or onerous cost sharing — many of the services provided under Ryan White go beyond traditional insurance benefit design, yet the programs that address the health-related social needs of people with HIV are essential to achieving the strong record of treatment adherence among Ryan White beneficiaries and are, in my view, a model for how health care and social service should be integrated in a modern health care delivery system.   

 My administration will increase funding for Ryan White. Funding has been essentially flat for the last six years. My first budget will reflect increases in funding to address both the loss of purchasing power due to inflation and the increased number of clients Ryan White must serve as more and more people learn their HIV status and seek treatment as part of our effort to end the epidemic. Funding levels will reflect my commitment to the overall program, recognizing that all parts of the country have faced increased demand, while also continuing to assist those communities hardest hit by the epidemic. I will also strengthen the Minority AIDS Initiative by increasing transparency about what minority populations are actually served, focusing on subpopulations such as Black and Latino gay and bisexual men and men who have sex with men, and transgender women of color, and supporting capacity-building by racial and ethnic minority-led organizations.   

5. Although millions of individuals have been insured through the implementation of Medicaid expansion and the Affordable Care Act, lack of access to healthcare is still a major driver of the HIV epidemic. If elected, how will you ensure that all people living with and affected by HIV have access to affordable healthcare? Please state your position on the ACA, and outline your views on the best ways to extend high-quality, low-cost healthcare to everyone, regardless of age, income, immigration status, or pre-existing condition--including in states that have not expanded Medicaid. 

I strongly support the ACA and will act immediately to reverse administrative steps taken by the Trump Administration that have weakened the ACA. This includes rebuilding outreach efforts, such as Out2Enroll, that target key constituencies for enrollment on the exchanges. That said, we must build on the ACA’s base. This includes developing a public option (Medicare for All who Want It), more generous marketplace subsidies for lower-income Americans, and expanded access to subsidies to include middle-income Americans. This should reduce costs and make more manageable premiums and other out-of-pocket costs that are causing too many Americans from seeking the care they need. I also support expanding coverage and subsidies to undocumented immigrants – something important as a moral issue but also from a practical issue in terms of ending the HIV epidemic. 

It is not clear how much more the federal government can do if a state hasn’t already expanded Medicaid, despite the ACA’s huge incentives (such as 100% coverage of the expansion population’s health care costs) and immense pressure from hospital groups and patient advocates. Their opposition is largely grounded in politics and not policy, and I think it’s unlikely we can entice states to expand Medicaid. That said, the initiatives outlined above regarding improving on the base of the ACA will fill at least some of the gaps in states that have not adopted a Medicaid expansion.   

Insurance coverage is essential, but as all those preventing and treating HIV know, the nature of the care and the benefits provided are equally important. I will make sure that all the regulatory levers of the federal government over Medicaid, Medicare, and the exchanges (as well as self-insured plans regulated by the Department of Labor) assure quality services for people living with and at risk for HIV. This includes assuring that experienced HIV providers are part of all networks, that state-of-the-art HIV drug treatment, PrEP, and substance use disorder treatment are available without bureaucratic hurdles, and that civil rights protections are enforced for LGBTQ beneficiaries. 

6. The Housing Opportunities for Persons with HIV/AIDS (HOPWA) program is the sole dedicated funding source for housing assistance and related supportive services for low-income people living with HIV and their families. Currently, HOPWA remains chronically underfunded despite the fact that housing has a greater impact on health outcomes for people living with HIV than any other factor, including demographics, substance use, mental health, or access to social services. Do you support increased funding for the HOPWA program and other programs that provide housing for people living with HIV?  

Housing is one of the most critical social determinants of health. We have known for some time that those who are stably housed are more likely to have improved health outcomes once they enter care. This has been shown again and again for those living with HIV. I will support increases in HOPWA and other programs that provide housing for people living with HIV. The current administration’s approach to housing seems to be to find as many ways as possible to limit access to housing support programs. For example, I will immediately rescind the proposed Department of Housing and Urban Development regulation requiring additional immigration documentation for those living in public housing and using housing vouchers. I will make ensuring stable housing for all Americans a central social ​and ​health priority. 

I will support increases in HOPWA funding, based on the needs identified in a revitalized National AIDS Strategy. Just as importantly, I will encourage states to explore the use of Medicaid funds to provide more supportive housing and short-term rental assistance, as some are already doing under waiver authority. This is a more stable funding stream and is not dependent on the annual appropriations process. 

7. What will you do to prohibit discrimination based on sexual orientation, racial and gender identity in housing, healthcare, the workplace, the legal system, privately-owned businesses, and access to federal benefits?  

We must pass ​the Equality Act, remove the deadline for the Equal Rights Amendment, and ensure that legal and regulatory measures be universally available to people and to communities to protect their health and human rights. To that end, we will​ revitalize the Office of Civil Rights in HHS and within all federal agencies to assure that all regulatory enforcement levers are readily available through federal law. We will support civil rights, health and environmental laws, policies and regulations that provide a framework for addressing health inequities, promote equal access, and prohibit discrimination (such as the Civil Rights Act, the Fair Housing Act, the Americans with Disabilities Act, the Affordable Care Act, etc.), and include provisions against discrimination in any future legislation. We will reverse the Trump administration’s conscience rules, which interfere with the basic health care needs of women (including access to abortion and contraception), LGBTQ Americans, and families by prioritizing a provider’s beliefs over care to patients. We will immediately rescind HHS’ proposed regulation weakening protections against discrimination based on sex, gender identity, sexual orientation, and primary language under the Affordable Care Act. We will empower state and local executives (Governors, Mayors) and legislative bodies to rebuild underfunded state and local human rights agencies, thus strengthening enforcement of existing civil rights laws and more effectively combating rising harassment and discrimination across health, employment, housing, and public spaces, at the local level. 

8. Americans living with HIV continue to be subject to stigma and discrimination, and many are subject to outdated and stigmatizing criminal laws where they are susceptible to enhanced sentencing based upon their HIV status. These laws violate the human rights of people with HIV, sometimes imposing extremely severe punishments on people with no intent to harm and behaviors that pose no risk of HIV transmission. Moreover, these statutes discourage those at risk from learning their HIV status and subsequently beginning treatment to extend their longevity and quality of life. Will you work to pass a law that ends the criminalization of HIV status? Will you work to extend federal protection from discrimination based on HIV status? What other steps, if any would you take to help reduce HIV/AIDS stigma and discrimination in the United States?  

I agree that HIV criminalization statutes are stigmatizing and could well discourage people from learning and/or revealing their status and/or entering treatment. I can assure you that my Department of Justice will not prosecute people (or seek enhanced sentencing) because of their HIV status. I will also order a review of Department of Defense policies in this regard to assure that no further prosecutions take place. The federal government has limited control over the biggest problem: prosecution (or the threat of prosecution) at the state level. That said, this is a serious public health issue and I will direct the Centers for Disease Control and Prevention’s public health law program to issue guidance to the states on this matter, and work with the National Conference of State Legislatures and National Governors Association to support model laws and strategies that would repeal these unnecessary and stigmatizing laws. 

9. Given the advances in medical treatment available to all servicemembers for over two decades, do you support lifting unnecessary restrictions that prevent individuals living with HIV from enlisting, being commissioned as an officer, or deploying in the Armed Forces of the United States? 

Yes. For the overwhelming number of people living with HIV, disease management is no more complex than for other chronic conditions that can be managed through medication and monitoring. People with HIV, whether in the armed services or in the foreign service, should be permitted to pursue their careers without HIV-specific restrictions. 

10. Despite the existence of antiretroviral medications that can render the viral load of a person living with HIV undetectable (and therefore untransmittable), and prevent transmission of the virus through pre-exposure prophylaxis (PrEP) many people in need of such medications cannot access them because of their high cost. In other instances, our insurance premiums go up, and/or taxpayers are stuck holding huge costs. If elected, how will you reduce excessive drug prices in the United States, through executive action, as well as legislation? Will your plan make use of government purchasing power to negotiate lower prices and work towards policies similar to all other developed countries to limit abuses of the patent monopoly system? 

The global goal to end the HIV/AIDS epidemic by 2030 is not only laudable but achievable in the US if we can confront the disease head-on with proven, effective preventive treatments like PrEP. However, PrEP’s high cost — $2,000 a month in the United States — is one of the main reasons why less than 10 percent of the 1 million people the CDC estimates should be on PrEP take the medication. We cannot broaden access to PrEP by only mandating full coverage of the drug and associated monitoring costs through public and private insurance plans. To make PrEP available to every American who needs it, we need to also address its cost. My administration will do this by ensuring that PrEP and associated testing costs are fully covered by insurance plans, and will give the federal government broader authority to negotiate lower prices for PrEP and antiretrovirals more generally; if those negotiations fail to make substantial reductions in price, we will enforce existing rules on compulsory licensing to take over drug company patents and lower drug prices.  

11. According to the CDC, an estimated 14 percentage of transgender women are living with HIV, with an estimated 44 percent identifying as Black/African-American, 26 per Hispanic/Latinx, and 7 percent White. The number of transgender people who received a new HIV diagnosis was 3 times the national average. If elected, would you support a reinterpretation of Section 1557 of the ACA as covering transgender people and champion the passage of the Equality Act? How would you protect the rights, well-being, and lives of transgender people living in this country, while ensuring that they receive the healthcare and housing necessary to be virally suppressed?

My administration will immediately rescind the Trump administration’s efforts to strip protections against discrimination for LGBTQ Americans. We will issue unequivocal guidance against discrimination based on sex, sexual orientation, and gender identity in all federal and federally-funded programs and activities. We will reverse the Trump administration’s conscience rules, HHS proposed regulation weakening protections against discrimination based on sex, gender identity, and primary language under the Affordable Care Act, and Department of Education guidance that strips protections against discrimination based on gender identity and sexual orientation. We will vigorously support the swift enactment of the federal Equality Act, which will prohibit discrimination based on sex, sexual orientation, and gender identity.  

 12. Many documented and undocumented immigrants living with and affected by HIV are refraining from seeking out HIV and general medical care due to fear of deportation or denial of citizenship. Please state how you would encourage this population to be screened for HIV and initiate treatment if diagnosed, and how to ensure healthcare spaces are safe spaces for immigrants and health providers from immigration enforcement? What are your views on potential changes to the “public charge” rule that would make any use of a very wide range of benefits (including healthcare programs such as the Affordable Care Act marketplace subsidies, Children’s Health Insurance Program and potentially some Medicaid benefits) detrimental to an immigrant’s chances at becoming a U.S. citizen? 

We will never end the AIDS epidemic if we push one segment of the at-risk population underground. It is morally wrong and it is very bad public health practice. In a Buttigieg administration, we will reverse any public charge provisions that the Trump administration puts in place. We will clarify — through policy and a public education campaign — that all immigrants, regardless of status are welcome to be served in all public health programs, including Ryan White, community health centers, and publicly funded family planning and STI clinics. I also believe that undocumented immigrants should have access to Medicaid and the ACA marketplace. And I am committed to working with Congress to find a pathway to citizenship for the undocumented immigrants currently in the United States. 

13. The escalating pace of the introduction and passage of federal and state bills that restrict legally protected health care services, including abortion and some forms of contraception, is already having adverse effects on young people, women, and people living with HIV. How will you ensure people of childbearing potential that, regardless of income, geography, or any other stigmatizing restriction, they will have unfettered access to all of their needed sexual and reproductive health services? Additionally, how will you communicate the government's full support of sexual and reproductive health, rights, and justice of all people living with HIV and those who may be vulnerable to contracting HIV? 

Sexual and reproductive health is a key issue for many Americans, and there’s a lot we must do, starting on day one, to ensure access to high-value, safe and evidence-based care for all. My administration will have a national strategy on reproductive health and wellness that strengthens access not only to abortion, but to all aspects of reproductive health, from sex education to research, to coverage and clinical care. It will address reproductive health comprehensively, throughout the lifespan, as well as the systemic barriers that minorities face, in particular women of color, LGBTQ communities and those who are living with HIV, including discrimination, housing and affordable health coverage. I will work to codify abortion rights into law and eliminate the Hyde Amendment to restore funding for abortion care for Medicaid and other federal health programs. I will seek judicial nominees that share my same sense of freedom about abortion rights. I will champion availability of Title X as a pillar of public health and support increased funding to increase the availability of Title X providers across the country.

 My administration will defend the contraception mandate across all health plans, including no cost-sharing, and support initiatives to expand access to affordable contraception. In addition, we will prohibit states from awarding federal Temporary Assistance for Needy Families (TANF) funds to Crisis Pregnancy Centers (CPCs) that do not offer comprehensive, unbiased, reproductive health care that facilitates successful family planning. We will also vigorously support efforts to require CPCs to clearly and prominently disclose their stated mission of preventing women from having abortions on their websites and property to assist women in making informed choices when seeking care.  Not all of these challenges can be addressed through federal policies. But the federal government can be a leader in encouraging state-level and private actors to support the sexual and reproductive rights of people living with and at risk for HIV. Using the bully pulpit of the White House, my director of the Office of National AIDS Policy can give voice to these issues and a revitalized National AIDS Strategy will also identify what players beyond the federal government can do.   

14. In recent years, the need for comprehensive prison and justice system reforms that focus on rehabilitation and the wellbeing of those who are incarcerated rather than punishment has become clearer than ever. What will you do to ensure that incarcerated people living with HIV and those who may be vulnerable to contracting HIV receive uninterrupted, unfettered and fully funded access to healthcare and medications for treatment both while they are in prison or jail, and when they are released for re-entry into their communities? 

An unjust criminal justice system means an unjust health care system. Currently, correctional health is neither paid for by federal health dollars nor subject to quality controls and oversight that would accompany these funds. The result is a separate and lower standard of care in jails and prisons that has deadly implications for people with HIV, opioid use and substance use disorder, mental health issues, and chronic illnesses. We will ensure that those who are incarcerated receive the same high-quality standard of treatment that all Americans deserve. We will support repeal of the Medicaid exception for incarcerated people. In the meantime, we will encourage states to take the option of suspending (rather than ending) Medicaid benefits for the duration of incarceration to assure continuity of care. The current Medicaid exception also creates avoidable gaps in care during re-entry into the community. We will support re-entry programs that fully integrate the formerly incarcerated into society by providing the tools necessary for success, including lifting barriers to accessing public benefits, including Medicaid, SNAP, and housing credits. We will promote coordination and continuity of care as part of the re-entry process. 

15. Ending the HIV epidemic in the United States is also dependent on ending the HIV epidemic across the globe. Traditionally, the US has taken a leadership role in funding for both PEPFAR and The Global Fund, but recent years have been characterized by flat-funding and the threats of massive cuts in funding for fighting these pandemics. Would you commit to launch a stepped-up effort to end the deadliest pandemics, including AIDS, and prepare for and prevent epidemic threats of the future with expanded results-oriented programming, doubled US investment in fighting pandemics, and US leadership to rally the world to join us in this effort? 

Our administration will end our withdrawal from international institutions, partnerships, and programming that provide for our shared health security. On HIV/AIDS, we will invest in evidence-based programming that prioritizes vulnerable populations and the promotion of gender equity, reproductive rights, transparency, and accountability. This means expanding funding for PEPFAR and the Global Fund to projected needs level and rolling back the Mexico City policy. On pandemic preparedness, we will resume our leadership in global and multilateral partnerships, meet our commitments to fund the WHO and pandemic programming at home and abroad at appropriate levels, and motivate allies to bring more investments to International Health Regulations (IHR 2005) implementation and related programs.