Today, we have the right data, the right tools, and the right leadership to end the HIV epidemic.
As Prepared for Delivery
Thank you, Dr. Redfield, for that introduction, and thank you all for welcoming me here today.
It is a true privilege to be here. While I certainly cannot match Dr. Redfield’s level of experience or expertise in what we’re discussing today, infectious diseases, including HIV, have been an area of interest throughout my career in healthcare.
It is also a special privilege to be talking with all of you at this particular time.
Today, in a way we did not 15 or 20 years ago, we have the tools to end the HIV epidemic in America.
We also have a strategic plan to do it within the next ten years—and we have leaders, all the way to the top, who are committed to this goal.
I want to begin by saying a sincere thank you to all of you, for coming here to this conference, for being eager to collaborate, and, most of all, for the tireless work you’ve done to get us where we are today.
Thank you for your work as advocates, activists, public health workers, caregivers, and researchers. Thank you for what you do every day, and what many of you have done for decades, to treat and prevent HIV in America.
Because of the work you have done, President Trump could say what he said in the State of the Union on February 5: that we have made remarkable progress in the fight against HIV, that a once-distant dream is within reach, and that, together, we can end the HIV epidemic in America in the next ten years.
Today, I want to talk to you about why we believe that goal is possible—and why this administration has identified it as one of our top health priorities.
We have a catchphrase around our HIV initiative, which you’ve likely heard from some of our HHS leaders already this week.
Today, we have the right data, the right tools, and the right leadership to end the HIV epidemic. I want to explain what we mean by each of those.
Together, they underlie the President’s Budget proposal we published last week, which proposes the largest single increase in domestic HIV prevention and treatment funding in more than a decade.
But most important, that budget request fits into a broader strategy—one that is based on the best science and evidence we have and that builds on 2015’s National HIV/AIDS Strategy.
The 2015 strategy recognized many of the same insights about the new tools and new data we have regarding HIV in America.
We are now in the process of updating the strategy for 2020, drawing on the work of the President’s Advisory Council on HIV/AIDS, or PACHA.
PACHA inaugurated new leadership at a meeting I attended last week.
These new members of PACHA include co-chairs Carl Schmid and John Wiesman, and members Gregg Alton, Wendy Holman, Marc Meacham, Rafaele Narvaez, Michael Saag, John Sapero, Robert Schwartz, Justin Smith—who’s based here in Atlanta—and Ada Stewart.
Several of these members are here today, and I’d like to thank them for bringing their diverse perspectives to the table.
The input of the whole HIV community will be vital to using the pieces of the strategy I’ll describe today—data, tools, and leadership—to deliver on the goals we’ve laid out.
I’ll begin with how we have built our strategy around data.
More than 50 percent of new HIV diagnoses in 2016 and 2017 occurred in just 48 out of the over 3,000 counties nationwide, plus Washington, D.C., and San Juan, Puerto Rico.
New infections are much higher among certain demographic groups, including men who have sex with men, black and Latino Americans, and American Indians and Alaska Natives.
New infections are also disproportionately concentrated in places where socio-economic and cultural barriers to treatment and prevention remain high, including the South.
That is why our strategy focuses new resources on these 48 counties, San Juan, D.C., seven rural states, and the demographic communities I mentioned.
We believe that this strategy can reduce new infections nationally by 75 percent in the next five years, and by at least 90 percent in the next ten years.
Certainly, we have a long way to go. Today, one in two Americans newly diagnosed with HIV has had the virus for at least three years before they’re diagnosed.
One in four people newly diagnosed has had the virus for at least seven years.
This is, in part, an issue of access to healthcare—and we need better access to care.
But it isn’t just that. Seven in ten people at high risk for HIV saw a healthcare provider during the twelve months before their diagnosis.
The breakdown can be stunning. NIH’s Tony Fauci has told me about patients coming into the NIH clinic not just with HIV that took far too long to diagnose, but actually displaying the classic signs of advanced HIV disease and AIDS, which their doctors had simply missed.
After steady decreases of new HIV infections into the early 2010s, we have seen the number plateau, at around 40,000 per year.
Frustratingly, this has happened at the same time that clinical trials have shown clearly that treatment is prevention.
People with HIV who take antiretroviral therapy every day as prescribed and who keep an undetectable viral load have virtually no risk of sexually transmitting HIV to their partners.
That knowledge is vital to making the best use of some of the tools I want to describe today.
There are four key areas of action for our strategy, each of which makes use of the biomedical, programmatic, and public health tools we have.
The four strategies are to diagnose, treat, protect, and respond.
First, we’ll aim to diagnose all individuals with HIV as early as possible after infection. Earlier detection can lead to quicker, better results in treatment and in prevention of transmission to others.
The latest diagnostics and advanced automation systems give us no excuse not to make voluntary HIV testing simple, accessible and routine.
Second, we must use the tools we have to treat the infection quickly and effectively after diagnosis.
As the CDC’s new report this week laid out, in 2016, 80 percent of new HIV infections are transmitted from people who are undiagnosed or not in treatment. Diagnosing HIV and connecting people to treatment bolsters not only their health, but the health of others, including their loved ones, as well.
We already have large-scale successes, such as the Health Resources and Services Administration’s Ryan White HIV/AIDS Program, which in 2017 achieved a remarkable 86 percent viral suppression rate among its clients.
We aim to leverage and build upon this program’s comprehensive system of care and treatment to increase viral suppression nationwide to 90 percent.
This is only possible by making the right investments in the communities with the highest numbers of new HIV infections, which is why we aim to make an initial investment of $70 million in new targeted funding in the Ryan White Program for 2020.
We’ve seen success in particular communities already, like at the Phoenix Indian Medical Center’s HIV Center of Excellence, where people have a viral suppression rate of 90 percent.
A key piece of boosting viral suppression is also reconnecting those who fall out of treatment back into care.
CDC already has experience doing this in a number of demonstration projects, including efforts such as Data to Care.
Through that initiative, HHS has funded local health departments to use data in identifying people who’ve fallen out of treatment and determine how to get them back in treatment—exactly the kind of targeted approach we need.
HHS will also continue our strong commitment to the development of new treatment tools.
I am pleased to announce to all of you today that the Food and Drug Administration will announce, this morning, final versions of two significant guidances to support development of prescription drugs for HIV, one for pediatric HIV infections and one for the development of new forms of pre-exposure prophylaxis, or PrEP, with a special focus on long-acting formulations.
PrEP is a key tool we need for the third strategy we’re pursuing, to protect individuals at risk for HIV by using proven prevention approaches.
When taken consistently, PrEP has been shown to reduce the risk of HIV infection in people who are at higher risk by 90 percent or more.
Yet, of the estimated 1 million Americans at substantial risk for HIV who could benefit from PrEP, some estimates show fewer than a quarter are actually using this tool.
Gaps in coverage for PrEP are especially acute among certain populations, such as black and Latino gay men, and in rural areas and places that face socio-economic and cultural barriers to care, like the South, so we will have a special focus on closing gaps there.
Fortunately, a number of the National Institutes of Health’s Centers for AIDS Research are located in the South. We plan to increase their resources to expand our knowledge of ways to deliver the best access to new tools like PrEP.
We already have promising signs that we can increase PrEP usage among high-risk populations.
CDC supports the PrIDE initiative, an acronym that stands for PrEP, Implementation, Data 2 Care, and Evaluation.
PrIDE supports targeted efforts to connect gay and bisexual men with PrEP, or, if they have HIV, uses data to ensure they are staying in treatment. PrIDE is now operating in more than a dozen cities and metropolitan areas.
Overall, for 2020, the President’s Budget proposes $50 million to expand the availability of PrEP in community health centers, which are located in our rural and urban focus areas and are already home to many Ryan White clinics. If we meet our goal of substantially increasing PrEP use among high-risk groups, we believe we can prevent almost 50,000 HIV infections by 2030.
We also have effective prevention tools for people who use injection drugs—sadly, a population we’ve seen grow as part of our country’s opioid crisis.
When the CDC determines that a community faces an increased risk of or surge in infectious disease transmission through drug use, they can offer funding and technical support to local health departments in establishing and running syringe service programs, or SSPs, which provide clean needles to people who use drugs.
I do have to note that SSPs should not be confused with safe injection facilities, which raise entirely different legal concerns.
In addition to clean syringes, SSPs often provide connections to PrEP, substance abuse treatment, infectious disease testing, and vaccinations.
Syringe services programs aren’t necessarily the first thing that comes to mind when you think about a Republican health secretary, but we’re in a battle between sickness and health, between life and death.
The public health evidence for targeted interventions here is strong, and supporting communities when they need to use these tools means fewer infections and healthier lives for our fellow Americans.
Fourth, when HIV infections do occur, we have to respond rapidly to detect and contain any growing clusters of infections. This means putting new public health resources right on the ground in communities where we know resources can be lacking.
Toward that end, the President’s plan for ending the epidemic includes the creation of an unprecedented HIV HealthForce, and an investment of $140 million for CDC in 2020 alone to increase their ability to assist local communities.
With the tools I’ve described today, we should feel that each new HIV infection is a public health failure.
But with full implementation of this strategy, especially in targeted areas, in the not-too-distant future, we can begin treating a new infection as a sentinel event—one where public health, social services and healthcare supports are mobilized to understand how the virus is still spreading.
In some places, new HIV infections do receive the kind of comprehensive response we need, thanks to initiatives that have been launched in places like New York State, San Francisco, and Washington State. These results are inspiring, and I want to congratulate the leaders involved in those efforts.
Now, it’s time for us at HHS to bring federal leadership to assist in turning the tide on the HIV epidemic all across our country.
I am proud to say that our HHS team is committed to providing that kind of leadership. From their first days at HHS, a number of our leaders have been focused on this challenge.
For the CDC’s Dr. Redfield, those first days weren’t so long ago, and I believe he has been focused on planning the President’s initiative since his very first day here in Atlanta.
You also heard from Dr. Tony Fauci yesterday.
His first days at HHS were a bit further back in the past than Dr. Redfield’s, and his peerless scientific leadership will continue to expand the data and tools we have to fight HIV.
Our Assistant Secretary for Health, Admiral Brett Giroir, has brought a passion for combating infectious diseases to the department and is coordinating the President’s initiative.
Our Surgeon General, Jerome Adams has firsthand public health experience with a tragic HIV outbreak in Scott County, Indiana, using the full range of public health tools he needed to tackle it.
Other leaders of key HHS divisions, including Dr. Sigounas of the Health Resources and Services Administration, and Admiral Weahkee of the Indian Health Service, are deeply committed to this effort too.
I want to make a promise to you today: Just like each of the leaders I’ve mentioned, the execution of this strategy to end our country’s HIV epidemic will be a top priority for my entire tenure.
I will put more focus on the execution of this strategy to defeat the HIV epidemic than any past HHS Secretary has.
We will ensure that the entire HHS team, from top to bottom, from the leadership to every public health worker, project officer, clinician, and researcher understands the goals we’ve set—and how important it is that we meet them.
That commitment runs straight to the top. I can personally tell you that the President was overwhelmed with the response to his call in the State of the Union. He knows HHS is the department that promised him results.
The fight against HIV, and the important battle it represents for so many communities in America, has already been on his mind for some time. It will remain front of his mind throughout his Presidency.
The President’s Budget asked for an initial funding commitment from Congress, and we’ll work closely with them to secure the funding we need for this year, and then in future years. Before I conclude, I want to briefly discuss two specific areas where this administration’s leadership will be focused: bringing down the high price of the latest HIV treatments, and renewing the battle against stigma surrounding HIV.
As some of you may know, reducing the high price Americans pay for prescription drugs is one of my top priorities as HHS Secretary.
Most Americans end up straining to afford prescription drugs at some point in their lives, but high drug prices are a particular challenge for Americans with life-threatening diseases like HIV. Now, we have a variety of important programs, including 340B and the Medicaid program, that provide access to the drugs that people with HIV need.
But in the commercial market and in Medicare, today’s drug pricing system is set up quite poorly to protect Americans with high drug costs, like Americans living with HIV.
Drug plans negotiate discounts on expensive drugs, but they don’t pass them onto the people who need those drugs, instead using them to bring down premiums overall, for sick and healthy people alike.
This is deeply unfair to people whose out-of-pocket costs for drugs can be not just a challenge, but in the case of HIV/AIDS patients, a life-threatening challenge.
That is why we have proposed replacing this current system with one where drug discounts must be passed on to people right at the pharmacy counter—reducing what can be very substantial out-of-pocket costs.
At the same time, drug plans today have no power to negotiate discounts in Medicare for HIV antiretrovirals. We believe, in the name of patient access, that needs to change. I know there have been concerns within the HIV community surrounding our proposal to give Medicare Part D plans more power to negotiate these discounts, because doing so can require use of practices like prior authorization.
I want to be clear: We put forth the proposals we have on drug pricing because we want to expand access to antiretrovirals and other expensive drugs, by driving down prices. If, for instance, prior authorization requirements are reducing adherence to HIV treatment, that would defeat the point of our efforts.
In the proposal we put out around Part D negotiation, we have extremely strong patient protections.
Plans will still be bound by the same processes around transparency and clinical appropriateness of formularies that currently protect patients on Part D. There is an expedited appeals process, as well, ensuring reviews within 24 hours. We’ve appreciated all of the comments we’ve received on this proposal, including from HIV patient groups. As part of this process, we’ve even learned about challenges for patients that we weren’t aware of, but are now seeking to address.
Manufacturers protest that we cannot make these changes to the protected class rules because access to these medication is so important. We agree about their importance—but that prompts the question of why they are so unwilling to offer discounts on these drugs. Under our proposal, they will no longer have any excuse not to.
The final area for leadership I want to address today is personally, painfully known to many of you: the stigma that still tragically surrounds HIV.
Stigma has been and continues to be a barrier to any effective fight against HIV, preventing someone living with the disease or at risk for it from receiving the care, services, and respect they need and deserve. Worse, it sometimes leads to internalized stigma, which can also prevent people from seeking out the tools we have to treat and prevent HIV.
We also know stigma can be an even greater challenge when it intersects with the historic marginalization of particular populations, including African-Americans, Latinos, American Indians and Alaska Natives, and gay men.
Listening to the perspectives of these communities in particular, and working with everyone in these and other communities, on the ground, is the only way we can execute on the strategy we envision—because we are failing to win this fight in these communities today.
That’s why I want to conclude by making clear what I mean when I say we have the right leadership to defeat the HIV epidemic.
I’m not just talking about public health experts or research scientists. We certainly do need them on our side. But when I talk about having the right leadership, most of all, I’m talking about all of you.
You are the leaders we need to defeat HIV.
You advocate for people with HIV; you provide treatment and prevention services in your communities; you comfort loved ones suffering from stigma, discrimination, and marginalization.
You are on the frontlines of this fight.
We cannot win this battle without the remarkable leadership so many of you have shown for many years—and that we’ll need you to show for a few more years yet to come. So many great leaders over the years help make a meaningful difference in the battle against HIV. One of the most famous early leaders against this disease was a fellow Hoosier, a young man who left a very big legacy: Ryan White.
His mother, Jeanne White Ginder, is also an incredible leader who continues to help share Ryan’s inspiring story today.
One of the most heartbreaking parts of his story that she tells is when Ryan found out about his diagnosis.
When she told Ryan he had AIDS, the first thing he said was, “Let’s just pretend I don’t have it.”
She said, “Ryan, we can’t really do that; we have to take these precautions to keep you from getting sick.”
Ryan’s sister was there, too, and she said, “That’s not what he means.”
Ryan said, “Mom, she knows me better than you. I just don’t want every time somebody enters the room to talk like, poor Ryan, he’s dying. I just want to go ahead and go on with my life, okay?”
Ryan was a leader because he was a powerful voice against the vicious stigma that surrounded HIV.
But he had a vision, too: of a world where people with HIV could live life stigma-free, almost like they don’t have it.
Of course, no one living with HIV or their loved ones can ever forget the disease entirely.
But together, we can deliver on Ryan’s vision—where almost no one in America hears the news he received 35 years ago, where almost no American is dying of HIV, and all Americans with HIV, no matter who they are or come from, can, like Ryan said, just go ahead and get on with their lives, managing HIV just like any other chronic health condition.
We not only have the tools to make that happen—we have the power to do it in the next ten years here in the United States.
With your help, we’re going to deliver on that vision, the vision so many of you have worked toward for so long.
Thank you for having me here today.