The right's escalating culture war — with vigorous attacks on abortion and gender-affirming care for minors — incurs ever-evolving collateral damage. In recent months, conservative lawmakers have introduced legislation centered on banning books with LGBTQ+ content, obstructing transgender care in both minors and adults, and removing nationwide access to mifepristone—one of the drugs used to manage both medical abortion and early miscarriage. Recent events suggest that the newest casualty in these battles may be access to HIV care.
On Thursday, a federal judge appointed by George W. Bush struck down a key provision of the Affordable Care Act requiring health insurance companies to cover PrEP, the highly effective drugs used for HIV prevention. The Texas judge found that this section of the 2010 law could no longer be enforced against employers because "compulsory coverage for those services violates their religious beliefs by making them complicit in facilitating homosexual behavior, drug use, and sexual activity outside of marriage between one man and one woman." The ruling could severely restrict access to an indispensable medication that is already underutilized due to race-based healthcare disparities, prohibitive costs, and physician under-prescribing, among other factors.
Months earlier, Tennessee's Department of Health revealed that they will be turning down $8.3 million in federal funding for the prevention and treatment of HIV. It's a shocking move, considering that parts of Tennessee, like much of the South, are HIV hot spots, with Shelby County (home to Memphis) reporting one of the highest new infection rates in the country. These funds, furnished by the Centers for Disease Control and Prevention, are split among various organizations that provide HIV care. Sources within the Tennessee Department of Health believe this wholesale rejection of federal HIV funding is at least partly motivated by recent right-wing attacks on gender-affirming care for minors.
Last fall, conservative political commentators including Matt Walsh and Ben Shapiro declared that Vanderbilt University Medical Center's transgender clinic was mutilating children. A Daily Wire article that followed described the state's volunteer-run Transgender Task Force—which provides HIV services to transgender individuals—as an extremist activist group that "promotes transgender surgeries and abortion." This got the attention of Tennessee Governor Bill Lee, who, through a spokesperson, promised that "these ideologies" would not be funded by the state. Rather than allow the Transgender Task Force to continue receiving just $10,000 in annual CDC funding, the Lee administration chose the nuclear option—rejecting all $8.3 million in federal funds earmarked for HIV prevention in the state.
The Lee administration claims they will provide the same level of HIV care using state funds. But the "vulnerable populations" that they've named as priorities are deeply concerning: "victims of human trafficking, mothers and children, and first responders." While everyone should have access to HIV care, the aforementioned groups are in grave misalignment with those actually facing the highest HIV risk. Human trafficking is not a major driver of new HIV infections in the U.S. In 2020, women represented a minority of new HIV diagnoses in Tennessee (16%), and it's unclear what percentage of those were mothers. In 2019, not a single Tennessee infant was born to a pregnant person living with HIV. And first responders who experience a needlestick injury face an HIV risk under 0.3%. Post-exposure prophylaxis medication reduces that risk to a near impossibility.
Transgender individuals, men who have sex with men, sex workers, people experiencing homelessness, and those who inject drugs are by far the most vulnerable groups that HIV funding should prioritize, with a particular focus on people of color. These groups' risk is further compounded by the costs of HIV care, the difficulties of navigating our country's convoluted healthcare system, and pharmaceutical marketing campaigns that have largely targeted pre-exposure prophylaxis toward white queer men and ignored communities of color and trans people.
As an HIV pharmacist who is intimately familiar with barriers to care, I'm enraged by the Lee administration's flagrant disregard for those most in need. Directing HIV funding toward a sanitized list of people the administration feels are most worth protecting may please some conservatives — but it should disturb anyone who cares about public health, as it may also be a bellwether for a nationwide disaster.
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Lest you think this is a Tennessee-specific issue, allow me to restate that federal funding for HIV care is often funneled through organizations that support gender-affirming care for minors and abortion. Planned Parenthood of Tennessee, for example, is another organization the Lee administration is pulling funding from, despite the state already having one of the most draconian abortion bans in the country. Planned Parenthood of Tennessee no longer provides abortions. But their association with reproductive choice is undesirable enough for the governor to kneecap their HIV preventative services entirely.
Currently, 38 states are pursuing anti-trans legislation, 21 of them focused on bans of gender-affirming care for minors. 24 states have outlawed or are likely to outlaw abortion, and five states have signed bills to defund Planned Parenthood. Anti-trans legislation has advanced across several states in just the last few weeks, including the Kentucky House and Senate overturning the governor's veto on a sweeping anti-trans bill, the Idaho House passing a bill that criminalizes gender-affirming minor care, Texas introducing a bill banning state funding for transgender care in Texans of any age. And on March 2, Gov. Lee signed into law a ban on gender-affirming care for Tennessee minors, which will require them to detransition by March 2024. States with Democratic governors are less likely to face these particular challenges, but where does that leave the 26 states governed by Republicans? The right-wing obsession with restricting abortion and transgender services for minors—and what this will mean for HIV care—is a national issue that should raise alarm bells.
To paint any of this legislation as a righteous attempt to protect children is ludicrous. The American Academy of Pediatrics and the American Medical Association, among other major medical groups, have decried bans on gender-affirming care for minors, insisting that these services are medically necessary. Studies have shown that gender-affirming care—particularly when integrated with HIV care—improves viral suppression in those living with HIV. And, perhaps most significantly, suicidality is already incredibly high among transgender individuals, with minors facing the highest risk. Meanwhile, gender-affirming care is associated with reductions in depression and suicidality. Children will quite literally die from these right-wing attempts to "protect" them.
The individuals most impacted by bans on gender affirmation, abortion, and HIV care overlap, and the funding for these varied services cannot be cleanly separated. Tennessee may be the first state to outright reject national funding for HIV care in favor of a state-run model that prioritizes all the wrong groups. Who's to say they'll be the last?
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