98% Of Counties Most At Risk For HIV Outbreaks Voted For Trump

An HIV outbreak in Indiana ravaged one rural community while Pence was governor. Will it happen again?

Illustration: Diana Quach
Dec 01, 2016 at 12:59 PM ET

Donald Trump talked little about HIV and AIDS on the campaign trail. But actions speak louder than words, and Trump has already chosen a governor whose policies helped cause an HIV outbreak as his vice president and a vocal opponent of the Affordable Care Act and LGBT rights as his secretary of health and human services. But while HIV prevention may not be a priority for the Trump administration, a sudden outbreak is likely to disproportionately affect Trump voters who live in rural counties hit hard by the nation’s opioid epidemic.

By far the most common cause of HIV transmission is male-to-male sexual contact, which accounted for more than 26,000 new cases in 2015. But another 2,300 cases last year were the result of using infected syringes to inject drugs. Nearly a tenth of those occurred in a single rural county in southern Indiana. It’s a story Vice President-elect Mike Pence knows well, given it was his reluctance as governor to go against his religious beliefs and institute a clean syringe exchange program that helped cause that HIV outbreak, which occurred in Scott County.

Earlier this year, the Centers for Disease Control and Prevention determined the 220 counties most at risk of an outbreak similar to what occurred in Scott County. Primarily clustered in Appalachia, these counties are overwhelmingly poor and rural, areas hit hard by unemployment and the opioid drug epidemic. They also have something else in common: 216 of the 220 counties voted for Donald Trump and Mike Pence on November 8, with the Republican ticket capturing 71 percent of the total vote in those most vulnerable counties, according to Vocativ’s analysis. Scott County voted 68 percent for Trump and Pence.

Because of its historical ties with advocacy by LGBT groups, advocacy for HIV prevention might appear to be a progressive, left-leaning issue. And it’s true that those hit hardest are still the black and LGBT communities. But on the particular issue of sudden outbreaks, where many are infected at once, the highest risk has shifted to rural, predominately white communities where syringe drug use has become more common and HIV awareness is lower. In other words, it’s the same overlooked population that helped drive Trump’s upset victory.

So how will the incoming administration approach a public health crisis that specifically affects its base? “The major concern that we have with Trump is we don’t know what he’s going to do,” Jeremiah Johnson of the Treatment Action Group told Vocativ. “He’s volatile. Right now, with HIV/AIDS, we’re fortunate in the sense he hasn’t even mentioned us in his efforts to scale back health care in the country.”

Whatever the incoming administration’s intentions, syringe programs and other preventative measures have support from powerful congressional Republicans like Senate Majority Leader Mitch McConnell and Chairman of the House Appropriations Committee Hal Rogers, both of whom are from Kentucky. So the risk isn’t necessarily that Trump or Pence will specifically target syringe exchange programs or change the national policy on HIV and AIDS prevention.

“I actually have reason to believe that he might be okay on syringe services, but in other areas he’s very much going to seek a major change in the health care safety net,” William McColl, the director of health policy at AIDS United, told Vocativ.

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Dismantling the Affordable Care Act, privatizing Medicare, and turning Medicaid over to the states — all policies Trump or his health care appointee Tom Price have talked about — could directly reduce access to and drive up the cost of the drugs needed to treat HIV. But it could also make prevention harder, making it more difficult to expand syringe exchanges and other programs that can stop an outbreak before it starts.

“This is about valuing communities that need our support to take care of themselves,” said Johnson. “These are not immoral, irresponsible, stupid people. These are just humans who when we don’t invest in these communities, when we neglect them, when we don’t spend public health dollars on them, this is what happens.”

HIV prevention doesn’t have to be hugely expensive — syringes are dirt cheap, especially compared to a lifetime’s worth of antiretroviral drugs and other health care costs — but it does require the government to see maintaining and expanding programs as a project worth undertaking.

“We’re only barely starting to make progress on this, and I’m very concerned that having only reluctant participation in that process is going to make the problem worse,” said Johnson.

An administration that values cutting domestic spending is unlikely to be a strong ally in that effort, even before getting into any moral objections decision makers like Pence might have. And other policies shaped by that same socially conservative ideology can also worsen the risk of the outbreak.

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“We know that there’s a real effort to defund Planned Parenthood throughout the U.S., and those clinics are often in places that are underserved,” said McColl.

Indeed, Pence’s slashing of state funding in Indiana led to the closure of the Planned Parenthood in Scott County a year before the outbreak began — shutting down a facility that offered HIV testing and key prevention and counseling services and leaving the area with just a single hospital. “Actually finding people who are able to do treatment and finding people who are likely to catch the beginning of the outbreak, I could see that being somewhat at risk.”

As with many of the specifics of Trump’s policies, what will actually happen next is an open question. But Johnson said there is reason for real concern, particularly when the best one can say is that Trump hasn’t really gone out of his way to demonize those with HIV or AIDS. It’s harder to argue the same for two of his most important allies in shaping the future of the country’s health care.

“This is about people’s lives and making sure they feel valued,” said Johnson. “And I think that’s something Pence and Price have proven they really don’t care about, quite frankly.”