WASHINGTON — In his State of the Union address, President Trump announced a bold plan to end the scourge of H.I.V. by 2030, a promise that seemed to fly in the face of two years of policies and proposals that go in the opposite direction and could undermine progress against the virus that causes AIDS.
In November, the Trump administration proposed a rule change that would make it more difficult for Medicare beneficiaries to get the medicines that treat H.I.V. infection and prevent the virus from spreading.
Mr. Trump has repeatedly urged Congress to repeal the expansion of Medicaid under the Affordable Care Act, even though Medicaid is the largest source of coverage for people with H.I.V. And he has promoted the sale of short-term health plans that skirt the Affordable Care Act, even though such plans usually exclude people with H.I.V.
To end the spread of the virus, federal health officials say they must reduce the stigma attached to gay men and transgender people who are at high risk so they will seek testing and treatment. But for two years the administration has tried to roll back legal protections for people in those groups.
Those opposing moves by the administration have AIDS activists baffled.
“The president’s announcement comes as a surprise, albeit a welcome surprise,” said Jennifer C. Pizer, the law and policy director at Lambda Legal, a gay rights group. “It represents an about-face on H.I.V. policy.”
The administration describes the plan to end the spread of H.I.V. as one of the most important public health initiatives in history. But the record shows a rather large gap between the administration’s words and deeds.
A Trump proposal would limit Medicare drug coverage.
Since Medicare’s outpatient drug benefit began in 2006, the government has required prescription drug plans to cover “all or substantially all drugs” in six therapeutic classes, including antiretroviral medicines to treat H.I.V.
In November, the Trump administration proposed a new policy to cut costs for Medicare by reducing the number of drugs that must be made available to people with H.I.V.
The proposal would allow certain exceptions to the requirement for Medicare drug plans to cover all drugs in the six “protected classes.”
Insurers could require Medicare beneficiaries to get advance approval, or “prior authorization,” for H.I.V. drugs and could require them to try less expensive medications before using more costly ones, a practice known as step therapy.
People with H.I.V. and doctors have condemned the proposals.
Bruce Packett, the executive director of the American Academy of H.I.V. Medicine, representing doctors who care for H.I.V. patients, said the administration’s proposals “could be catastrophic” for Medicare patients with the virus, as well as for the president’s campaign to end the epidemic.
“At least 25 percent of all people living with H.I.V. who are in care in the United States rely on Medicare as their insurer,” Mr. Packett said.
Those patients are 65 or older or have disabilities and often have other chronic diseases or conditions, so doctors need access to the “full arsenal” of medicines to treat H.I.V., Mr. Packett said.
Many of the Medicare patients with H.I.V. are taking medicines for their other conditions, so doctors have to worry about drug interactions, Mr. Packett said. In addition, he said, some have drug-resistant strains of H.I.V., and different patients often respond to the same drug in different ways.
“It’s important that providers have access to all the available options” among drugs to treat H.I.V., he said.
Requirements for prior authorization and similar restrictions can delay the start of treatment. Studies show that a rapid start to therapy, within a week or even a day of diagnosis, produces better results for patients and reduces the likelihood that they will infect others while waiting for treatment.