It is not an overstatement to say that the nation Americans woke up to November 9 is charted on a fundamentally different course than the day before. The differences in both temperament and in policy between the now President-elect Donald Trump and Hillary Clinton could hardly have been starker. For people living with or affected by HIV, the choice was between a woman who had been working to end the HIV epidemic for more than 2 decades as a First Lady, Senator, and Secretary of State and a man whose campaign didn’t have an HIV/AIDS policy. On Tuesday, America chose the latter to be their next president, a decision that will force HIV advocates to confront some new and unexpected challenges. These challenges may be daunting, but they will not be insurmountable. We know this because we have been here before. And because of this, we know that we can succeed. Our roles as advocates for policies and rights are needed now more than ever.

Making matters more difficult for those working to promote the health and wellbeing of people living with HIV is the fact that, in addition to winning the White House, the Republican Party held onto control of Congress. The GOP lost only 2 seats in the Senate in Tuesday’s elections with Tammy Duckworth (D-IL) and Maggie Hassan (D-NH) defeating incumbents Mark Kirk (R-IL) and Kelly Ayotte (R-NH) and 6 seats in the House of Representatives. Republicans will have control of both the Executive and Legislative branches of the federal government for at least the next 2 years. In addition, the continued uncertainty surrounding President Obama’s nomination of Merrick Garland to replace Antonin Scalia and the advanced ages of Justices Breyer, Ginsberg, and Kennedy leave the ideological leanings of the court very much in doubt.

What does this mean for US health care and HIV policy? It’s hard to know for sure, but based on President-elect Trump’s recently released plan for his first 100 days in office and remarks from Senate Majority Leader Mitch McConnell, one of the first actions that the Trump administration and Republican-led Congress will likely take on is one that the GOP has been trying in vain to do for 6 years now: to repeal the Affordable Care Act. The days of President Obama’s signature piece of legislation may be numbered and, although a full repeal of the ACA is unlikely given the Republican Party’s slim majority in the Senate, the fallout for people living with or vulnerable to HIV will be significant.

Using the Restoring Americans’ Healthcare Freedom Reconciliation Act of 2015 that was passed by the House, but vetoed by President Obama last year as a template, we can be relatively certain a Trump administration would aim to roll back Medicaid expansion, eliminate the individual health insurance mandate, and get rid of subsidies to help middle-income families purchase health insurance. According to the Congressional Budget Office, the repeal of the portions of the ACA outlined in the Restoring Americans’ Healthcare Freedom Reconciliation Act of 2015 would leave an additional 22 million Americans without health coverage. 

With the partial repeal of the Affordable Care Act on the horizon, it is impossible to overstate how important the Ryan White Care Act is to the health of people living with HIV in America. Now, more than ever, it is incumbent upon us to defend the Ryan White Program with every ounce of energy at our disposal. Without the ACA, the Ryan White Program will be the primary safety net for hundreds of thousands of people living with HIV. Under a Trump administration and a Republican Congress, we must prepare ourselves to protect the Ryan White Care Act, because it very well might be threatened. Attempts to flat fund or cut funding to the Ryan White Program are likely during the next 2 to 4 years and it is up to us as HIV advocates to stem the advance of those who threaten to limit access to HIV treatment and support services.

For three decades, the HIV movement has fought tirelessly to emerge from a place of hopelessness and chaos to one of strength and transformative power. Whether you’ve been fighting for the rights and welfare of people living with or affected by HIV since the epidemic’s inception or are new to the cause, we all have the responsibility to stand up and demand that our government be accountable to those that they might otherwise ignore or disenfranchise. We have every right to expect a federal response that promotes the health of all Americans, regardless of gender, sexual orientation, race, creed, or health status. No matter what the response of the next administration and Congress, we must remain a united coalition that will do anything and everything that is needed to serve people living with and affected by HIV.