In his State of the Union address this year, President Trump announced an initiative “to eliminate the HIV epidemic in the United States within 10 years.”

The man who pitched the president on this idea is Alex Azar, the Secretary of the Department of Health and Human Services.

“We have the data that tells us where we have to focus, we have the tools, we have the leadership — this is an historic opportunity,” Azar told NPR’s Ari Shapiro Monday. “I told the president about this, and he immediately grabbed onto this and saw the potential to alleviate suffering for hundreds of thousands of individuals in this country and is deeply passionate about making that happen.”

Trump’s push to end HIV in the U.S. has inspired a mix of enthusiasm and skepticism from public health officials and patient advocates. Enthusiasm, because the plan seems to be rooted in data and is led by officials who have strong credentials in regards to HIV/AIDS. Skepticism, because of the administration’s history of rolling back protections for LGBTQ people, many of whom the program will need to reach to be successful.

For instance, transgender people are three times more likely to contract HIV than the national average, according to the Centers for Disease Control and Prevention. Trump has banned transgender people from serving in the military and undone rules that allow transgender students access to bathrooms that fit their gender presentation.

Azar himself has strong Republican credentials — as a young man, he clerked for Justice Antonin Scalia. And yet he’s now touring the country promoting this plan to end HIV, which includes supporting needle exchange programs to reduce HIV infection among intravenous drug users.

“Syringe services programs aren’t necessarily the first thing that comes to mind when you think about a Republican health secretary,” Azar acknowledged at an HIV conference last month. “But we’re in a battle between sickness and health — between life and death.”

This interview has been edited for clarity and length.

This morning you toured facilities in East Boston, a neighborhood in one of 48 counties targeted in Trump’s plan. What did you learn there?

I was able to be at the East Boston Neighborhood Health Center and they have a remarkable program called Project Shine. What I was able to do is meet with the entire team that provides this type of holistic approach. It is very much what we’re going to try to do in the most impacted areas.

You find the individuals who may have HIV — get them diagnosed. Get those who are diagnosed on the HIV antiretroviral treatment — so that they have an undetectable viral load and can’t spread the disease to others, as well as live a long healthy life themselves. Get those who are most at risk of contracting HIV on a medicine called PrEP so that they dramatically reduce their chance of getting HIV. And then, finally, respond when you have clusters of outbreaks. So, just getting to see the the holistic approach there was extremely helpful for me.

Given that Medicaid is the single largest payer for medical care for people with HIV, do Republican efforts to block Medicaid expansion in high-infection states like Mississippi and Alabama undermine your efforts to get more people treatment?

The program that we have is based on the assumption that Medicaid remains as it is. …. And even were we to change Medicaid, along the lines of what the president has proposed in the budget …

Meaning the major reductions to Medicaid that are in the president’s budget?

Well, there are there are some reductions. But what it would do is actually give states tremendous flexibility. One of the challenges in the Affordable Care Act was that it prejudiced the Medicaid system very much in favor of able-bodied adults, away from the more traditional Medicaid populations of the aged, the disabled, pregnant women and children.

What we would do is restore a lot of flexibility of the states so that they could put those resources really where they’re needed. We would expect that those suffering from HIV/AIDS infection would be in the core demographic of people that you would want to make sure were covered. What we will do here, by stopping the epidemic of HIV, is have a dramatic reduction in cost for the Medicaid and Medicare programs in the future.

So one big part of your plan is expanding access to PrEP, the HIV prevention drug. Without insurance it can cost around $1,600 a month in the U.S. A generic version available overseas costs roughly $6 a month. AIDS activists say your department could ‘march in’ and break the patent that Gilead holds in order to make a generic version available to Americans. Is your agency going to pursue that?

I don’t know what you’re saying by breaking the patent. There’s no such thing as a legal right to break patents in the United States …

The Centers for Disease Control and Prevention also has a patent for PrEP, which Gilead disputes …

Well, that’s very different than breaking a patent. That would be asserting patent rights held by the CDC. So the CDC has a patent on the product and Gilead has a patent on the product. We are actually in active negotiations and discussion with Gilead right now on how we can make PrEP more available and more cost effective for individuals as part of this ending the HIV epidemic program.

I recently went to Jackson, Miss., which has one of the highest rates of HIV infection in the country. I talked to Shawn Esco, a black gay man, who told me that stigma, homophobia, and racism prevent people from seeking care, and he has very little hope. What would you say to him?

That is exactly what the president and I want to solve. I want to give him that hope. So many of the infections are happening in areas of our country where there’s intense stigma against individuals — males who have sex with men; the African-American community, Latino community, American Indian, Alaska Native communities. What’s really made this is a historic opportunity right now is we have data that show us that 50 percent of new infections are happening in 48 counties as well as the District of Columbia and Puerto Rico, and so we can focus those efforts.

We want to learn from people on the ground, as I did this morning here in East Boston. How do we reduce stigma? How do we provide a holistic approach for Shawn and others? We can get them diagnosed and get them on treatment in ways that they find acceptable — or, as one of the individuals said to me this morning, meet people where they are.

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When a rural community loses its hospital, health care becomes harder to come by in an instant. But a hospital closure also shocks a small town’s economy. It shuts down one of its largest employers. It scares off heavy industry that needs an emergency room nearby. And in one Tennessee town, a lost hospital means lost hope of attracting more retirees.

Seniors, and their retirement accounts, have been viewed as potential saviors for many rural economies trying to make up for lost jobs. But the epidemic of rural hospital closures is threatening those dreams in places like Celina, Tenn.. The town of 1,500, whose 25-bed hospital closed March 1, has been trying to position itself as a retiree destination.

“I’d say, look elsewhere,” says Susan Scovel, a Seattle transplant who came with her husband in 2015.

Scovel’s despondence is especially noteworthy given that she leads the local chamber of commerce effort to attract retirees like herself. She considers the wooded hills and secluded lake to hold comparable scenic beauty to the Washington coast — with dramatically lower costs of living; she and a small committee plan getaway weekends for prospects to visit.

When she first toured the region before moving in 2015, Scovel and her husband, who had Parkinson’s, made sure to scope out the hospital, on a hill overlooking the sleepy town square. And she’s rushed to the hospital four times since he died in 2017.

“I have very high blood pressure, and they’re able to do the IVs to get it down,” Scovel says. “This is an anxiety thing since my husband died. So now — I don’t know.”

She says she can’t in good conscience advise a senior with health problems to come join her in Celina.

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Susan Bailey has lived most of her life in Celina and started her nursing career at Cumberland River Hospital. She now worries that its closure will drive away the town’s remaining physicians.

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The closure adds delays when seconds count

Celina’s Cumberland River Hospital had been on life support for years, operated by the city-owned medical center an hour away in Cookeville, which decided in late January to cut its losses after trying to find a buyer. Cookeville Regional Medical Center explains that the facility faced the grim reality for many rural providers.

“Unfortunately, many rural hospitals across the country are having a difficult time and facing the same challenges, like declining reimbursements and lower patient volumes, that Cumberland River Hospital has experienced,” CEO Paul Korth said in a written statement.

Celina became the 11th rural hospital in Tennessee to close in recent years — more than in any state but Texas. Both states have refused to expand Medicaid in a way that covers more of the working poor. Even some Republicans now say the decision to not expand Medicaid has added to the struggles of rural health care providers.

The closest hospital is now 18 miles away. That adds another 30 minutes through mountain roads for those who need an X-ray or blood work. For those in the back of an ambulance, that bit of time could make the difference between life or death.

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Staff members posted photos and other memorabilia in the halls — reminders of happier times — in the weeks before its closure.

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“We have the capability of doing a lot of advanced life support, but we’re not a hospital,” says emergency management director Natalie Boone.

The area is already limited in its ambulance service, with two of its four trucks out of service.

Once a crew is dispatched, Boone says, it’s committed to that call. Adding an hour to the turnaround time means someone else could likely call with an emergency and be told — essentially — to wait in line.

“What happens when you have that patient that doesn’t have that extra time?” Boone asks. “I can think of at least a minimum of two patients [in the last month] that did not have that time.”

Residents are bracing for cascading effects. Susan Bailey hasn’t retired yet, but she’s close. She’s spent nearly 40 years as a registered nurse, including her early career at Cumberland River.

“People say, ‘You probably just need to move or find another place to go,’ ” she says.

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Closure of the hospital meant 147 nurses, aides and clerical staff had to find new jobs. The hospital was the town’s second-largest employer, after the local school system.

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Bailey and others are concerned that losing the hospital will soon mean losing the only three physicians in town. The doctors say they plan to keep their practices going, but for how long? And what about when they retire?

“That’s a big problem,” Bailey says. “The doctors aren’t going to want to come in and open an office and have to drive 20 or 30 minutes to see their patients every single day.”

Closure of the hospital means 147 nurses, aides and clerical staff have to find new jobs. Some employees come to tears at the prospect of having to find work outside the county and are deeply sad that their hometown is losing one of its largest employers — second only to the local school system.

Dr. John McMichen is an emergency physician who would travel to Celina to work weekends at the ER and give the local doctors a break.

“I thought of Celina as maybe the Andy Griffith Show of health care,” he says.

McMichen, who also worked at the now shuttered Copper Basin Medical Center, on the other side of the state, says people at Cumberland River knew just about anyone who would walk through the door. That’s why it was attractive to retirees.

“It reminded me of a time long ago that has seemingly passed. I can’t say that it will ever come back,” he says. “I have hopes that there’s still some hope for small hospitals in that type of community. But I think the chances are becoming less of those community hospitals surviving.”

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