How 40 years of HIV/AIDS progress is now at risk

Imagine waking up tomorrow and finding out the medication that keeps you alive is gone.

Imagine if HIV evolved into being drug-resistant, and treatment no longer worked.

Imagine if HIV/AIDS returned to being a global health crisis.

These are the very real risks facing people across sub-Saharan Africa and the world today.

It’s 10 days since Trump started his second term as US president.

This exchange of power in the world's most powerful office has resulted in some decisions that could completely shift the course of the global fight to end HIV/AIDS.

Since 1984, the world has seen amazing advancements in HIV treatment and care. 40 years ago, HIV/AIDS was a ‘death sentence’ for many. Today, it's a highly manageable condition. But decisions made by the current US Administration could undo much of this progress, both in the US and globally – especially for the most vulnerable communities.

What just happened?

On 20th January 2025, Trump signed an executive order temporarily suspending all US foreign assistance programmes for 90 days, pending reviews to determine whether they align with his policy goals.

Several federal websites in the US also reportedly removed resources on HIV (which also happened when Trump took office in 2017).

HIV is a global health issue. It is a medical issue. And it affects people from every walk of life, of every ethnicity, gender and sexual orientation. Yet, this move appears to categorise HIV as a 'queer topic' and is part of a rollback of LGBTQ+ rights. And it comes despite a commitment from Trump, in 2019, to end the HIV epidemic in the US by 2030.

The freeze on foreign aid included stopping the supply of essential HIV medications to over 50 countries and disrupting lifesaving treatment for millions of people, who rely on support through programmes like the President's Emergency Plan for AIDS Relief (PEPFAR).

What is PEPFAR?

According to the U.S. Department of State:

"PEPFAR is the largest commitment by any nation to address a single disease in history, enabled by strong bipartisan support across ten U.S. congresses and four presidential administrations. It shows what is possible through compassionate, cost-effective, and transparent American foreign assistance.

Since its inception in 2003, PEPFAR has invested over $100 billion in the global HIV/AIDS response, saving 25 million lives, preventing millions of HIV infections, and supporting several countries to achieve HIV epidemic control – all while significantly strengthening global health security."

It is the world's leading HIV initiative and is widely regarded as one of the most successful global health programmes in history.

Today, more than 20 million people living with HIV globally depend on daily services provided with support from PEPFAR programme. That's two-thirds of people living with HIV and receiving treatment – including 550,000 children.

More HIV treatment = better health outcomes and more protection for all against the virus.

As of 2023, 77% of people living with HIV globally were accessing treatment (UNAIDS).

To be able to end AIDS (a.k.a. late-stage HIV) and to stop new cases of HIV, this figure must continue to rise.

The impact of this 90-day freeze

A few comments following the executive order on 20th January 2025 (as quoted in the Washington Post):

“It’s bad, bad”

— a State Department official who works on PEPFAR

“It’s very hard to communicate the scope of this”

— a USAID official

“We can very rapidly return to where the pandemic is exploding, like it was back in the 1980s. This really cannot happen”

— Dr. Steve Deeks, an HIV expert at the University of California (quoted in the NY Times)

“I really have to wonder if the people mandating this at the State Department have any tangible idea of what this will mean in practice”

— Jeremy Konyndyk, president of Refugees International and a former USAID official

What it meant in practice was the immediate issue of 'stop-work orders' in the field, such as this one (posted on 27th January 2025):

In the fact sheet below, amFAR (the Foundation for AIDS Research) outlines the full scale:

Some of the headlines:

• Every day, more than 220,000 people pick up life-saving medication through the PEPFAR programme, including 7,400 children

• PEPFAR directly supports 271,000 Health Workers – doctors, nurses, midwives, lab technicians, pharmacists and community health workers, all being told to stop working immediately

• The impact on pregnant women would mean 135,000 babies acquiring HIV within this 90 days (these would highly likely be undiagnosed, due to infant testing services being suspended)

• 4,500 daily diagnoses missed

• The most affected countries are South Africa, Mozambique, Kenya, Tanzania, Uganda, Nigeria and Zimbabwe

It will likely hit children the hardest – as they are less likely to be diagnosed, and progression of the virus can be much more rapid than in adults.

And if the freeze was to continue?

According to one estimate (highlighted in the NY Times):

in South Africa alone, PEPFAR’s shutdown would add more than half a million new HIV infections and more than 600,000 related deaths over the next decade

That is double the number of AIDS-related deaths that there were globally in the 1980s.

In South Africa alone.

Why is adherence to HIV medication so important?

If you're living with HIV, and you skip doses, it's dangerous.

HIV drugs (usually taken daily) work by suppressing the virus.

When patients stop taking the drugs, the virus rebounds — and quickly.

This rebound effect can cause complications that lead to HIV infection advancing quickly to the late stage (a.k.a. AIDS).

If doses are missed, the drugs can stop working

It's crucial to take HIV medication regularly, as prescribed.

As people lose access, people might try to ration their medication or share it with others, which would mean they take their doses inconsistently.

Inconsistent treatment can make the virus resistant to the drugs, as HIV learns how to get around them.

This increases the risk of HIV transmission and further complicates any future treatment, as the drugs initially prescribed may no longer work.

On a large scale, this could have catastrophic consequences – potentially rendering treatment plans for millions of people ineffective, with enormous knock-on effects in terms of financial cost, health systems, and loss of human life.

My perspective, as a survivor of late-stage HIV

I am here thanks to HIV medication.

To think of losing access to the drugs that keep me alive, overnight... I can't get my head around it. I cannot imagine it.

The impact will be much more than physical.

Seeing all these statistics written down – loads of zeros, thousands and millions – it's easy to detach yourself from the human stories.

Every one of those numbers is a human being – just like me – each with their hopes, dreams, talents and potential to offer the world.

We cannot abandon people like this.

We cannot jeopardise global health like this.

PEPFAR-funded services must be restored immediately.

A development this week

On 28th January 2025, the Trump Administration issued a waiver to allow for "lifesaving humanitarian assistance" – including the distribution of HIV medications.

This is welcome news, but it wasn't clear whether the waiver extended to preventative drugs (PrEP) or other crucial services.

HIV clinics remain shut, and there is still uncertainty about the future of PEPFAR.

What is there to gain from all this?

The justification?

To prioritise 'America First.'

To focus on domestic issues over global.

To save the U.S. money, by reducing U.S. commitments to overseas spending.

But what does that mean for the lives of ordinary people (Americans included) across the world?

Stopping PEPFAR would not only lead to a resurgence of HIV/AIDS – which, to date, has taken the lives of more than 40 million people.

It would also have a knock-on effect on both global and American health security.

Is this a risk worth taking?

What are the goals here?

More efficiency? This is understandable.

Better value for money? Everyone wants that.

Wanting countries to be less reliant on the US? This makes sense.

But do it carefully.

Do it in a way that doesn't instantly endanger the lives of millions of people.

Do it in a way that doesn't mean withholding lifesaving medication from people.

Do it in a way that doesn't affect the job security of hundreds of thousands of health workers.

Trump has previously committed to ending HIV/AIDS and has shown public support for PEPFAR (despite requesting significant budget cuts, which were rejected by Congress). The first Trump Administration also secured a historic donation of billions of dollars in HIV prevention drugs.

So there is hope.

At the end of the day, fewer people with HIV means:

• more people in the workforce, contributing to the economy

• fewer people in hospitals, reducing the strain on health services

• less mental health issues, meaning a more productive society

If you work in the fields of HIV or Global Health: please, stay vocal about this. We cannot regress.

More HIV will hurt everyone eventually.

Progress for HIV means progress for all.

It’s that simple.

P.S. Repost this article to raise awareness of this risk to millions of lives