Radical changes in US policy threaten two decades’ progress in HIV

The global HIV response is suffering serious disruption due to cuts in US government funding, the closure of USAID and a lack of clarity about future financing, Professor Chris Beyrer, Director of the Duke Global Health Institute at Duke University, North Carolina, told the Conference on Retroviruses and Opportunistic Infections (CROI 2025) in San Francisco on Monday.

Criticising the US government’s ban on the use of the terms equity, diversity and inclusion in the work of any federally funded programme, Professor Beyrer emphasised the diversity of the global HIV pandemic and of the global HIV response. “Diversity is in our DNA. It’s who we are. We can’t not address diversity because we are dealing with a diverse pandemic,” he said.

“The achievement of getting three-quarters of people living with HIV living on this planet onto antiretroviral therapy is the greatest achievement of equity in global health.”

But this achievement is now threatened by radical changes in US policy, which began with a freeze on all US foreign aid assistance on the day President Trump took office, followed by the abrupt closure of USAID, the agency which managed US foreign aid, including much of the $6.5 billion PEPFAR programme that funded HIV treatment and prevention in over 50 countries in 2024.

Beyrer reminded delegates that the global HIV response was already falling short of its targets before the new US administration began to cut funding. Although UNAIDS had called for 95% of people who knew their HIV status to be on treatment by 2025, a quarter of people with HIV were still not on treatment in 2023. AIDS-related deaths have not declined as rapidly as hoped; 630,000 people died of an HIV-related cause in 2023, far above the 2025 target of 250,000 AIDS-related deaths. And HIV incidence remains stubbornly high. An estimated 1.3 million people acquired HIV in 2023, far above the 2025 target of 370,000 per year. HIV incidence is rising in three regions of the world: eastern Europe and central Asia, the Middle East and north Africa, and most recently, Latin America.

Even in settings where HIV treatment and prevention coverage are high, HIV incidence remains alarmingly high. Incidence in the placebo arms of several large prevention trials was over 4 per 100 person-years in women taking part in the ECHO and HVTN 703 trials, representing a one in five lifetime risk of acquiring HIV for this group of women in sub-Saharan Africa. A similar level of HIV incidence was seen in men who have sex with men in the MOSAICO HIV vaccine trial, which recruited in Europe, North America and Latin America.

Significant increases in primary prevention programmes will be needed to achieve a sustained reduction in HIV incidence. An estimated 40 million people need to start PrEP to achieve epidemic control in sub-Saharan Africa, according to modelling, Beyrer said.

“Ninety-one per cent of all oral PREP starts have been funded by PEPFAR programmes, so there is no PREP programme without PEPFAR,” said Beyrer, but HIV acquisition in eastern and southern Africa continues to outpace new PrEP starts by a ratio of 1.5 to one. PrEP coverage is still not high enough to decisively reduce HIV incidence.

“But aside from PMTCT [prevention of mother-to-child transmission], prevention in PEPFAR is now on pause,” he pointed out. A waiver issued by US Secretary of State Marco Rubio on 6 February 2025 authorised the resumption of PEPFAR funding for PrEP for pregnant or breastfeeding women but stipulated that PEPFAR could not fund PrEP for anyone else.

Services for key populations have been funded extensively by PEPFAR in sub-Saharan Africa. Modelling of the impact of stopping PrEP for key populations in sub-Saharan Africa by Professor Peter Vickerman and colleagues shows that in the countries with the highest coverage of PrEP, HIV acquisition could increase by 30% in female sex workers, by 20% in men who have sex with men and transgender women, and by 15% in people who inject drugs.

“The countries that were doing the best will now fare the worst,” Beyrer told the conference.

Even the 90-day pause in PEPFAR funding disbursement announced on 20 January will have lethal consequences. Modelling carried out by Khai Hoan Tram at the University of Washington projects 100,000 lives lost and 130,000 perinatal HIV transmissions as a result of service interruptions or closures due to the funding freeze.

An even larger crisis is looming. For PEPFAR to continue, Congress needs to reauthorise it by 25 March and the future level of funding is uncertain. Any reduction in funding will limit the number of people who can be enrolled on treatment.

PEPFAR has saved an estimated 25 million lives and at least 5.5 million infants have been born HIV-free as a result of PEPFAR programmes. But modelling carried out by PEPFAR last year shows the fragility of this achievement. The model estimated that PEPFAR support would avert 5.2 million AIDS-related deaths in 12 countries between 2024 and 2030 and as a result, 4 million fewer children will be orphaned. Removal of this support would lead to increases in HIV-related deaths and orphaning.

With HIV prevalence set to stabilise around 40 million until at least 2050, “There is no scenario in which we will not be treating millions and millions of people for decades to come,” Beyrer said.

But PEPFAR-funded programmes already face huge disruption.

“PEPFAR is essentially a funder,” Beyrer explained, with implementation delivered by USAID, the Centers for Disease Control and Prevention (CDC) and others. “The devastation and disruption of USAID means there is no implementation arm for most of these programmes,” he said.

Sixty per cent of PEPFAR funding was implemented by USAID, but with the agency closed and its bills unpaid, PEPFAR partners funded through USAID are having to close services and lay off staff. On 5 March, the US Supreme Court ruled that the US government must pay bills owing to USAID grantees by Monday 10 March, after AVAC sued over non-payment.

A rapid survey of 153 PEPFAR partner organisations in 27 countries (61% in eastern and southern Africa) carried out by amfAR found that 86% of organisations expected clients to lose access to HIV treatment services, over 60% had already laid off staff and 36% had already closed down.

Professor Beyrer called for a restoration of PEPFAR funding for prevention, as well as support for key population services. Support for the eighth round of Global Fund replenishment – a key funder of medicines and commodities – will be critical, along with protection of human rights.

In conclusion, Beyrer reminded delegates of President George W. Bush’s choice of words from the Old Testament book of Deuteronomy, quoted at the close of the first PEPFAR replenishment conference in 2008: “I have set before you life and death. Therefore, choose life.”