Michael Jennings, SOAS, University of London
Enormous progress has been made in tackling the global HIV epidemics over the past two decades. The number of people dying from HIV-related causes has fallen by 51% since 2010; and the number of annual new infections has fallen from 2.1 million new infections in 2010 to 1.3 million in 2023 (a drop of 39%).
This is the impact of the roll out of massive global programmes for prevention and treatment in this period. In 2003, around 400,000 people living in low and middle-income countries were able to access the life-saving anti-retroviral therapy drugs to manage the virus. Today it stands at more than 25 million people.
A large part of this success is due to the role of the President’s Emergency Plan for AIDS Relief (Pepfar), established by George W. Bush in 2003. Pepfar now accounts for around 70% of the total funding for the global response to HIV. And it has been a rare example of successful bipartisan support within the US.
Or at least it was, until the Trump administration included Pepfar in its attack on US aid spending in January. HIV spending under Pepfar was included in the initial freeze on aid grants imposed by executive order. And on February 27, news broke that the US secretary of state, Marco Rubio, had signed off on cuts affecting more than 90% of USAid grants, including the ending of US global HIV funding. Pepfar-funded programmes in South Africa were terminated with immediate effect; and UNAids was sent a letter confirming that the US was stopping its funding to the organisation.
Although details on what, if any, Pepfar programmes might survive in some form have not yet been forthcoming, the programme has been gutted in its current form, and few now hold out hope for anything significant remaining.
It has been a remarkable fall for an organisation that at the end of 2024 was funding the treatment of more than 20 million people (including over 560,000 children) across 55 countries; supporting over 90% of the use of pre-exposure phrophylaxis to prevent new infections; funding the testing of 83.8 million people in 2024 (up from 71 million the previous year); and was directly supporting 342,000 health workers across the world.
The importance of Pepfar as a tool of global soft power, the bipartisan support, and the relative uncontroversial focus of its activities, had led many to assume it would survive the administration’s swingeing reductions of aid. This was not to be the case.
In hindsight, that bipartisan support had started to weaken as early as two years ago. In 2023, in the face of growing Republican hostility to the programme, former president, George W. Bush, warned Congress not to drop its support for Pepfar. In March 2024, its mandate and funding was renewed, but for 12 months rather than the usual five years. Criticism increased in the days before Trump took power in January of this year when Pepfar notified Congress (as it was bound to) that four nurses funded through Pepfar in Mozambique had performed abortions (entirely legally). Funding had been suspended and an investigation launched, but enraged Republicans insisted on an additional inquiry.
Trump is expected to reinstate the controversial Mexico City policy. Abortion issues were already an area of heightened sensitivity and contributed to renewed calls from some Republicans for an end to Pepfar. The executive order removing funding from the World Health Organization was another indication of the direction of travel, and a signal that not even relatively uncontroversial support for health funding (where the impact of aid can be seen most clearly) was safe.
Whatever the reasons and politics of Pepfar’s decline, the ending of US support for global HIV programmes is a disaster for those in low and middle-income countries. In South Africa, for instance, Pepfar supports around 17% of the budget of the world’s biggest HIV programme. Around 8 million people live with HIV, and around 5.5 million people are being treated, most of whom are supported by Pepfar funds. The immediate challenge is now to fund ongoing treatment in the weeks and months to come before an alternative secure source of funding can be found.
But even if new funding can be found, the knock-on impact will be serious. The disruption caused by the initial freeze was immense. And the crisis in addressing HIV will also impact wider health issues, especially TB, sexual and reproductive health care. A report published prior to the confirmation of Pepfar’s destruction, suggested ending US support could lead to an additional 565,000 new infections and 601,000 more deaths over the next decade.
In countries where the US funding for HIV programmes is a higher proportion – and for many low and middle-income countries, Pepfar accounts for about two-thirds of the HIV prevention and treatment budget – it will be even harder to plug the funding gap. The former head of UNAids, Peter Piot, has raised the prospect of countries like Zimbabwe and Zambia running out of anti-HIV drugs.
Treatment programmes in in Lesotho, Eswatini and Tanzania have already had to close. Amongst the 350,000 people affected are more than 10,000 pregnant women living with HIV who require treatment to prevent passing on the virus to their unborn child.
The tragedy of the end of Pepfar is that it was one of the clear success stories in how aid can support and transform lives and countries. It played a major role in turning the tide of the epidemic back. The programme was also instrumental in enabling those with the virus to lead full, active lives and contributed to major reductions in the numbers of people newly infected. With a stroke of a pen, that progress has not just been threatened, but reversed.
Rebuilding a global HIV response less dependent on any single donor is essential. But at a time when big donors are stepping back, rather than stepping up in response to the US aid cuts, prospects for filling the gaps quickly to minimise the harm look very dim.
Michael Jennings, Professor in Global Development, SOAS, University of London
This article is republished from The Conversation under a Creative Commons license. Read the original article.
