Global HIV fight faces major setbacks amid funding and research cuts

Ambitions to end the global HIV epidemic as a public health threat by 2030 look increasingly out of reach as experts fear there could be an increase in new infections for the first time in decades.

Concerns among scientists, health workers and community advocates have grown in recent months following billions of dollars in foreign aid and medical research being slashed by the US government.

"It's almost like an existential crisis for the field," said Sharon Lewin,  internationally renowned HIV researcher and director of the Doherty Institute in Melbourne.

Globally, around 40 million people live with HIV, including 1.4 million children. Since 2010, new HIV infections have declined by almost 40 per cent but remain well short of global targets.

Historically, the US government has provided almost three quarters of all international government assistance for HIV.

But since Donald Trump took office in January, it has suspended much of its foreign aid program and dismantled the US Agency for International Development (USAID), in a move it says is aimed at ensuring all humanitarian assistance is aligned with its "America First" agenda.

The Trump administration has also terminated almost 1,400 medical research grants, an estimated 30 per cent of which supported research into HIV/AIDS.

Many of the scrapped studies focused on health equity, racial disparities, and sexual and gender minorities — research the administration said "prioritised ideological agendas over scientific rigour".

One of the biggest blows to HIV research came last month when the US government terminated a $258 million research program that was developing a HIV vaccine — a decision Professor Lewin described as "devastating".

"It was by far and away the largest investment in HIV vaccine research, and an extraordinarily successful group of researchers," she said.

While there are highly effective drugs to prevent the transmission of HIV — known as pre-exposure prophylaxis or PrEP — they need to be taken regularly, which means prevention programs are "expensive" and "labour-intensive" to run, Professor Lewin said.

"You've got to keep people on treatment, and keep monitoring them ... So a cheap and effective vaccine is still really needed."

Funding cuts disrupt treatment and prevention programs

One of the biggest concerns among HIV experts is the disruption to and future uncertainty of the US president's Emergency Plan for AIDS Relief, better known as PEPFAR, said Australian Global Health Alliance executive director Selina Namchee Lo.

The $7.5 billion program, established in 2003, funds a significant proportion of HIV prevention and treatment services in low- and middle-income countries, and is considered one of the most successful global health programs in history.

"Since its initiation, PEPFAR has saved more than 26 million lives and supported more than 20 million people on HIV treatment. It's truly been a game changer," Dr Lo said.

In January, the Trump administration froze all PEPFAR funding as part of a review into US foreign aid, before later issuing a waiver to allow "life-saving HIV services" to continue.

The waiver, however, only permits funding for certain programs, including the prevention of mother-to-child transmission, but not HIV prevention among other at-risk groups. This includes men who have sex with men, transgender women, injecting drug users and sex workers, all of whom "are hugely over-represented in HIV statistics", said HIV researcher Andrew Grulich.

According to UNAIDS, the suspension of US funding and dissolution of USAID, which delivered the majority of PEPFAR's programming, has caused disruptions to HIV services and the availability of life-saving medicines.

"In some settings, it has led to people turning up [to health services] and being told 'you can't get your treatment this month, or you can only get one month at a time,'" Professor Grulich, head of the HIV epidemiology and prevention program at UNSW's Kirby Institute, said.

The potential rationing of HIV antiretroviral treatment was "highly likely" to cause drug resistance, he said, and if people were to stop treatment altogether, they would become highly infectious "within a week or two".

"They might remain relatively well for a year, or even five years, but in the absence of treatment, most people will go on to develop AIDS, and almost all of them will die."

Researchers recently estimated that if PEPFAR was discontinued and international aid cuts proposed by four European countries went ahead, there could be almost 11 million additional infections by 2030, and 3 million AIDS-related deaths.

While the future of PEPFAR remains unclear, the Trump administration has proposed cutting $1.9 billion from its budget in 2026.

According to the US Department of State, this will allow the US "to accelerate the transition of HIV control programs to recipient countries and increase international ownership of efforts to fight HIV/AIDS".

Professor Lewin said the plan for PEPFAR "was always for it to be phased out" and for countries to sustain their own HIV programs, but that funding had instead been cut "very quickly".

The US Congress has also been asked to revoke a further $8.3 billion in foreign aid, including $400 million for PEPFAR.

Uncertain future for research and promising drugs

In addition to the direct impact on people's lives, Professor Lewin said aid cuts — as well as a recent directive that restricts US scientists from distributing funding to overseas research partners — was reducing "capacity building" and research operations in countries with significant HIV challenges.

"Capacity building … including in South Africa, Uganda and other countries has been unbelievably successful over the last ten to 20 years," she said.

South Africa has the largest number of people living with HIV globally — approximately 7.7 million individuals, or 12 per cent of its population.

"Lots of vaccine trials, treatment trials, prevention trials that have transformed our care for people with HIV have been done in South Africa," Professor Lewin said.

But recent cuts have led to several HIV studies in the country to be halted, in some cases just days before human trials were due to start.

Professor Lewin also expressed concern about the future of a "novel antiviral drug" called Lenacapavir, which last year was found to provide almost 100 per cent protection against HIV in clinical trials.

While not quite a vaccine, the twice-yearly injection had researchers "hugely excited" that as a long-acting formulation, it may help to overcome key barriers to current prevention drugs, including the burden of daily use, frequent healthcare visits, and stigma.

"In Africa … most young women don't take [preventative] tablets consistently. When you have an injection for six months, you don't have to worry about it," Professor Lewin said.

Last week, Lenacapavir was approved by the US Food and Drug Administration, and the drug manufacturer, Gilead Sciences, has agreed to sell it to low-income countries at affordable prices.

But the defunding of global health programs that would have likely bought and distributed the drug has raised questions about if and how it will reach people who really need it.

"A lot of the next phase of implementation studies would have been done by PEPFAR," Professor Lewin said.

Funding gaps left by US 'very difficult' to fill

The scientists, community advocates and health leaders who make up the HIV sector are a "resilient community", Professor Lewin said, and there was now lots of activity underway to "identify different ways of doing things".

"Some African countries have stepped up their investment … and there's movement from the African Union to negotiate on behalf of many countries to maintain the low cost of drugs, which is very important," she said.

"But the scale of what the US did, what it supported in HIV … it was a very significant investment, so to fill that will be very difficult."

Dr Lo from the Australian Global Health Alliance said it was critical that donor countries such as Australia remained committed to funding international aid, both to improve health equity and health security.

"Australia, unlike some other countries — including the UK, France, Germany which have reduced international aid — hasn't stepped back … but our investment into [official development assistance] could be larger."

The Asia Pacific region is home to the largest HIV epidemic outside of Africa, with 300,000 new cases and 150,000 AIDS-related deaths in 2023.

In March, the federal government redirected foreign aid to support Pacific and South-East Asian nations grappling with Trump administration cuts, including for HIV programs in PNG, Fiji and the Philippines.

"Without continued support … [the HIV response] risks collapsing, leaving a system that is weakened and vulnerable to resurgence," Dr Lo said.

Globally, although there is an "emergency need" to address HIV funding gaps now, the US' decision to drastically reduce aid also presented an opportunity for the sector to look for stronger and "more sustainable" partnerships, she said.

"It is really important in global health that we work in partnership, either with countries or communities, to both capacity share, knowledge share, innovation share, and to build up in co-design and partnership support for health overall."