6 February 20256 February 2025 Janette Bennett

A giant falls

HIV

How the US is destroying its legacy of leadership 

Once upon a time, America was great. It led the world in global health interventions, economy, trade, philanthropy, technology, space exploration and just about anything you can think of. Many also saw it as a bastion of democracy.

No matter how you might have felt about it, the influence of the US on so many things was immense, everywhere. And it took decades to build up this standing.

Then the world changed

Along came the second coming of Donald Trump. He wooed just enough voters with his promise to “Make America Great Again”, aka MAGA, to take the US presidency. He did this with the huge financial backing of a bunch of oligarchs, particularly Elon Musk, who also supported Trump on his increasingly right-wing social media platform, X. (You know what they say about controlling the messaging.)

Trump placed his buyer, Musk – unelected by voters – in the dubious Department of Government Efficiency, or DOGE, and gave him a free hand. While Trump flooded the zone, Musk worked behind the wall of confusion and outrage, destroying the fabric of government in what many are calling a coup.

Trump/Musk erased the legacy of American greatness in a matter of days. Not that long ago, Trump promised, “In four years, you don’t have to vote again, we’ll have it fixed so good you’re not going to have to vote.” I’d say this was a warning.

Multi-faceted assault

We could talk about the widespread impact of this apparent insanity, but that would take a thesis. I’d like to focus on just one area, HIV and AIDS, where I have been involved since the early 1990s.

The assault on the global response to HIV has been multi-pronged, with access to lifesaving antiretrovirals (ARVs) a first casualty. Here are just a few (interlinked) prongs of the assault.

1 Freezing PEPFAR

The US led the world in getting HIV services to people in the most HIV-affected regions. President George W Bush, a Republican like Trump, set up the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) in 2003.

At that time, central, eastern, southern and western Africa accounted for about 70% of all people living with HIV globally – very few had access to treatment. Estimates were that up to 100 million people would die of AIDS-related causes over the next 20 years if nothing was done to stop it.

And so PEPFAR was born, both to save lives and as an important part of US foreign policy. PEPFAR became the largest commitment by any country to address a single disease in history – through it, the US government has invested over $110 billion in the HIV response.

More than any other initiative, PEPFAR turned the tide in the HIV pandemic. Working in 55 countries, it has saved about 26 million lives and prevented millions of people from acquiring HIV.

One of the first things Trump did when he took office on 20 January was freeze new foreign aid funding for 90 days. Four days later, his administration stopped all funding to PEPFAR and imposed a stop-work order on existing grants and contracts. Staff were banned even from distributing ARVs already in their clinics. A waiver and clumsy clarifications followed, but the structures and chains were already destroyed. PEPFAR-supported clinics across Africa remain closed.

Millions of lives are threatened. PEPFAR provides HIV treatment for 20.6 million people, including 566,000 children. It reaches 2.3 million adolescent girls and young women with HIV prevention services and 6.6 million orphans, vulnerable children and caregivers with care and support. It directly supports 342,000 health workers. Just in 2024, 2.5 million people started pre-exposure prophylaxis (PrEP) to prevent HIV through PEPFAR. All of that is now in jeopardy.

Every single day, more than 222,000 people collect ARVs from a PEPFAR-supported service. Some could be collecting refills (most supplies are for a couple of months); some could be newly diagnosed with HIV and starting treatment. Very little of that is happening.

A PEPFAR Impact Tracker shows that 4,283 adults and 455 infants have died from the time Trump suspended funding until 2.35pm, South Africa time, today.

You have to look past the numbers and remember that these are real people, real lives.

When a person stops taking ARVs, their viral load builds up. They can then develop illnesses as their immunity lowers, and HIV can be transmitted again. So, HIV resurges and AIDS returns (AIDS and HIV are not the same thing). This comes when the world is celebrating new HIV acquisitions falling for the first time – by 59% in eastern and southern Africa.

From the start, PEPFAR aimed to support sustainable country-owned HIV programmes and enhance global health security. Many countries have been moving towards this, and as Time magazine says: “Sudden shocks, like freezing aid overnight, do not accelerate the transition process; they blow it up and can cause disease resurgence.”

And as Linda-Gail Bekker, the head of the Desmond Tutu Health Foundation at the University of Cape Town, explains, PEPFAR IS what makes America great.

2 Imploding USAID

The United States Agency for International Development (USAID) is the US government’s biggest and flagship foreign aid agency – the world’s biggest aid agency. Well, it was. Trump/Musk targeted USAID first, absolutely disembowelling it. Some believe this is Musk’s revenge for USAID auditing his Starlink company for dodgy contracts in Ukraine; some believe it’s a trial run for gutting other federal agencies.

USAID, more than 60 years old, is a key implementor for PEPFAR and manages a big chunk of PEPFAR funding. It provides humanitarian aid to more than 100 countries and employs 10,000 people, two-thirds of whom work overseas. All those jobs are on the line. USAID’s work – now under the axe – includes containing outbreaks of mpox, Ebola and Marburg virus; developing and implementing a malaria vaccine; supporting tuberculosis treatment and prevention programmes; and clearing landmines.

USAID also supports important HIV research, including a Phase 1 trial of two experimental HIV vaccines in South Africa, Kenya and Uganda. All of that research is now on hold.

3 Hobbling the World Health Organization

Trump wasted no time in withdrawing the US from the World Health Organization (WHO). As the world’s biggest economy, the US contributes about 15.6% of WHO funding (contributions are based on such factors as a country’s wealth and population size).

The US withdrawal threatens coordination of global health responses, from HIV and tuberculosis to mpox and Ebola. Reuters quotes Lawrence Gostin, a professor of global health at Georgetown University in Washington and director of the WHO Collaborating Center on National and Global Health Law: “This is the darkest day for global health I’ve ever experienced. Trump could be sowing the seeds for the next pandemic.”

In the same executive order, Trump ended US participation in the pandemic treaty, involving 194 countries and aimed at strengthening global preparedness for pandemics. Any pandemic could disrupt HIV services and lead to inequitable access to vaccines and treatment, as COVID-19 did.

The withdrawal also isolates the US and endangers its people – diseases do not respect national boundaries.

4 War on science

Follow the science – after 40 years of the HIV pandemic, that’s a proven mantra for people in the HIV response.

First, let’s not forget that Trump’s pick for Secretary of the Department of Health and Human Services is none other than Robert F Kennedy Jr., who has claimed that HIV does not cause AIDS and other outrageous, unscientific things.

Trump has silenced and limited some of the world’s most important health science organizations, including the Centers for Disease Control and Prevention (CDC) and the National Institutes for Health (NIH).

The CDC plays a big role in PEPFAR. Among other things, it supports over 11,000 labs or point-of-care testing sites in more than 33 countries, channels about half of PEPFAR funding for HIV treatment, and supports over 60% of people on PEPFAR-supported HIV treatment. I’d link you to those websites if I could, but Trump/Musk has taken them offline (see the screenshots).

The NIH, too, has strong links with PEPFAR around, for example, funding HIV research, educating healthcare workers, and building capacity to implement HIV programmes.

Where those official US government sites have remained or reappeared, they have been scrubbed of data that covers HIV transmission, women’s health, maternal morbidity and mortality, contraception, LGBTQI, gender diversity, race and anything else that does not fit into a Handmaid’s Tale view of the world – and all of which are crucial to inform HIV interventions.

5 Exclusion and disruption

That exclusion ideology is enshrined in Trump’s order on “defending women from gender ideology” – an attack on hard-won protections and rights for trans and gender-diverse people – and his diversity, equity and inclusion (DEI) order to eliminate such federal programmes.

In the ensuing operational disruption (wasn’t that the intention?), health agency websites like the CDC’s went down, researchers were forced to withdraw their names from journal articles, entire research articles were withdrawn, and data were erased. Some call it a digital book burning – much like Hitler’s Nazis did with their bonfires of books.

In complete disregard for the health of women and children, Trump brought back the “global gag rule”, cutting off access to safe abortions, contraception and family planning. Research shows that this policy led to about 90,000 new HIV acquisitions and almost 30,000 maternal and child deaths each year it has been in place due to disruptions in HIV services. Most deaths were among children.

6 Giving human rights the finger

Respect for human rights is a pillar of the global response to HIV. Trump/Musk have repeatedly shown their disdain for pesky human rights. Trump has just rubberstamped that by withdrawing the US from the UN Human Rights Council (UNHRC).

Each of these actions destabilizes global health programmes. Together, they are devastating, vastly setting back progress towards ending HIV as a threat to public health and individual well-being.

No fairy tale

You’d need to look hard for a silver lining to this tragedy. If anything, it could be this: America has drastically rolled back its standing, influence and surveillance all over the world, and soon it will be annihilated. With a growing trust deficit, it is unlikely the US will ever regain that position. Others will take its place.

I don’t know if that is good or bad. I do know that this is no fairy tale – the dystopian future is here.