On January 28, a week after Donald Trump's announcement of a 90-day freeze on official development assistance distributed by the US Agency for International Development (USAID), the waiver granted to the fight against HIV (human immunodeficiency virus), the cause of AIDS, initially came as a great relief. But it did not dispel fears that the global system designed to overcome one of the most deadly epidemics in modern history would be permanently undermined.
This waiver does not anticipate the decisions that may be taken at the end of the three months during which the new US administration intends to scrutinize all the agency's commitments against the yardstick of its motto: "America first." And it is already undermining essential pillars of response by calling into question prevention measures, providing less care for populations most at risk from the virus – sexual minorities, sex workers, drug users – and putting a massive halt to research programs.
The anxiety felt is commensurate with the importance of the US in global funding for the fight against the virus, which still infects 1.3 million people a year and remains the cause of 630,000 deaths, 60% of them in Africa. Through the President's Emergency Plan for AIDS Relief (PEPFAR) program, launched by George W. Bush in 2003 to help low-income countries gain access to antiretroviral drugs, the US government pays for 20 of the 30 million people on treatment. It provides 90% of the so-called "pre-exposure prophylaxis" (PrEP) which prevents contamination of people at risk, and is considered one of the essential weapons for curbing the epidemic in the absence of a vaccine and curative medication.
At the center of the upheaval provoked by the American decision, the specialized United Nations agency UNAIDS – half of whose budget depends on USAID – is trying to cope. "We have received a 'stop order' and have had to suspend much of our support to governments and communities. We also have to do our audit and prepare ourselves for the measures that could be announced at the end of the 90 days," admitted Christine Stegling, its deputy executive director. The organization produces and monitors all HIV-related data worldwide. This data is what governments – including that of the US – use to set their targets.
Despite the long five-page memo published by the State Department on February 6, assuring the resumption of deliveries of antiretroviral treatments, PrEP for pregnant and breast-feeding women, screening tests, supply chain management and so on, confusion continues to prevail. Many associations that closed their doors at the end of January have not reopened, and public health services are trying to reorganize. "It's a big problem, because community associations play an essential role in the network of players that make up the global response to HIV," worried Stegling.
In South Africa, the country hardest hit by the epidemic, where over 8 million people are living with the virus, the government funds most of the anti-infection program, in particular the distribution of antiretroviral drugs in public clinics. But a multitude of organizations help to bridge the gap between these clinics and patients or populations at risk. In Johannesburg, Engage Men's Health, an association for homosexual men that used to run three treatment centers, has closed. So has Nacosa, one of the leading organizations fighting violence against women. "If funding ceases, we will survive, because we have other funders, but we are worried about smaller organizations that get funding through us," said Sophie Hobbs, Nacosa's communications manager. "Those are the link between the treatment and the communities who struggle to access the public clinics or feel a stigma when they go to those clinics."
In Côte d'Ivoire, where PEPFAR covers 90% of HIV-related expenses, including the free distribution of antiretrovirals, the government has decided to redeploy the staff of the Ministry of Health to make up for the lack of personnel caused by the defection of partners excluded by USAID. HIV has been integrated to routine consultations in health facilities. But in the meantime, in Yopougon, a working-class neighborhood of Abidjan, minimum service has become the norm. "Our beneficiaries can receive their treatment, but all screening, prevention and support activities for vulnerable populations are at a standstill," said the coordinator of a community association, speaking on condition of anonymity.
In South Sudan, the healthcare system, which provides antiretroviral treatment to over 75.000 people, has come to a screeching halt. "People are going to die," warned a source at Juba University Hospital, where the HIV treatment center has scaled back its activities, with the withdrawal of staff employed by the NGO Catholic Medical Mission Board, paid with US funds. The NGO National Empowerment of Positive Women United has seen three of its four projects wiped out by the White House's decision. "Fifty of our Community outreach volunteers (COV) have been laid off," explained Arop Daniel, the NGO's advocacy officer. "Their job is to move from community to community to give and refill ARTs to the people living with HIV who refuse to come and access services at health facilities due to the fear of stigma and discrimination. So currently some of the people we follow are running out of treatment."
His colleague Onek Benson added: "The freeze of US foreign aid has created anxiety and a return to the dark days where we didn't have treatments for HIV in the country. The persons living with HIV feel like the same situation is happening today. The only thing they see is death approaching."
The fate of sexual minorities – often criminalized in Africa – is of particular concern. The derogation excludes them, for example, from the benefits of prevention programs through pre-exposure prophylaxis. "In Senegal, HIV affects marginalized groups such as homosexuals. It's among them that the epidemic could pick up again, if resources decrease," feared an activist from a Dakar NGO.
The withdrawal of the United States also has a destabilizing effect on the scientific community. Research programs are excluded from the waiver. The American National Institutes of Health are no longer processing any funding applications. And, pending future decisions by the White House, clinical trials have been suspended. The first phase of trials of two HIV vaccines in eight African countries was due to start at the end of January. Volunteers had been enrolled in South Africa, Uganda and Kenya. Health personnel had been trained, reported Glenda Gray of the South African Medical Research Council and head of the Brilliant consortium, which launched the project with a guaranteed $45 million in funding from USAID, in Science on February 5. "It would be unethical to start a study that you cannot continue," the researcher said.
The blow is all the harder to take given the recent emergence of highly promising new therapeutic tools, in particular lenacapavir, whose two injections a year are enough to ensure total immunity. In October 2024, the American laboratory Gilead, which holds the patent, announced that it had signed several contracts for the production of generics. A "game-changing" decision, according to UNAIDS.
"Over the years, the fight against HIV has become an exemplary model of international cooperation, demonstrating that the battle against major epidemics cannot be won on a country-by-country basis. We are astonished at what is happening," said Yazdan Yazdanpanah, director of the National Agency for AIDS Research in Paris. "Infected people who were controlling the progression of the disease thanks to treatment will see their viral load increase. Those in whom the virus was undetectable will transmit it more."
Researchers are gearing up for dark days: "Donald Trump's freeze will affect all research, but HIV research in particular, because we represent everything he wants to dismantle by attacking gender, diversity and sexual minorities," anticipated Alexandra Calmy, head of the HIV Unit, Infectious Diseases Department at the Geneva University Hospitals. She who also warned: "HIV kills. If we go backward, we know what that means. We experienced it at the end of the 1980s. An infection that is not adequately treated is 80% fatal."
Translation of an original article published in French on lemonde.fr; the publisher may only be liable for the French version.