In just under six months, the Trump administration has implemented policy changes that critics say have undermined longstanding efforts in the global fight against HIV and AIDS.
During his first day in office, US President Donald Trump ordered a 90-day pause on foreign aid.
He went on to slash $US4 billion ($6 billion) the US had pledged for the global HIV response for 2025, and in July his administration closed down the US Agency for International Development (USAID), the world's largest humanitarian aid agency.
This week, a new report by the United Nations AIDS agency (UNAIDS) said the withdrawal of that aid had caused a "systemic shock", and warned that if the funding wasn't replaced, it could lead to more than 4 million AIDS-related deaths and 6 million new HIV infections by 2029.
The UNAIDS report said the funding losses have "already destabilised supply chains, led to the closure of health facilities, left thousands of health clinics without staff, set back prevention programs, disrupted HIV testing efforts and forced many community organisations to reduce or halt their HIV activities".
It also said that it feared other major donors would scale back their support, reversing decades of progress against AIDS worldwide — and that strong multilateral cooperation was in jeopardy because of wars, geopolitical shifts and climate change.
USAID — a six-decade-old humanitarian and development organisation that officially closed down at the beginning of July — was responsible for implementing the bulk of the assistance under the US president's Emergency Plan for AIDS Relief (PEPFAR), the world's leading HIV/AIDS initiative.
Mr Trump claimed the agency was run by "radical left lunatics" and rife with "tremendous fraud".
Years of US-led investment into PEPFAR has reduced the number of people killed by AIDS to the lowest levels seen in more than three decades, and provided life-saving medicines for some of the world's most vulnerable.
"It feels like an intentional tactic," said Kate Rees, public health physician at the Anova Health Institute in South Africa.
"It really only takes a couple of weeks to dismantle something that has been built over more than twenty years," she said.
Funding a 'lifeline' for countries with high HIV rates
PEPFAR was launched in 2003 by then US president George W Bush, the biggest-ever commitment by any country focused on a single disease.
UNAIDS called the program a "lifeline" for countries with high HIV rates, and said that it supported testing for 84.1 million people, treatment for 20.6 million, among other initiatives.
Sub-Saharan Africa remains the epicentre of the AIDS pandemic and South Africa has almost 8 million people living with HIV, the largest number of people in the world.
"There is so many parts of the HIV response — because it is so huge in Africa — that need to be dealt with outside of business as usual, which is where PEPFAR and USAID came in," Dr Rees said.
She said that USAID and American money was contributing 80 to 90 per cent towards the Anova Institute.
"To suddenly have that huge amounts of funding slashed is a real problem."
Mr Trump's cuts have restricted the availability of drugs that millions of Africans have taken to prevent infection — particularly vulnerable communities such as gay men and sex workers who take Pre-Exposure Prophylaxis, or PrEP.
"Some of the services [provided by USAID] are for key populations including LGBTQIA+ and people who use and inject drugs," Dr Rees said.
The number of initiations, or people who have taken at least one dose of the drug, rose in Africa from fewer than 700 in 2016 to more than 6 million by late 2024, according to PrEPWatch, a global tracker.
More than 90 per cent of new initiations last year were financed by PEPFAR, using cheap generic versions of the drug.
Dr Rees said that the suddenness in which they money was pulled was "the real difficulty" because there was no chance for transition planning at both a financial and client level.
"There was no chance to make sure our patients had their next step or could be transitioned into other programs," she said.
Sub-Saharan Africa had 390,000 AIDS-related deaths in 2023, or 62 per cent of the global total, according to UNAIDS.
That death toll was down by 56 per cent from 2010, according to the World Health Organization.
UN assistant secretary-general Angeli Achrekar, a UNAIDS deputy executive director who was PEPFAR's principal deputy coordinator until January 2023, said the program is under review by the Trump administration, though Secretary of State Marco Rubio issued a waiver "to continue life-saving treatment".
Cuts threaten innovation within Africa
Last month, the US Food and Drug Administration (FDA) approved a twice-yearly injectable that many hope could end HIV, called Yeztugo.
The drug was tested in clinical trials across South Africa.
Dr Rees said there were a lot of important projects across South Africa that people had invested money, time and planning into that would have to now be scrapped.
"A lot of the innovation in HIV space comes from South Africa because of course there's so many people here with HIV," Dr Rees said.
"We are losing so much of that innovation — it is not just going to affect South Africa, it's going to affect everybody."
The FDA approval of Yeztugo should have been a "threshold moment" for stopping the AIDS epidemic, said Peter Maybarduk of the advocacy group Public Citizen.
Instead, the drug's pricing will put it out of reach of many countries that need it.
"We could be ending AIDS," Mr Maybarduk said.
"Instead, the US is abandoning the fight."
'We don't want to go back'
In 1981, the New York Times reported the first cases of the disease in the US. A year later, the first case was reported in South Africa.
It took then-US president Ronald Reagan four years — and 12,000 reported deaths in the US alone — to utter the words AIDS in public.
The road from simple acknowledgement to a worldwide effort to end the disease has been long — and no-one wants to go back, Dr Rees said.
"You can't overstate how much of an impact there's been in the last 20 years, and we didn't really don't want to go back to those days when funeral homes and funeral companies are popping up everywhere and it's just really, really bleak times," she said.
"We we don't wanna go back."
She said that a lot of the response for South Africa now was about looking forward and looking for other sources of funding.
"We've kind of accepted that the US is not going to fund us, and even if they did, their values of the current administration, in terms of like the diversity, equity and inclusion and LGBTQIA+ and women's rights, doesn't align with what we have to do in our program.
"So, we're looking towards more internal South African funders like philanthropies, and other countries," she said.
So, how do they do that?
"It's critical, difficult and challenging, but it needs to happen."
ABC/AP/Reuters
