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PROMISE OF VICTORY OVER H.I.V. FADES AS U.S. WITHDRAWS SUPPORT  
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Stephanie Nolen
June 25, 2025
The New York Times
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_ A new drug that gives almost complete protection against the virus
was to be administered across Africa this year. Now, much of the
funding for that effort is gone. _

A nurse in the dispensary of a clinic in Mhlosheni, Eswatini, which
once had the world’s highest rate of H.I.V. infection. From January
to April, nearly 5,000 people with H.I.V. failed to pick up their
medication, likely because their clinics were closed., Gulshan Khan
for The New York Times

 

This was supposed to be a breakthrough year in the 44-year-long
struggle against H.I.V.

Decades of research and investment produced new approaches to vaccines
that were going into their first significant clinical trials.

The hunt for a cure was homing in on key mechanisms to block the
virus, which can lurk dormant and near-untraceable in the body for
years.

Most critically, a breakthrough preventive drug, lenacapavir, a
twice-yearly injection that offers total protection from H.I.V.
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was to be rapidly rolled out across eastern and southern Africa. The
main target: young women. About 300,000 of them were newly infected
with the virus last year — half of all new infections worldwide.

Every one of these plans has been derailed by the Trump
administration’s slashing of foreign assistance.

There is more potential than ever before to end the H.I.V. epidemic,
scientists and public health experts say. But now, H.I.V. programs
across Africa are scrambling to procure drugs that the United States
once supplied, replace lost nurses and lab technicians, and restart
shuttered programs to prevent new infections.

“We imagined we would be in a different world right now,” said Dr.
Leila Mansoor, a senior research scientist at the Centre for the AIDS
Program of Research in Durban, South Africa. She had planned to spend
2025 analyzing data from one H.I.V. prevention trial, preparing for
another and tracking how lenacapavir was transforming the epidemic —
alongside colleagues testing new vaccines and cure strategies.

“And instead we’re moving backwards at warp speed,” she said.

Already, there are fears that H.I.V. infection rates are rising in the
hardest-hit countries, but there is no clear way to measure the damage
because data collection was mostly reliant on the terminated U.S.
funding. Stocks of prevention drugs once supplied by the U.S. are
running out across Africa.

In South Africa, which has led much of the H.I.V. work in close
partnership with the United States, clinical trials of vaccines that
had participants ready for their first shot have been canceled, the
immunizations left in the back of lab refrigerators. Scientists
leading cure studies have laid off their staffs and turned out the
lights in their departments
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The Trump administration says that too much foreign aid is wasted by
corrupt governments and bloated programs. The president and his allies
have repeatedly said that the United States has shouldered an unfair
share of responsibility for global health support and that other
countries must do more.

 

[A portrait of Leila Mansoor, who wears a blue head scarf and blue
dress with white dots and poses seated at a glass table.]

Dr. Leila Mansoor, a senior research scientist at the Center for the
Aids Program of Research. “We imagined we would be in a different
world right now,” she said.Credit...Ihsaan Haffejee for The New York
Times

[A portrait of Nkosiphile Ndlovu, who wears a lanyard, blue sweater
and poses seated in a black chair in an office.]

Dr. Nkosiphile Ndlovu, at Wits RHI in Johannesburg, worked on the
clinical trial that proved lenacapavir’s effectiveness, then moved
into H.I.V. cure research. “I could see we were making a
difference,” she said. “We would not want it to go to
waste.”Credit...Gulshan Khan for The New York Times

The United States has historically contributed about three-quarters of
the global spending on H.I.V., about $6 billion annually in recent
years. This is a legacy of a commitment made by President George W.
Bush more than two decades ago. Mr. Bush made ending the AIDS pandemic
a U.S. priority, saying this was a wealthy nation’s humanitarian
obligation, and that it would also benefit American health and
security, to bring the deadly virus in check.

Now, even as the Trump administration has dismantled numerous H.I.V.
research and prevention programs, Secretary of State Marco Rubio has
insisted that the United States will preserve its support for
treatment programs.

Among the prevention programs cut is U.S. support for an ambitious
plan to distribute lenacapavir, which the U.S. Food and Drug
Administration approved this wee
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Rapid rollout of the new injection is seen by many public health
experts as the best opportunity the world has yet had to stop the
spread of H.I.V. in the United States and abroad.

Historically, it has taken years for H.I.V. treatments and prevention
methods to reach Africa, where three-quarters of people with the virus
live, even when those drugs and interventions were first tested on
Africans.

Lenacapavir was supposed to be the product that showed that the world
was finally doing things differently, said Dr. Linda-Gail Bekker,
director of the Desmond Tutu H.I.V. Centre at the University of Cape
Town, who was a principal investigator in the trial that proved the
drug’s extraordinary effectiveness.

The company that makes the drug, Gilead Sciences, applied for
regulatory approval in African countries where it was tested at the
same time as in the United States. The company also issued a
voluntary license to makers of generic
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including companies in India and Egypt, so that an affordable product
would be available in a few years.

 

[A jumble of boxes and other office equipment seen through a gauzy
window.]

Files and office equipment left behind at the Mbabane office of the
Elizabeth Glaser Pediatric AIDS Foundation after it abruptly lost its
funding in February.Credit...Gulshan Khan for The New York Times

To bridge the gap until that time, Gilead committed to producing
enough of the drug to protect two million people over three years, to
be sold at “a no-profit price.”

However, about half of those doses from Gilead were supposed to be
purchased by the President’s Emergency Fund for AIDS Relief, known
as PEPFAR. But the Trump administration has decided that PEPFAR should
no longer support H.I.V. prevention for anyone except pregnant and
breastfeeding women, and will most likely fund only a sliver of the
planned Gilead purchase.

The other half of the doses were meant to be bought by the Global Fund
to Fight AIDS, Tuberculosis and Malaria, a multilateral donor agency
to which the United States has historically been the largest funder.
But the Trump administration is also cutting deeply into its support
to the Global Fund.

The third potential buyer for lenacapavir is the countries themselves.
But many are already straining health budgets to patch gaping holes
created by the reduced PEPFAR support and loss of other U.S.
assistance.

“The promise of lenacapavir for prevention was — everybody thought
this is the last stage to bring the H.I.V. epidemic down to its knees,
and there was such enthusiasm for what we would see,” said Dr.
Ntobeko Ntusi, the chief executive of the South African Medical
Research Council. “That’s now all up in the air.”

Executives at Gilead Sciences say the company is producing the bridge
doses now, and publicly say they are confident that the planned two
million people will receive the drug.

“Gilead has not stopped or slowed down in our ambition to make sure
we get lenacapavir to as many people as possible,” said Janet
Dorling, senior vice president for global patient solutions at Gilead.
“The changing landscape means we might have to do that differently.
I would not tell you that everything is as we expected.
But_ _everyone’s working very hard to find a way to make this
happen.”

Privately, however, the company is somewhere between anxious and
panicked about who will pay for the product, according to people who
have been part of negotiations.

 

[A close up view of a dose of lenacapavir in a syringe, which can be
read on its label.]

A dose of lenacapavir at a clinic run by the Desmond Tutu Foundation
in Cape Town.Credit...Samantha Reinders for The New York Times

Gilead would not disclose what price it would charge for these initial
doses for Africa, but H.I.V. program managers in several countries
said they had been told the target price was about $100 per patient
per year.

That is roughly double what African countries pay for daily H.I.V.
prevention pills, but ultimately cost-effective for public health
services because it offers much greater protection, said Hasina
Subedar, who oversees the design of H.I.V. prevention programs for
South Africa’s health ministry. Women who tested the injection said
it worked better for them than pills because they didn’t have to
remember to do something every day, and they didn’t have to worry
about stigma associated with H.I.V.-related tablets that a parent or
partner might see.

There is widespread hope in African countries that the Gates
Foundation may step in to cover the lost U.S. government funding for
the purchase — Bill Gates has often expressed enthusiasm about the
potential of lenacapavir to accelerate the end of AIDS
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but the foundation is resistant to buying the product from Gilead, the
people familiar with the negotiations said, because its executives are
reluctant to make a large payment to a major pharmaceutical company.

“We’ve been working on how quickly we can get the generic version
activated,” said Trevor Mundel, president of global health at the
Gates Foundation. The foundation will guarantee large-volume purchases
to encourage the generics makers to ramp up production, he said, in
the hope that the low-cost version of lenacapavir is available by
early 2027.

But prevention experts are concerned that generic drug makers will be
reluctant to scale up production of lenacapavir if demand hasn’t
already been proven — potentially keeping supply limited for years.
Mitchell Warren, executive director of the H.I.V. prevention
organization AVAC, said a potential buyer like the foundation was best
placed to negotiate the price down further in this complicated moment
for Gilead. (The foundation is a major backer of the Global Fund and
would contribute to a lenacapavir purchase in that way.)

Peter Sands, executive director of the Global Fund, has been lobbying
politicians in Washington to support lenacapavir, hoping that some
part of the U.S. funding pledge for the rollout might be restored.

“If you want countries to take on the responsibility for their
H.I.V. responses, in terms of both leadership and funding, it’s a
very different thing to take on a problem that is still growing than a
problem where you have made a significant dent in the numbers of new
infections,” he said. “And lenacapavir gives us that opportunity
to dramatically reduce new infections.”

 

[Linda-Gail Bekker smiles slightly, wearing a green knit sweater and
glasses on a chain around her neck as she poses through the window of
a glass office.]

Dr. Linda-Gail Bekker, director of the Desmond Tutu H.I.V. Center at
the University of Cape Town, who was a principal investigator in the
trial that proved lenacapavir’s effectiveness.Credit...Samantha
Reinders for The New York Times

[Sindy Matse poses on a black leather couch, wearing a dark blazer and
a green skirt in front of a blue wall. A poster behind her reads in
part, “Get tested.”]

Sindy Matse, program manager of the Eswatini National AIDS Program, in
her office in Mbabane.Credit...Gulshan Khan for The New York Times

The Children’s Investment Fund Foundation, a British charity, has
pledged $150 million to the Global Fund to support the rollout of
lenacapavir, and the fund is urgently seeking new philanthropic and
private sector donors, Mr. Sands said, as well as urging recipient
countries to rejigger their budgets where possible to help fast-track
the introduction of lenacapavir.

The South African government, which now pays for the daily oral
prevention drug, was counting on PEPFAR assistance to introduce the
twice-yearly injection of lenacapavir as an additional, most likely
more popular option. Ms. Subedar said South Africa hoped to use it
fast and widely, interrupting viral transmission and swiftly pushing
infection rates down.

She had envisioned getting lenacapavir to 800,000 young women in 2026,
blitzing college dorms and minibus stops. Now, she said, South
Africans are once again stuck, knowing a revolutionary technology
exists but unsure if and when they will have access to it.

In Eswatini, the country which once had the world’s highest rate of
H.I.V. infection, Sindy Matse, program manager of the Swazi National
AIDS Program, said the rates of H.I.V. testing in the country had
fallen precipitously since January. And from January to April, nearly
5,000 people who take H.I.V. treatment failed to pick up their
medication, most likely because their clinics were closed or their
outreach workers were fired, she said.

Ms. Matse worries that infected people aren’t starting on treatment
and that pregnant women may give birth to infected babies — but she
doesn’t know for sure what’s happening because much of her
program’s data was collected and processed by clerks whose salaries
were paid by PEPFAR and whom the government has yet to replace.

“We never got time to transition,” Ms. Matse said. “Now we are
expecting to see new infections, and drug resistance from people whose
treatment is interrupted.”

South Africa has also seen a sharp drop in the number of people taking
pills to prevent infection. In Cape Town, Dr. Bekker fears that South
Africa’s hospitals will soon start to see a surge of people with
tuberculosis — people whose H.I.V. treatment has been interrupted,
or who have not been diagnosed. Clinicians will need a crash course in
what AIDS-related infections look like, she said; young doctors will
not have seen them because South Africa’s H.I.V. program has been so
effective over the past 15 years. Soon they will be back.

“The stars were aligning, with these new innovations, to really
bring this thing to its knees,” she said. “But this money was
critical to get there. And now it’s gone.”

_Stephanie Nolen [[link removed]] is a
global health reporter for The Times._

 

* HIV
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* Trump cuts
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* U.S. foreign aid
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