Making the World a Better Place: The Case for HIV/AIDS Prevention in Mozambican LMICs, Persistently Suggested by President and CEO Eric Goosby
In a News Feature this week, we report on how swift cuts to the program have led to chaos and confusion. Thanks in large part to PEPFAR, the world was on a path to reducing, by 2030, the number of new HIV infections and AIDS-associated deaths by 90% compared with 2010 levels. More than 228,000 people are being tested for HIV/AIDS each day because of the program.
Eric Goosby is an infectious-disease physician at the University of California, San Francisco.
Beyond the strong political and financial commitment at the time, what made the endgame attainable was an unprecedented understanding of AIDS. “We understand how this virus moves through an individual, attacks their immune system, what parts are attacked more preferentially, how they decline in function,” Goosby says.
Research enabled the development of pre-exposure prophylaxis (PrEP) — medication that prevents HIV infection — and antiretroviral therapies that suppress viral replication and stop transmission. They transformed HIV from a fatal diagnosis into a manageable, preventable chronic condition, according to Deb.
As recently as the early 2000s, a positive HIV test was a death sentence in most LMICs, says Ntombi Ginindza, a former nurse in Mbabane, Eswatini, a small country sandwiched between Mozambique and South Africa. The AIDS epidemic cut nearly two decades from life expectancy there, bringing it down to just 39 years in 1998.
Due to cost concerns and regulatory delays, getting a drug to where it’s needed most will be difficult, according to an executive director. Still, she is hopeful about a promised partnership between Gilead Sciences and generic manufacturers to make low-cost doses of lenacapavir for 120 LMICs.
It speaks to a broader pattern of activism and market interventions putting life-saving tools within reach of millions. Since 2000, pharmaceutical companies have adopted differential pricing, lowering the cost of branded antiretrovirals on the basis of a country’s income, region and HIV burden. Thailand is one of several governments that have used public-health exemptions to produce inexpensive generic drugs in the country.
Complacency is especially common among younger generations, who never witnessed the full horror of the AIDS epidemic, Moracha says. More than one-quarter of new HIV infections are in people aged 15–24 years old, in part because of declining condom use and low testing rates. “There is now a whole new generation that doesn’t see HIV as a big deal,” she says.
The world will soon get a reminder. A person with HIV stops taking antiretrovirals and the virus starts replicating in a few hours. Their viral load is measured within a week. With waves of HIV leaking into the bloodstream, after four to six weeks, white blood cells start to get chewed up, leaving the body vulnerable to opportunistic infections. “The average number of infections you’d get through is three or four, before it kills you,” Goosby says. He predicts that hospitals will be overrun with HIV patients when it is three to six months.
Terminated research grants from USAID and the US National Institutes of Health (NIH) have also derailed promising advancements and innovations, says Glenda Gray, chief scientific officer at the South African Medical Research Council in Cape Town. For example, Gray’s experimental HIV vaccine trial was shut down, and Phanuphak recently had to close about half of the Institute of HIV Research and Innovation, despite its strong history of testing life-saving interventions. As of early April, nearly 30% of terminated NIH grants were related to HIV/AIDS.
Trump’s executive orders, which include declaring that there are only two genders and places restrictions on funding organizations that promote gender ideology, will have an adverse effect on HIV policy reforms. Thailand, for example, continues to criminalize sex work, ban the distribution of clean needles and syringe and prevent legal gender recognition for trans individuals. She thinks that, because of US actions, Thai policymakers could be more emboldened to block ongoing reform efforts. It isn’t an enabling environment to tackle HIV.
The George W. Bush Institute, a think tank based in Dallas, Texas, is right to say that the US Congress needs to authorize PEPFAR for another five years, so that the programme can complete its mission and so that countries, organizations and funders can plan for the transition to a world without USAID by strengthening local health systems, investing in primary care and establishing local medicine supply chains.
Critics of aid programmes say that aid should both assist nations with their immediate needs and support them to become self-sufficient. The improvement plans that PEPFAR establishes are with recipient countries.
On the first day of his second term, Donald Trump issued an executive order to freeze almost all foreign aid, pending a 90 day review. The US Agency for International Development, the world’s largest aid donor, was dissolved. In 2024, it distributed some US$44 billion for disaster recovery and long-term projects, from growing free markets to treating and preventing diseases.