Without Reliable U.S. Funding, What Might the Future of HIV Science and Services Look Like | IAS 2025

From left: Beatriz Grinsztejn, Kenneth Ngure, Linda-Gail Bekker, Sharon Lewin

More diversified, regionally based funding and a greater reliance on China were among the possible scenarios that may emerge in the wake of what appears to be the end of an era of major U.S. funding for HIV research and programs around the world, a group of leading HIV researchers said at a press conference yesterday at the International AIDS Society meeting.

In a wide-ranging, hourlong briefing, the four experts also defended continued research into identifying an AIDS vaccine and discussed the nuances of integrating HIV services into other healthcare services, including the risk of groups that have been stigmatized dropping out of HIV prevention and care efforts. The sheer abruptness of the cuts in U.S. funding caused its own set of problems, the researchers said, crippling a number of research projects that were years in the making and eroding hard-won trust with communities in the process. Spending cuts at the U.S. National Institutes of Health (NIH) could unravel a team-based model of scientific research that American funding largely created that involves large groups of researchers working in many different countries, said one of the researchers, Sharon Lewin, director of the Peter Doherty Institute for Infection and Immunity in Melbourne, Australia.

Team-based science is “the way to tackle really significant, major challenges,” Lewin said. “You can't do it in isolated, single laboratories in Cape Town or Melbourne or Nairobi. You really need big consortia, and no other funder has done it, globally, in the same way the NIH has done it,” Lewin said.

The Trump administration’s decisions to slash foreign aid and shutter the United States Agency for International Development, both of which have affected funding of projects focused on HIV and AIDS, have loomed as the backdrop to the IAS meeting, which is structured as a scientific meeting, not a policy one. Sessions are devoted to the consequences of cuts and straitened circumstances, and they surface as topics even when the focus is elsewhere. Speakers have decried the cuts but also looked ahead to weaning HIV and AIDS research and programs off of U.S. support.

“I would really hope that the African footprint would be larger, not only in the provision of care, which is obviously our mandate, but even in the R and D (research and development) space,” said Linda-Gail Bekker, M.B.Ch.B., Ph.D., director of the Desmond Tutu HIV Centre at the Institute of Infectious Disease and Molecular Medicine at the University of Cape Town. Bekker noted earlier in the press conference that African governments had not lived up to the 2001 Abuja Declaration that pledged them to allocate 15% of their national budgets to improving healthcare.

State of the funding cuts

The scope of the U.S. funding cuts is difficult to determine, said Bekker. “The confidence intervals about the numbers” have been wide, she said. The U.S. President's Emergency Plan for AIDS Relief, better known by its acronym, PEPFAR, was initially threatened by the Trump administration’s foreign aid freeze but then granted waivers that allow some of its funding to continue. The situation has been complicated by the administration’s shuttering of the United States Agency for International Development (USAID), which implemented many of the programs funded by PEPFAR. According to KFF, Congress approved $6.5 billion for PEPFAR for the fiscal year ending in September 2025 that includes $4.8 billion for bilateral HIV efforts and $1.7 billion for multilateral efforts, $1.65 billion for The Global Fund to Fight AIDS, Tuberculosis and Malaria, and the remaining $50 million for the Joint United Nations Programme on HIV and AIDS. Politico reported today that the Trump administration is backing away from a plan that would have cut $400 million from PEPFAR funds in response to Republican senators’ objections.

The net result of the funding pullback so far seems to be preservation of funding for AIDS treatment programs and for HIV prevention programs for pregnant and breastfeeding women but an end to funding for prevention for other groups and for community-oriented HIV programs, some of which focus on stigmatized groups, such as transgender women, men who have sex with men, and sex workers.

Bekker mentioned two projects that ground to a halt because of the foreign aid freeze’s effect on PEPFAR: MOSAIC, a seven-year project designed to promote the development of HIV prevention products among adolescent girls and young women, and CATALYST, designed to test and assess the uptake of different types of HIV preexposure prophylaxis (PrEP) for women. Bekker said the teams running the programs had to be dispersed and the beneficiaries had to be notified. One result is an erosion of trust with people who participate in these and other projects, Bekker said.

Another researcher on the panel, Kenneth Ngure, M.P.H., M.Sc., Ph.D., an associate professor of global health and dean of the School of Public Health of the Jomo Kenyatta University of Agriculture and Technology in Kenya, also mentioned the MOSAIC project and the promise it held for identifying ways to make prevention products more acceptable and therefore more effective. “The science that has been crippled is humongous,” he said.

Apart from PEPFAR, research funds from the National Institutes of Health have flowed into HIV treatment and research. Bekker said that 80% of the Desmond Tutu HIV Centre’s HIV research budget was supported by competitive NIH grants. Lewin said that a 2022 estimate found that 80% of the $480 million for research into vaccines and possible cures for HIV came from NIH. “If there is going to be a 40% cut in NIH funding, we're going to see a dramatic reduction in funding,” Lewin said. The U.S. is the only major funder of HIV vaccine research, she said, with France a distant second.

Bekker said that NIH grants to her center seemed like they might be imperiled because of the freeze on foreign aid to South Africa. She said there had been some signs in recent weeks that because they have been deemed research grants and not related to foreign aid, the funding would come through. Science reported earlier this month that a hold on payments for many grants to South Africa had been lifted.

Integration pros and cons

One response to the funding constraints for HIV programs in Africa has been calls to fold HIV services into other healthcare services for efficiency and sustainability reasons. The new HIV guidelines the World Health Organization issued yesterday called for HIV services to be integrated with services for diabetes, hypertension care, mental health, and alcohol use disorders. Bekker said integration of HIV health with sexual and reproductive health services is a step towards person-centered care. But incorporating HIV services into primary care runs counter to the recent history of providing HIV care for vulnerable populations in other ways and settings to avoid stigma and criminalization. Bringing those services may drive people in those populations underground, she said, undercutting the “last mile” to control the HIV epidemic by 2030. ”This word integration has now become somewhat of a dirty word,” Bekker said. If there is going to be more dependence on domestic funding, the national government should understand the need for community-based and community-led facilities, which can be local and don't have to cost huge amounts, she said. But Bekker also said that primary health care facilities, at least in certain centers of excellence, need to develop some of the better ways of dealing with a broad population. “That is a hard thing to do, and we've struggled over many decades to try and get that right, but I think we have to keep working at that,” Bekker said.

Ngure said integration could create some efficiencies, and he spoke about the advantages of using private pharmacies as a place to deliver prevention services. “We need to meet people where they are. We need to demedicalize prevention,” he said.

Will China fill the void?

Lewin mentioned Europe, Japan, and Singapore as possible sources of funding to begin to replace the void left by the U.S. She also mentioned foundations, such as the Gates Foundation and Schmidt Family Foundation, founded by former Google CEO Eric Schmidt. She noted that China is investing heavily in technology, artificial intelligence (AI), and scientific capabilities that will be crucial for future research, and she expressed hopes that the AI would be developed collaboratively with the rest of the world rather than China developing and selling it to the rest of the world.

“China has had a good HIV response. They're investing heavily in science in areas around pandemic preparedness and virology. There are a lot of very good HIV scientists there,” Lewin said, adding, though, that she didn’t think China would fund science the way the U.S. has—selecting to fund the best science in any country—but she predicted that they will become an important partner.

Beatriz Grinsztejn, the president of IAS and a leading HIV/AIDS researcher in Brazil, opened the press conference and moderated the questions from reporters.