Global Health Watch: LEN for PrEP commitments, US budget cuts shift from basic research, “trade over aid” raises global health concerns

Issue 64

April 17, 2026

This week, a new commitment to expand the reach of lenacapavir for HIV PrEP is a step forward but not enough to deliver impact, detail on the proposed US budget cuts reflects a shift away from basic research, and a broader shift toward “trade over aid” raises new concerns for global health financing and impact.

Lenacapavir for HIV PrEP Target Expands to 3 Million, But Falls Short of Need

The US Department of State, Global Fund and Gilead Sciences announced a new volume commitment for lenacapavir for HIV PrEP (LEN), increasing their three-year target of reaching two million people with LEN to three million people. This builds on prior commitments from the Global Fund, with strong support from the Children’s Investment Fund (CIFF), and PEPFAR, and investments from the Gates Foundation and Unitaid to accelerate development and access to generic LEN at lower prices. However, the global PrEP data that AVAC tracks shows that this is not yet in line with what the market can bear and what is needed for impact. Ultimately, LEN must reach more than five million people per year to have real impact, build a sustainable market, and drive prices down even further,” AVAC’s Mitchell Warren said in a statement. “This week’s announcement is progress, but it does not go far enough or fast enough, and the entire field must act faster and think bigger to achieve meaningful progress.”

According to the Global Fund, early program data suggest strong uptake of LEN among “priority populations”, including adolescent girls and young women and people accessing PrEP for the first time. However, it remains unclear how “priority populations” are being defined and who exactly is included among those accessing PrEP for the first time. Without explicitly naming these groups, there is a significant risk that key populations will be overlooked and effectively erased from early introduction efforts. A GBGMC and AVAC report released in September shows that the annual global need for PrEP among key populations will be 11.5 million by 2030. By the end of next week, eight of the nine countries identified by the Global Fund for early LEN introduction, with the exception of South Africa, will have begun to rollout LEN.

IMPLICATIONS: The announcement highlights the progress and what is possible: rapid early rollout, aligned partnerships, and market-shaping efforts, including generic licensing. But without ambitious targets and bigger volume commitments for at least four million people in the next two years, clear pricing and financing, reliable supply chains, well-supported service delivery, and robust monitoring to ensure equitable access, LEN risks following the same rollout as earlier innovations like oral PrEP, which reached too few, too slowly. As LEN rollout expands, impact will depend on clearly defining and reaching all priority populations, tracking uptake across groups, and avoiding patterns of inequity in access where new prevention tools reach some communities while leaving others behind.

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Proposed Office of AIDS Research (OAR) Budget Cuts and Shift to Implementation Science

The US President’s Fiscal Year 2027 budget request to Congress proposes a $5–6 billion budget cut for the National Institutes of Health (NIH). This includes a 28% budget cut to the National Institute of Allergy and Infectious Diseases (NIAID) and a nearly $600 million reduction to the Office of AIDS Research (OAR), which coordinates HIV research across the NIH. The accompanying Congressional Budget Justification (CBJ) issued by the NIH reiterates that NIAID is transitioning away from its “historic triad” of HIV, biodefense and pandemic preparedness and other infectious and immunologic disease to two new pillars: infectious disease research and immunological, allergy and autoimmune research. The CBJ also offers no explicit mention of HIV cure or vaccine research, instead placing a strong emphasis on implementation science. As reported in August, this reflects a potential dramatic shift of the NIH’s budget and priorities: away from basic science toward implementation science, with an emphasis on how best to use existing tools (including lenacapavir for PrEP) to end the epidemic in the US.

IMPLICATIONS: The President’s FY27 budget is a proposal that Congress will consider through the annual appropriations process. Lawmakers will recommend funding allocations for Labor, Health, and Human Services programs, including the Department of Health & Human Services (HHS) and the NIH. Historically, NIH funding has enjoyed bipartisan support, with Congress often rejecting proposed cuts or structural changes from Administrations. However, the scale of the proposed reduction in the OAR budget and NIH overall (see last week’s Global Health Watch), and vocal shift toward implementation research, raises serious concerns about the potential ripple effects across the HIV research and development portfolio. LEN for PrEP could have a critical role to play in ending the epidemic in the US and around the world, and implementation science is needed to optimize its potential impact. But LEN is not the only intervention needed, and it will be critically important to embed any implementation science agenda into a comprehensive “R&D and delivery” research agenda that shows the appropriate balance of the overall HIV/AIDS research portfolio.

US Administration Pushes “Trade Over Aid” Agreements

Ahead of an anticipated announcement at the United Nations later this month, the US Secretary of State called on national governments to support a new “trade over aid” initiative that would scale back traditional humanitarian assistance in favor of trade and investment partnerships. The move signals further intention to distance the US from its long-standing role as a leading provider of humanitarian aid and move toward a model grounded in economic exchange.

IMPLICATIONS: This shift raises significant concerns for global health, particularly for HIV and other disease responses that rely on sustained, predictable public financing. While trade and investment can play an important role in long-term development, it is not a substitute for life-saving humanitarian and health programs. Concerns are emerging that a shift towards a trade first model, would favor large private sector companies and risk exploitation of countries that are dependent on critical foreign assistance and aid to support public health systems and infrastructure. The bilateral agreements as part of the America First Global Health Strategy for example, also model this shift with provisions appearing in these agreements on US access to a country’s minerals in exchange for foreign assistance. At a moment when new tools like long-acting PrEP are emerging, the success of the global HIV response will depend not only on innovation, but on maintaining the public funding and partnerships needed to deliver these advances at scale.

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