March 27, 2025
By Jeanne Baron and Cat Verde-Hashim
In the months leading up to the US funding freeze, the HIV prevention field was slowly gaining momentum—expanding PrEP access, introducing new products like injectable CAB for PrEP (CAB-LA) and the dapivirine vaginal ring (DVR), and strengthening delivery systems to ensure the rollout of injectable LEN for PrEP (LEN) reached those most at risk. This progress has been as a result of years of investment, collaboration, and community engagement. But the freeze has brought this momentum to a halt. Service delivery has been disrupted, community-led programs suspended, and healthcare workers laid off. Stockouts loom, research has been paused, and demand generation efforts have gone silent—just as the sector was beginning to overcome longstanding barriers. Without urgent, coordinated action, the gains made in HIV prevention could be reversed, leaving communities more vulnerable and equity further out of reach.
The global health community ended 2024 with a historic opportunity in sight. With key lessons in hand from the rollout of oral PrEP, it is possible to get rollout right in 2025 with next generation long-acting PrEP and put the world on track to end the AIDS epidemic by 2030.
What’s more, ongoing research, presented at the Conference on Retroviruses and Opportunistic Infections, showcased the promise of new research and development in HIV prevention and PrEP. PrEPWatch offers a PrEP-specific conference round-up along with this summary article from Spotlight South Africa: A jab that could protect against HIV for a year at a time, and other highlights from major conference.
But as the new US administration took control of the government at the end of January and decimated every aspect of foreign assistance and global health, the impacts could set back the HIV response by decades, allowing the epidemic to resurge. Robust PrEP programs, beefed up to deliver long-acting PrEP, will be essential to delivering injectable Lenacapavir for PrEP and other long-acting PrEP. PEPFAR has been the foundation of PrEP delivery for the world, responsible for 79% of PrEP uptake globally in the last year. That number reached 83% by the end of September of 2024. 84% of surveyed PEPFAR implementers reported disruptions to their programs, many characterized as severe. See our new analysis—Impact of PEPFAR Stop Work Orders on PrEP—for an in-depth look at what’s at stake for PrEP as an instrumental tool in the effort to reach epidemic control.
Also documented by the PEPFAR Impact Tracker, PEPFAR Watch, amfAR, Lancet HIV, GBGMC, and HIV Modelling Consortium, the scale of the devastation is mind-numbing: Criminalized populations such as sex workers, transgender individuals and gay men are finding sites that once provided safe access to treatment and prevention shuttered. And governments fear blacklisting from future US government funding if they support these sites. A new UNAIDS analysis finds “there would be a 400% increase in AIDS deaths, amounting to 6.3 million deaths,” if PEPFAR is not re-authorized (which it was not) and no other resources fill the gap. The HIV Modelling Consortium finds without funding for prevention programmes in Africa, over the next ten years, incidence rates amongst adults could triple and vertical transmission is likely to double. See AVAC’s March PxWire for details.
PEPFAR’s goal had been to initiate 100,000 users across ten African countries on injectable cabotegravir (CAB) by the end of 2025. By the end of October 2024, they had initiated 5,000 users across four countries, but in January 2025, procurement for 2025 was paused. Projects studying CAB and DVR serving over 11,000 participants have been terminated, and other projects were suspended. In Kenya, 17% of total nurses (22,000) and (12,000) ancillary staff have stopped work; in Zambia and Malawi numbers rise to 20% (17,000) and 43% (4,500) of nurses, respectively.
With these threats to PrEP scale-up jeopardizing the HIV response, the ambitious announcement, made in December 2024, by PEPFAR and the Global Fund to reach 2 million people with LEN for PrEP over three years must be supported. Early in March, Global Fund Executive Director Peter Sands told the Bhekisisa Centre for Health Journalism, it will fund the rollout of LEN for PrEP with or without PEPFAR.
“We are still maintaining our ambition on lenacapavir for PrEP,” said Sands, “We see lenacapavir as a potential game changer in the fight against HIV as an injectable, long-acting PrEP solution that is pretty well 100% effective. It’s not going to be right for everybody, but we need to find out more from having people use it.”
Now what?
The field must not delay in the face of this destructive and lethal attack on global health and HIV prevention. Instead, the field must adapt to a significantly changed landscape for PEPFAR and beyond. Most countries are seeking alternative funding sources (Global Fund, government financing) and integrating service delivery (comprehensive care clinics and key population services) into public health systems. Those efforts are a start but will take time and will not be enough alone to rebuild the collapsed foundation that PEPFAR provided until January 20, 2025. Ongoing commitments from the Global Fund and Unitaid are essential but will also not be enough. An expanded role for the private sector and other innovations in delivering HIV prevention could be part of the solution. But more is needed. The solutions are out there, it will take courage and vision to work in solidarity to preserve existing programs that offer oral PrEP and expand with long-acting PrEP. The world must re-start and sustain the introduction of CAB for PrEP and the dapivirine vaginal ring (DVR) to make choice a reality. Investments by the Global Fund and Ministries of Health in PrEP must increase.
Peter Sands is pointing the way. The promise of HIV prevention is just as real as it was before the new administration took office. Only now we must find a new path. To stay on track will require trust, innovation, commitment and investment.
Let’s do it.