The President’s Emergency Plan for AIDS Relief (PEPFAR) has long been hailed as one of the most successful and bipartisan efforts in global health. Established in 2003 under the Bush Administration, PEPFAR has saved millions of lives by providing critical HIV treatment and prevention services and building partnerships with countries and communities. But this work ground to halt last week, with a chilling pause on all work.
This week, the State Department approved a limited waiver to re-start some treatment and PMTCT programs is a small step forward, but far from a victory at all. And it is especially short-sighted and cruel in it approach (or lack thereof) to primary HIV prevention. One of the most effective tools in the fight against HIV has been Pre-Exposure Prophylaxis (PrEP), a medication regimen that reduces the risk of acquiring HIV by over 99% when taken consistently. Yet, with this new guidance, the Trump Administration is choosing politics over science, discrimination over compassion, and ultimately, death over life.
The February 6th guidance from the Trump Administration stating that “people other than pregnant and breastfeeding women who may be at high risk of HIV infection or were previously initiated on a PrEP option cannot be offered PEPFAR-funded PrEP during this pause of US Foreign Assistance or until further notice” is not only a dangerous deviation from sound public health policy—it is a death sentence for thousands of people at risk of HIV globally.
PrEP is one of the most powerful tools available in the fight against HIV/AIDS. Public health experts and epidemiologists agree that expanding access to PrEP is essential to curbing new infections. The administration’s directive effectively shuts the door on communities around the world, depriving them of life-saving medication and increasing the risk of new HIV transmissions. This move not only contradicts decades of scientific research but also undermines the very mission of PEPFAR: to save lives and reduce the burden of HIV/AIDS worldwide.
The restriction on PrEP access is particularly troubling in regions where the HIV epidemic is most severe, such as sub-Saharan Africa. In these areas, young women account for a disproportionate number of new infections, but so do men who have sex with men (MSM) and transgender individuals—groups that are now explicitly excluded from PEPFAR-funded PrEP under this new policy. By denying these populations access to PrEP, the administration is actively allowing the HIV epidemic to spiral further out of control.
Research has continued to produce newer modalities of PrEP that are long-acting products, which create even more possibilities for people to protect themselves for up to six months per dose. One long-acting prevention tool, injectable lenacapavir, is currently under FDA review and could provide a valuable option for people who have trouble with daily pill-taking or fear the stigma that is sometimes associated with ARVs in their communities. With regulatory approval and WHO guidelines expected by the middle of the year, injectable lenacapavir provides the best chance to drive down the number of new infections. So stopping current PrEP programs makes seizing this new opportunity that much harder.
This decision appears to be less about public health and more about an ideological agenda that seeks to police morality rather than protect lives. The new Trump Administration, just weeks into its second term is demonstrating a careless pattern of undermining global health programs, including cutting funding for international health organizations that provided comprehensive sexual health services. This latest move is yet another example of the administration prioritizing conservative politics over the well-being of vulnerable populations.
By selectively restricting PrEP access to only pregnant and breastfeeding women, the administration is effectively signaling that only certain groups are deemed “worthy” of HIV prevention. This echoes the stigmatizing rhetoric that has long plagued HIV/AIDS policy, one that associates the disease with so-called “immoral” behavior and seeks to punish those who are at highest risk. Such policies not only fail to address the reality of the HIV epidemic but also reinforce dangerous stereotypes that fuel discrimination and stigma.
The repercussions of this policy extend far beyond the immediate communities affected. As the largest funder of global HIV/AIDS programs, the United States has a moral and strategic responsibility—and opportunity—to lead with science and evidence-based solutions. The decision to restrict PrEP access will not only increase new infections but also put added strain on already overburdened healthcare systems. The cost of treating HIV is significantly higher than preventing it, making this policy both a moral and fiscal failure.
Moreover, at a time when the world is grappling with multiple global health crises, the US should be strengthening, not weakening, its commitment to international health initiatives. This policy shift undermines trust in US global health leadership and sends a dangerous message to other nations that discrimination and exclusion are acceptable public health strategies.
Congress, global health advocates, and the public must demand the immediate reversal of this harmful policy.
The fight against HIV/AIDS is far from over. We cannot afford to take steps backward when so many lives are at stake. The Trump Administration’s decision to deny PrEP to those most at risk is a dereliction of duty, a moral failing, and a betrayal of the very principles that PEPFAR was founded upon. The world is watching, and history will not judge kindly those who choose exclusion over compassion, politics over science, and death over life.
