The Future Of US Funding For HIV Treatment And Prevention

0:06In recent years we have made remarkable progress in the fight against HIV and AIDS. scientific breakthroughs have brought a once distant dream within reach. My budget will ask Democrats and Republicans to make the needed commitment to eliminate the HIV epidemic in the United States within 10 years. We have made incredible strides. It's incredible. That was a goal stated by President Donald Trump in his 2019 State of the Union address. But last month, Trump asked Congress to pull back hundreds of millions of dollars currently budgeted for the president's emergency plan for AIDS relief or PEPFAR as part of the rescissions bill the Senate passed.

1:00Senate Republicans made it clear in recent weeks they didn't want PEPFAR on the chopping block, and they got their way. After a meeting with the White House on Tuesday and a late-night vote, the cuts to PEPFAR are out of the rescissions package. But it's not the first time that funding for HIV research, treatment, and prevention programs and studies has come under threat in the first year of the second Trump administration. And it has those working to understand and fight the epidemic, both at home and abroad, worried. I'm Jen White. You're listening to the 1A Podcast. We break down the future of U.S.

1:32funding for HIV right after this. Stay with us.

1:40Let's get right into it with our guests. Here to help us understand the future of HIV funding is Aporva Mandavilli. She's a science and global health reporter with the New York Times. Aporva, thanks for joining us. Thanks for having me. Also with us is Dr. Rachel Bender Ignacio. She's a physician, scientist, and researcher at the University of Washington and the Fred Hutch Cancer Center. Dr. RBI, it's great to have you with us. Thank you for the opportunity. Aporva, let's start with the news of the week. According to the U.S. State Department, PEPFAR is the, quote, largest commitment by any nation to address a single disease in history.

2:16It's invested over$100 billion in the global response to HIV and AIDS. How did the State Department program get started and what is it set up to do? It started in 2003. It was a revision by several people, but most notably President George W. Bush really sort of championed this cause and started the program. And it's expanded greatly over the years. but it's also really widely considered probably the most successful global health program ever. It's estimated to have saved 26 million lives. Essentially, it provides HIV treatment and prevention to countries all over the world, low and middle income nations.

2:53And it's really transformed HIV treatment across the world. You know, in the early 2000s, we had drugs here, but in a lot of parts of the world, people just couldn't get them. And so people were still dying by the thousands of HIV all over the world. And so PEPFAR really changed things, not just for treatment and prevention, but also funded a lot of really important science. Dr. RBI, from your perspective as a doctor and researcher, how would you assess the success of PEPFAR? Phenomenal. So, you know, I think one of the key principles that we think about in our work is making sure that the people who most need the new inventions or new drugs are getting them first.

3:34and or at least at the same time as everybody else. And as Apoorva just said, PEPFAR really took that shift from thinking about let's invent something for Americans or for people who can have the funding and someday it will trickle down to other people. And it's really making sure that everybody around the world, the people that are living in the countries most impacted by HIV are getting the care that's life saving. So Apoorva, why then is PEPFAR something the administration would even want to cut? Well, I think the thinking is that PEPFAR has been supporting these countries for a very long time and that it's time for them to do this on their own.

4:17And a lot of people agree with that sentiment. I mean, it's not the first time that that's been articulated. And really, a lot of countries were on the path to taking ownership of their HIV programs. And this particular time, the new sort of law that looks at PEPFAR has just sort of made that handoff very explicit and said countries need to take over. In the past, it's been sort of a softer emphasis on that. And I think it just hasn't happened very quickly. So we have been paying, the U.S. has been paying for a lot of this treatment. I think the administration really wants to change that. Well, as the Senate began discussing the proposed cuts to PEPFAR last month, Maine Republican Susan Collins had this to say.

4:55I do want to know two areas of particular concern to me. The first is the proposed$400 million rescission of funding for the President's Emergency Plan for AIDS Relief, better known as PEPFAR. Launched in 2003 by former President George W. Bush, PEPFAR has saved more than 26 million lives. and enabled 7.8 million babies to be born HIV-free to mothers living with HIV. This program remains a bipartisan priority of Congress. Collins and other PEPFAR supporters got their way. When the Senate passed President Trump's rescissions package, the cuts to the fund were no longer included. So, Aporva, what happens now that the bill goes back to the House?

5:53Well, hopefully the PEPFAR money will stay in there. It's too early to say what's going to happen. I think it's been extremely fluid, this whole situation. But if the House also goes along with what the Senate said, then PEPFAR won't lose that$400 million. But I want to mention that that does not mean that PEPFAR is operating at full capacity or that PEPFAR is safe because PEPFAR is still facing really big cuts for 2026. and even now, all of the programs that PEPFAR funds are not functioning at full capacity by any means. Tell us about the cuts in 2026 that the program may be facing. So PEPFAR is set to lose about$2 billion from its funding for next year.

6:35That's out of about$5 billion that it was previously funding. And a lot of that is going to come out of prevention. So for whatever reason, this administration does not want to support prevention efforts. And that is extremely important for what we call key populations. So gay and bisexual men, sex workers, trans people, people who are really at high risk of this. And that is no longer supported. So a lot of that money is going to really affect prevention. And then the other thing that we are really worried about, the community, you know, the HIV community is really worried about is infections in young babies.

7:09because, as the senator was just saying, the PEPFAR efforts have really, really cut down on transmission of HIV from mothers to babies. And we are already hearing of reports from a lot of countries, including Uganda and places where this was a huge problem before that had gotten to a point where no babies were being born with HIV. And they're now once again seeing lots and lots of babies being born with HIV again. And would those 2026 cuts have impacts here in the U.S. as well? They would. You know, PEPFAR funds a lot of science, like I mentioned, and that has really benefited all of us. It's benefited prevention and treatment efforts even in the U.S.

7:48And separately, too, the Trump administration has cut a lot of prevention programs in the U.S. itself. So it's sort of a double whammy. Dr. RBI, what sorts of conversations have you and your colleagues been having as Congress and the White House negotiate the future of this program? Well, I would take a step back and put this beyond just what's happening to PEPFAR because I think it's important to understand that the research ecosystem and the care provision ecosystem is several interlocking parts. So we partner very closely with industry colleagues who are manufacturing, who are in some cases inventing, producing the medications with the National Institutes of Health, with PEPFAR, with USAID.

8:35We need all of these pieces to be functioning, to be able to do the work that we do. And I would say this is really, this is a moment of sheer panic. And as much as myself and my colleagues who have dedicated our whole careers to working on eliminating HIV are panicking, it's the people in the community who are really feeling the brunt of this. I think when I talk to my friends, to our community members who are living with HIV, they're having flashbacks to the 1980s and the 1990s before there was a treatment when they were seeing all of their friends dying. and they think about how much work people living with HIV, people who have been volunteering for these studies who are not living with HIV, but have decided to help with prevention and treatment and vaccine studies have put an effort in the United States and all around the world to make HIV a condition that is really preventable and treatable.

9:36And it feels like going back several decades. And it's a really, really scary time. It's scary for scientists because it seems like our work is being undone, but it's really more scary for the community, for the people whose lives are being immediately impacted. And I think it's a good moment to just level set and talk about what it looks like to be treating HIV for someone who's living with HIV right now and for HIV prevention because people ask me all the time from a wide range of, you know, are people still dying from HIV to is there a cure for HIV? Around the world, there are 21 million people who are receiving one pill once a day for HIV.

10:20It has three medications in it. It's generically manufactured. It's distributed in many cases by PEPFAR, by the Global Fund. And it is one pill once a day to treat HIV. It's very easy to take for people who have that ability to take a medication daily. There's a lot of reasons why that's challenging for people. But one pill once a day treats HIV. Well, I want to get to this message we got from Del in New Hampshire, who says, should America just supply HIV and AIDS drugs to the world forever? At what point do we ask other countries to take over and take care of their citizens? And Dr. RBI, I would love your perspective in your response to those questions, especially from your position as a physician scientist?

11:03Yeah, absolutely. I think that's a great question, Del. I think that none of us, including my colleagues who are in countries receiving the benefit of PEPFAR programs, want this to go on forever. But if we're really focusing on what is the benefit to people, the best way to make that transition is a carefully considered transition, probably over several years, in which case not only the keys are handed off, but there's a clear transition plan for distribution of medications and funding and testing and all of these things. What has happened is that most clinics in many countries, including some that my colleagues have told me about in Malawi, have just been shuttered with the medications inside, medications that could be going immediately to people.

11:54And the door locked and nobody to distribute the medications. And people are leaving their jobs in other parts of the sector to just go and hand out medications. So this is not the way to do it. There are careful and considered ways to do it. And I do think that that transition is something that both people in those countries want at some point. And we should be thinking about, but not like this. We also got this message from Miles in Las Vegas. I was a Peace Corps volunteer who served in the Republic of Zambia about a decade ago, and I saw PEPFAR in action. It saved a lot of lives, and it gave people hope.

12:30And my hope is that Congress will continue to fund the program so that one day HIV and AIDS will no longer exist in this world. Thanks for that message, Miles. Aporva, this week you traveled to Kigali, Rwanda, to attend the International AIDS Society's 2025 conference. And you spoke to a biomedical scientist, Linda Gail Becker, while you were there. She was part of a team that won a$45 million grant from USAID in 2023. And that grant was to run an HIV vaccine trial in eight African countries. Just days before its start date, the Trump administration sent a stop work order. What's the status of that trial now?

13:08And what's the outlook for its future? It's really hard to say. The trial has been canceled. Linda Gail Becker's lab has lost a lot of money. their entire team has lost probably up to 80 % of their funding, she said. And not just that trial, but lots of other HIV vaccine projects are on hold. And it doesn't look like they're going to restart anytime soon because there just isn't that kind of money anywhere else to keep it going. There are some countries that have made some investments, but the US was by far the largest funder of this kind of work. And I really want to emphasize Rachel's point here about the abruptness of this, because it's not that anybody was expecting even this kind of work necessarily to only be funded by the U.S., but without any warning to just have the rug pulled out from under them, all these trials have just suddenly gone on hold.

13:59And that's just a huge blow to the research efforts. Dr. Arbi, when we talk about research, how close are we to finding a vaccine for HIV? It's hard to know how close we are. I hesitate to give a number of years because because I think that number has continued to move. Scientists thought that we were close three decades ago. HIV is one of the most challenging pathogens, immune foes that we have. And that's because it hides in the very cells that our body needs to kill it. And it mutates so rapidly. So by the time that we come up with a vaccine that we think should be producing antibodies to it, it's already sort of changed its face.

14:47So I think that we're getting closer. There's some very promising results that came out just a couple months ago about the use of mRNA technology, which is a very rapidly evolving, very adaptable way to make an immune response, a very good immune response. So I think those results are promising, but we're not close yet. As we've said, PEPFAR spends a lot of money abroad and the fund works with partners in 50 countries. Apoorva, what other organizations or governments could possibly step in to replace funding, to play the role the U.S. has traditionally played in this space? There really aren't any.

15:25There are, of course, organizations like the Gates Foundation and Global Fund and lots of other global health organizations that have helped in this space, but a lot of them, including the Global Fund, were dependent on U.S. funding and have also been experiencing cuts. And no organization like the Gates Foundation can really make up for government funding, especially at the scale at which the US was providing it. So right now, what we're looking at is really catastrophic loss of funding to all of these countries. And at this meeting in Kigali, there was just so much distress. So people just so upset and so worried about the future of HIV.

16:03The thing I kept hearing over and over was, we can't go back. We can't go back to those years when people in those countries did not have access to drugs and prevention. But unfortunately, it looks like that might actually happen at least for a couple years. Kenneth emails, PEPFAR is not broken and thus no fixing is required. While it's been removed from the rescissions package, I am unsure of what will occur in the future of the Trump administration. So to come, we talk more about the canceled HIV vaccine efforts in the U.S. and the promising new HIV prevention tool that the Food and Drug Administration approved this June.

16:36We'll be right back.

16:44Apoorva, we've been focused a lot on the work the U.S. has been doing globally to research treatment and prevention for HIV and AIDS. But in May, you wrote about the Trump administration terminating a$258 million program here in the U.S. That was working with the National Institutes of Health to find a vaccine. Tell us about that program and what happened to it. So the$258 million program was actually a sort of multi-side consortium. It was based at two universities, but they worked with lots of researchers all across the country and the world. And, you know, the HIV vaccine work, we may not have seen a vaccine quite yet, but this kind of work has really helped with all kinds of things.

17:24And one of the things they've really helped with is our understanding of the immune system generally. And so that work has helped with developing COVID drugs. It's helped with therapies for autoimmune diseases. And I actually recently wrote a story about the search for a universal snake antivenom, and their work also really helped with that. And so, you know, we are losing a lot of really fundamental understanding of immune system with the shutdown of that particular program. Dr. RBI, we've talked about vaccines, and we've talked about treatment and prevention. We haven't really talked about a cure.

17:59Now, HIV patient Timothy Ray Brown was given a bone marrow transplant by a donor who was naturally resistant to the virus. This happened in 2007, and he remained free of the virus until his death in 2020. How is the scientific community thinking about finding a cure, and what sort of resources would be required? Yeah, so to find a cure, I think that work intersects right now very closely with the vaccine work. We need a protective immune response to keep HIV out of the body for people who haven't been exposed to it or might be exposed to it in the form of a vaccine. And similar immune responses will also help find a cure.

18:37So several of the same antibody infusions or vaccines are being tried in both scenarios. And the general understanding of the immune system that Apoorva really highlighted is one of the ways that we get there. Um, I work very closely with, um, the ACTG, which is the longest running and largest, um, global network, um, to treat and to, um, to innovate treatments for TB, tuberculosis, hepatitis, also HIV treatment and HIV cure have been really the main focuses of that. And our funding right now is very much in jeopardy. we are not doing the work that we should be doing with these clinical trials, with some of that work to get, you know, the translational work, meaning the work that goes into the lab before we get these things into people because of the funding cuts.

19:38And so, you know, that work for HIV cure, HIV remission is also very much at risk right now. Let's go back to our voicemail box. We I am concerned for global health. I'm concerned for the devastation that it may cause to millions of people potentially. And also the possibility that a disease that is left to fester and not be treated also has the ability to mutate and potentially be transmitted in different ways. And I think not addressing something like this is really short-sighted and cruel. Rachel, thanks for that message. It echoes what we heard from Mark, who emails, Viruses have no national borders.

20:34HIV spread around the world and has continued to mutate. Without international health care containing this disease, the mutations and virulence will return even to the USA. Dr. RBI, we're talking about stop work orders, cuts in funding, studies left without resources. When we press pause on this kind of work, how easy is it to restart or how difficult? Extremely difficult. I can speak for just, you know, the small microcosm that is my research center at the University of Washington is called UW Positive Research. We're one of the nodes in the network of the ACTG network that I mentioned that works globally with 64 sites throughout the world.

21:17My staff right now has very, very minimal funding coming in from the NIH. And if I didn't have another project that was working with an industry partner, an industry-funded study, I would have completely laid off my entire staff by now. And that's not an overestimate. People have been working there since 1999. In some cases, it's an incredible amount of institutional knowledge. And we have people continuously on study. So our number one duty in research is to do no harm. And next after that is to make sure that we are doing something productive with the effort that people give us. So when people volunteer for studies, we have to make sure they're safe.

22:07We also have to make sure that we are using their sacrifices of time, their blood, and sometimes risk for trying a new intervention, to advance science for other people. And right now, we are very carefully making sure that our people are safe, that the people that are volunteering with us are still on study, that they're still safe. But there's no funding left over to be enrolling new participants in studies, to be opening new studies, to be doing any new work. In most cases, that, quote, new work has been in the pipeline for five, if not 10 years, just in the clinical trial planning phase, and in some cases has been at the bench in lab science for two decades.

22:52So it's a continuous cycle. It's something that's very, very difficult to pause for a number of reasons. And it's also exceedingly unfair to the people who are planning on and have already contributed so much to that science. You mentioned fairness. And I wonder if you get the chance to restart or rebuild these efforts in the coming months or years. How does the U.S. scientific community rebuild trust, both with the global partners and with the communities they're trying to help? That is, I think, the key question in places in which we're doing international research or PEPFAR partner countries.

23:36because, you know, it is, there's been a long history of mistrust and then a very, very careful, concerted effort by people working in clinical programs and in PEPFAR programs and in research to really make sure that this is a bilateral partnership, that we're involving the community. So people who are at risk of being exposed to HIV, people who are living with HIV, people who are in the communities that care. And it's really, really hard to say to somebody, well, we were doing this together as a partnership, but we just locked the door and walked away. And why? Well, somebody made a decision that doesn't have anything to do with the science or the safety of it.

24:20It's very hard to explain and rebuild. We got this email from Kit who says, are the anti-HIV drugs distributed by PEPFAR sourced from U.S. companies? If so, do non-U.S. companies have the recipes in case other countries might want to partly replace PEPFAR? Apoorva, what can you tell us? Some of the drugs that are used right now have been around long enough that there are generic versions available. And there are companies in Brazil and India, in many parts of the world that are making generic versions of some of these drugs. But the main issue is even at cheaper prices, you still need funding to buy them.

24:58And one of the big things is USAID was really, really invested in logistics, in distribution. And with those supply chain distribution networks completely destroyed, it's just really hard to get the drugs to the people who need them, even if they're affordable. The Trump administration often points to the private sector to do the kind of work being cut from the federal government or funded by the federal government. And Dr. Arbi, can the kind of work and research being done in your sector be done effectively in the private sector? The short answer is no. The slightly longer answer is it really needs a partnership.

25:40And I think one of the places that COVID research got us to with programs like what was originally Operation Warp Speed and became the U.S. government COVID response was a public-private partnership in which the ability of our network of sites and investigators, researchers who come at research from an unbiased standpoint to have the interest of making sure that things are being done. ethically and fairly, and that we're answering the important questions for society, partners with the incredible resources, and often case the molecules being provided by industry. And so I don't think the answer is for industry to go this alone.

26:27I think the answer is that we needed to have and still need to have, you know, this careful partnership. And some of the studies that I'm working on on long-acting HIV medications, I think are a very good example of how we can partner with the people that are making either already FDA-approved medications or investigational medications, medications that are in the pipeline, to carefully design studies and implement studies that are going to get these medications first to the people who need them in the U.S. Well, speaking of long-acting HIV medications, Apoorva, a new prevention option for people at risk for HIV, was approved by the FDA in June.

27:06Tell us about it. So this is called Lenacapavir. It's actually already available for treatment, but there was so much excitement about this particular preventive tool because it's essentially an injection given every six months. That's it. And it prevents HIV with almost 100 % efficacy in lots of different groups that it's been tested in, either 100 % or close to 100%. So it's this amazing, miraculous tool that people are just incredibly excited about. And PEPFAR was supposed to purchase and be able to distribute this. So the sad thing about it is that at this meeting, there are both, you know, in Rwanda that I was just at, there were both lots of sessions dedicated to how amazing this preventive tool is, but also lots of confusion and concern over how people are actually going to get it.