“We will not go back!”: a powerful, resolute response to funding cuts at IAS 2025

One year ago, UNAIDS announced that the HIV response was at a critical crossroads. Apart from a handful of countries, the world was not on track to meet the ambitious 2030 goals: 95% of those with HIV diagnosed, 95% of those diagnosed on treatment, and 95% of those on treatment virally suppressed. The impending 2025 global targets, of fewer than 400,000 new HIV acquisitions and 250,000 AIDS-related deaths yearly, would not be met either. 

However, there were hopeful signs: sub-Saharan Africa has continued to make remarkable progress towards these goals. With the results of the PURPOSE 1 and 2 trials announced last year – showing lenacapavir to be a potent prevention tool with only two injections a year – there was a renewed energy and hope that HIV could finally be eliminated as a public health threat.

That was all before the entire global HIV response was turned upside down by the US government’s sweeping funding cuts this January. Now, questions that haven’t been pondered in decades – such as where to find the money for basic HIV services – are being asked again.

The 13th International AIDS Society Conference on HIV Science (IAS 2025), taking place this week in Kigali, Rwanda, would usually be focused on scientific advances. This year it is overwhelmingly focused on the funding crisis and what do about it. Governments, donors, HIV experts, healthcare workers, advocates and people living with HIV have been left floundering in the wake of the funding cuts; a rapid evolution in the response to HIV is urgently needed.

“We no longer stand at a crossroads,” Professor Linda-Gail Bekker of the Desmond Tutu HIV Foundation in South Africa, stated during her moving address at the IAS 2025 opening session. “We now find ourselves at a precipice.”

The 2025 UNAIDS global update

“The story up to December last year showed remarkable achievements,” Winnie Byanyima, UNAIDS Executive Director, shared at the launch of its 2025 Global Update in Johannesburg last week, ahead of IAS 2025. “New infections were declining, AIDS-related deaths were declining. We were not directly on target, but the direction of travel – particularly for this region, but even globally – was good.”

There were indeed hopeful signs at the end of 2024. While an estimated 1.3 million people acquired HIV last year, this represented a 40% decrease from 2010. Of the nearly 41 million people living with HIV, 87% were diagnosed, 77% were on treatment, and 73% were virally suppressed.

Sub-Saharan Africa, home to half of all people who acquired HIV in 2024, had seen a 56% reduction in new cases since 2010. Astoundingly, life expectancy in this region went from 56.5 years to 62.3 years in a mere 14 years.

Some of the most important advances made in 2024 were in terms of AIDS-related deaths and transmission to children. While AIDS-related deaths were still unacceptably high at 630,000 cases, they had come down by 54% since 2010. Cases of vertical HIV transmission have dropped 62% since 2010, with 120,000 cases of HIV in 2024. UNAIDS estimates that 4.4 million cases of HIV have been averted among children over the last quarter century. 

“The story is one of the most successful public health responses in history, saving more than 26 million lives,” Byanyima added, estimating the total number of deaths averted.

While the report focuses on data up to the end of 2024, it paints a grim picture of the potential impact of the recent funding cuts. There could be six million new HIV acquisitions before 2030, with four million additional AIDS-related deaths.

Apart from the single largest donor to the HIV response slashing funding, there have been gradual reductions from other major donors over time, weakening mechanisms such as the Global Fund. And while some countries have been able to develop the systems needed for greater self-reliance, many have simply not had enough time to do so.

Bynanyima reminded the audience that while sub-Saharan Africa has been the most dependent region with the highest disease burden, it has also made the fastest progress and produced some of the best innovations. This has not been a one-way street: these cutting-edge innovations have benefitted people vulnerable to and living with HIV in many high-income countries. A resurgence of HIV will be devastating for all countries, not just those who’ve had the largest epidemics. “Global solidarity is needed,” Byanyima stated. “Solidarity must not be confused with charity.”

South Africa’s Minister of Health, Dr Aaron Motsoaledi, was also present at the UNAIDS presentation. The South African government has been criticised by HIV experts and activists such as Zackie Achmat – who’s come out of retirement to respond to this new crisis – for not responding swiftly and decisively to the funding cuts. South Africa is home to the largest HIV treatment programme, currently at 96-79-94 in terms of percentages of those diagnosed with HIV, treatment coverage and viral suppression.

While Motsoaledi emphasised that over 75% of South Africa’s HIV response is funded nationally, he also expressed surprise at the fact that the Global Fund’s contributions to South Africa would also be impacted, in addition to PEPFAR and USAID funding, as the US is the largest donor to the Global Fund, too. “How did we arrive here, where we are so dependent on one country?” he asked.

Motsoaledi outlined steps South Africa was taking to mitigate the funding cuts, which he had announced in his health budget speech the previous day. The South African Treasury has allocated over R750 million ($42 million) to respond to the crisis, along with generous additional contributions by The Gates Foundation and the Wellcome Trust – specifically earmarked for research. Motsoaledi committed to providing the necessary prevention tools needed to end the epidemic, focusing on one of South Africa’s most vulnerable populations: “We will move mountains and rivers to make sure that every adolescent girl who needs lenacapavir gets it. I am making that promise.”

Bridging the precipice

Linda-Gail Bekker, also the principal investigator on PURPOSE 1 – the trial of lenacapavir that had zero HIV acquisitions among adolescent girls and young women in Africa – evoked an emotive narrative of the global HIV journey so far during the conference’s opening ceremony. Using music and images of those impacted by HIV, including many who had lost their lives before treatment became accessible in southern Africa, she referenced both scientific and cultural milestones from the past four decades. Her message was clear: we will not go back to the darkest moments of the epidemic.

Prevention services have been some of the hardest hit by the cuts. This has happened against a backdrop of already lower-than-hoped-for global oral PrEP initiations – approximately 8 million, missing the 2025 target mark of over 10 million. Uptake of injectable PrEP in the form of cabotegravir has been particularly slow, with only 25,000 global users. The dapivirine vaginal ring has only 2000 users. Most PrEP users were supported by PEPFAR, with an estimated 2.5 million new oral PrEP users in 2024 losing access this year. The prospects for injectable lenacapavir access and uptake are uncertain, unless concerted energy and resources are directed towards its roll-out.

In addition to powerful prevention agents, Bekker also reminded the audience of the great benefits of treatment as prevention. Undetectable = Untransmittable (U=U) remains one of the most formidable means of ending the HIV epidemic, by ensuring that all those with HIV are on treatment and reach undetectable viral loads. This means that they cannot transmit the virus to sexual partners.

While there are still 9.2 million people who need access to HIV treatment – half of whom are in sub-Saharan Africa - PEPFAR’s impact has been undeniable. An estimated 25 million lives have been saved, with 20 million people on antiretroviral therapy (ART) because of PEPFAR. Similarly, the Global Fund has also made seismic contributions to ending the epidemic, supporting around 21 million people on ART.

However, Bekker pointed out data from the UNAIDS 2025 update showing that while international HIV funding has grown by 12% since 2010, domestic contributions rose by 28% over this time. Despite these efforts towards greater national self-reliance, there are still 22 countries that rely heavily on external donor funding, many of them in Africa.

“What contributed to really making America great was the 92 million lives saved by USAID over 21 years, including 30 million children under the age of five,” Bekker said. USAID officially closed earlier this month.

Bekker believes that this is our moment to build a ‘resilience bridge’ to take us towards HIV control. “We need to reduce the loss of ground. Countries must devise emergency plans to mitigate the gaps in services due to the funding freeze. Local and international bridging funding must be found to fill this gap.”

This also requires a recalibration of how to get to the 2030 goals. Some international donors will need to provide transitional funding to allow for tailored plans to move countries towards self-reliance. Novel funding mechanisms will be needed, both locally and globally, to achieve sustained epidemic control. Innovations such as artificial intelligence, digital health and behavioural economics will need to be used.

“It can’t be done without community and the community needs resources and backing,” Bekker added.