LANSING, Mich. (WZMQ) – Sweeping changes to U.S. global health funding have dismantled much of the infrastructure that supported HIV prevention and treatment around the world, creating immediate disruptions and long-term risks that experts say could set the global response back decades.
Robin Lin Miller, a professor at Michigan State University who has spent four decades evaluating HIV programs in the United States and abroad, said USAID played a central role in implementing the U.S. President’s Emergency Plan for AIDS Relief, or PEPFAR, the largest global HIV initiative in history.
“USAID essentially was the primary implementing government agency that was overseeing, in partnership with the State Department, the work of the largest global program to address the HIV epidemic essentially in the world, the President’s Emergency Plan for AIDS Relief,” Miller said. “The stop work order that was issued the first week of President Trump’s administration essentially stopped all activity that was under the direction of USAID.”
Miller said the pause did not affect just one agency, but multiple pillars of the global HIV response.
“That included probably the lion’s share of the portfolio of the PEPFAR work that was going on underneath that agency,” she said. “That work was also being carried out by the Peace Corps, which has taken a substantial cut, and by the CDC, which has also taken a substantial cut.”
From an HIV perspective, Miller said the result was devastating.
“What these cuts meant, both the suspension of work meant, but also what the cuts have meant, is almost a complete dismantling of the primary infrastructure for ensuring that people around the world have access to HIV prevention resources, to treatment, to clinical care, and to lab infrastructure,” she said. “It’s been incredibly disruptive, and this kind of disruption is incredibly dangerous for global health.”
Miller said the funding supported a wide range of services, spanning prevention, testing, treatment, and social support.
“If you’re an HIV expert, we tend to think of this as a cascade,” she said. “It covers the range of the kinds of things we can do for HIV prevention at the level of individuals at risk, but also for groups of people at risk.”
Those services included education, mental health support, condoms, pre-exposure prophylaxis medications, STI screenings, HIV testing, linkage to care, antiretroviral medications, family planning, and economic empowerment programs.
“It included programs for economic empowerment because we know that when people are employed and stably housed, that they are better able to protect their health,” Miller said. “It included referrals… to make sure that their basic needs were met, that their human rights weren’t violated.”
After the funding pause, Miller said disruptions to treatment happened quickly and had serious consequences.
“When you stop programs cold, as happened in January, you’re interrupting service delivery in ways that are incredibly dangerous,” she said. “It doesn’t take long to be off your medications before that level of viral suppression is no longer the case, that you’re able to transmit the virus again, and you often become very sick quickly.”
She said the interruption led to medication shortages, breakdowns in laboratory systems, and rising hospitalizations.
“You see increases in hospitalization, increases in healthcare costs, and decreases in adherence to regimens for people who are still able to get access to their medications,” Miller said. “It takes a really long time to recover from that.”
While limited funding has since resumed, Miller said the current version of PEPFAR is dramatically scaled back.
“What’s important about what the current strategy looks like is that it’s very narrowly focused and prioritizes pregnant women and breastfeeding women,” she said. “That is a minority of the people who are at high risk of HIV infection.”
Miller said most new HIV infections globally occur among so-called “key populations.”
“A sizable majority of new infections globally are in what are called key populations,” she said. “They’re especially vulnerable to HIV infection, but they’re also especially vulnerable to discrimination, to stigma, to greater challenges accessing healthcare.”
She said the current strategy eliminates services tailored to those groups.
“The current strategy essentially guts programming for the people who fall into those vulnerable groups,” Miller said. “They no longer have access to prevention… or to the kind of support services around prevention that were once in many country contexts exclusively provided through the U.S. support.”
In many countries, Miller said, peer-led clinics were the only safe option.
“We know that for these groups of people going to the government hospital, it is not a safe place to seek services,” she said. “When you don’t have these sort of peer-led services supported, you are likely to see declines in access to care, access to testing.”
Miller said modeling shows the long-term consequences could be severe.
“They suggest that the rate of new infections globally will increase four to six times over what they were in 2024,” she said. “They also suggest that mortality will increase.”
She said those projections are based on credible historical data.
“They’re taking models that examine the rates of new infections and the rates of mortality from the past and projecting out into the short term what would happen under different sets of scenarios,” Miller said.
The impacts, she said, were already visible during the shutdown.
“People were showing up to clinics, and the clinics had shut down,” Miller said. “This was true from Ukraine to South Africa.”
Children were especially vulnerable.
“Children were especially vulnerable to having had their HIV infection under control and leading very healthy, normal lives to essentially dying within a matter of weeks,” she said.
Rebuilding the system, Miller said, will not be easy.
“It is 20 years of infrastructure that was just destroyed overnight,” she said. “And you can’t build that in a day.”
She said the loss of U.S. leadership extends beyond health.
“When the peace and prosperity in a region declines because it’s struggling with a health crisis, that affects us,” Miller said. “And it doesn’t take long for it to affect us.”
Miller said the cost of the program was small compared to its impact.
“In the scheme of the U.S. federal budget, this was a drop in the bucket,” she said. “That small investment brought huge global gains.”
She urged Americans to stay engaged.
“They are there to represent us,” Miller said. “If you care about HIV, reminding them that you care about that is important.”
Miller also warned that cuts are affecting HIV programs domestically.
“We’re in trouble domestically when it comes to the HIV epidemic,” she said. “We may see our own parallel rise in infections, parallel rise in mortality… in tandem to what’s happening on a global level.”
