ARI SHAPIRO, HOST:
HIV has been in retreat around the world. Fewer people are dying of the disease. New infections are decreasing. More HIV-positive people have access to lifesaving medicine. Those trend lines have been moving in the right direction for decades, and U.S. investment is one big reason.
It's less clear where the trend lines go from here. While the Trump administration dismantled foreign assistance through USAID, it continued PEPFAR - the President's Emergency Plan for AIDS Relief. But much of that work is either no longer happening or happening at a very reduced capacity. And last week, the U.S. said it will invest in a new drug that can prevent HIV with just two injections a year.
So to understand where things stand and where they are going, Emily Bass is here. She's author of "To End A Plague: America's Fight To Defeat AIDS in Africa." Welcome.
EMILY BASS: Hi.
SHAPIRO: OK, if you could draw a chart showing the trend line since the '90s on HIV transmission and treatment, where do things stand right now, and where do they need to get to eradicate HIV?
BASS: Well, let's talk about where they stood in December of 2024...
SHAPIRO: Sure.
BASS: ...Ari, because that's what we can really talk about with confidence, as I'll explain in a little bit. But in December 2024, on the brink of the new year - the year we're currently in - we were looking in many countries in sub-Saharan Africa in particular, which is where PEPFAR has focused its investments - at countries being on the path towards or having achieved a set of milestones that were associated with ending HIV as a public health threat...
SHAPIRO: Wow.
BASS: ...By 2030.
SHAPIRO: So, like, the finish line in sight?
BASS: Yes, very much so.
SHAPIRO: So we've seen people fired and rehired. We've seen grants frozen and unfrozen. Can you say right now what the U.S. role in global AIDS prevention is and will continue to be, or is it all just totally murky and uncertain?
BASS: In the past nine or 10 months, the lights have gone out. We don't know what has happened in the countries where PEPFAR has been supporting programs. We simply don't know. The data that would normally have been made available on a quarterly basis have not been made available. It's very difficult to get a clear picture. All of the reports from the ground tell the same story of massive disruptions, particularly in the service delivery approaches.
So the ecosystem within which HIV services are delivered is not just the clinic and is there a drug on the shelf? It's how does a person get to the clinic? Are they greeted there by somebody who is friendly and non-judgmental? Are the drugs delivered to their community? Is there a peer - someone with their lived experience - who can help them understand the importance of accessing prevention or treatment and who will follow up with them if they stop accessing?
SHAPIRO: OK, so even if the program still exists, its infrastructure has been partially or largely dismantled. The data is in some cases nonexistent. And then you have this announcement that the United States is going to support this new HIV prevention drug, lenacapavir, which the medical community calls a breakthrough and a game changer. Is that enough to keep the trend lines moving in the right direction?
BASS: So absolutely not. It's good news. There's a couple of things about that. It's good news. It is affirmation of a commitment that was actually made in the Biden administration. And it's only a piece of what we could have expected PEPFAR, if we were speaking a year ago, to be doing to create an environment where a drug like lenacapavir could be part of a truly game-changing approach to HIV.
And I just want to say - when you say the infrastructure isn't there, I think it's really important to be clear. The infrastructure is human beings. It's the community. It's the clinic staff. It's the clinic buildings. All of those things are there. PEPFAR did not have - you know, it's not like McDonald's. It didn't - there aren't PEPFAR sort of branded buildings across sub-Saharan Africa. The infrastructure - the human beings and the clinics and the community connections - are all still there, but the people who were being paid to support the ecosystem have lost their jobs or have been rehired temporarily. And the clinics are still there, but they're overcrowded, and people are now waiting 10 or 12 hours a day to get their drugs or to be told that the nurses are done and they're going home.
SHAPIRO: To continue this conversation about lenacapavir, the U.S. says it plans to focus the rollout of this new medication on pregnant and breastfeeding women. They say in plans released last week that they plan to do it without NGOs - without nonprofit organizations. Is that possible?
BASS: Well, there's two things there, right? So let's take them one by one. Prior to 2025, PEPFAR was an evidence-based, evidence-driven, data-driven program that invested its resources in the most impacted communities and the communities where there was the most need for HIV prevention and treatment. Pregnant and breastfeeding women absolutely need access to pre-exposure prophylaxis, or PrEP, which is what we're talking about with this injectable. But there are many other communities in all of these countries who are not pregnant, who are not breastfeeding, who are at tremendous risk of HIV.
SHAPIRO: The Trump administration has been talking about transition plans and reducing global reliance on the U.S. Can other countries step in to fill the gap that the U.S. is leaving?
BASS: You know, transition planning was underway before all of these changes occurred. When we were talking about ending HIV as a public health threat as 2030, that was the horizon line for moving countries first towards control of their HIV epidemics and then to a maintenance phase, where they would be able to increasingly manage that continuation of HIV in the community, in the country, but with their own resources and perhaps with additional overseas development aid but in different ways or diminished levels. That's an off-ramp. What we did is take the car off the off-ramp, if you will, and just drive it into a wall, right? So sure, transition is possible. It's less possible now than it was at the end of 2024.
SHAPIRO: So where do you think the trend lines are going to go in the next few years?
BASS: I think the trend lines are already going in terrible directions, Ari. I think the trend lines are going in the direction of new HIV infections, including for infants and newborns. I know this from my own work. I was in Uganda and Tanzania in the first hundred days after the freeze, where drug supply was incredibly unstable in some contexts. And I spoke to clinic directors who had seen 25% of their pregnant women give birth to babies with HIV.
SHAPIRO: Which is preventable?
BASS: Which is preventable, and they had had none for years prior. So we're going to see new infections, but we're also going to see people with interruptions in their treatment. People with HIV that I've spoken to are skipping doses. They're hoarding their medication. They're seeing the news. They're anticipating a point where they won't have medications anymore, or they can't wait 12 hours at a clinic, or the community support that brought the drugs to their community is no longer there. And when people disengage from care, they get ill. And unfortunately, the way that the data blackout has happened, some of this is already happening and we can't tell the story of it yet.
SHAPIRO: Emily Bass is author of the book "To End A Plague: America's Fight To Defeat AIDS In Africa," and she's also co-author of a Physicians for Human Rights report this month on the impact of the foreign aid transitions in Uganda and Tanzania. Thank you so much for speaking with us.
BASS: Thank you.
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