When Austerity Kills: The Ethical Cost of US HIV/AIDS Policy Shifts

IF 1 3区 哲学 Q3 ETHICS
Udo Schüklenk
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And so it's going to take much longer to answer these questions than if you had South Africa there’.4 Gray's colleague, Francoise Venter, offers an equally sobering assessment: ‘We're watching the largest HIV treatment programme in the world unravelling in real time’.5</p><p>In Gray's considered view South Africa, a middle-income country, doesn't have the financial capacity to continue funding the existing projects and infrastructure. She puts it in these stark terms, ‘I'm going from bankrupt to absolutely bankrupt in terms of our ability to do work’.6 Venter's predictions are similarly dire, he writes, ‘we are about to see a wave of new HIV infections, sickness and death, with children born infected in record numbers. We will see our public hospitals further overwhelmed, and our hard-won victories against TB reversed. … In South Africa, NGO-led clinics closed overnight, stockouts were reported of antiretrovirals, and thousands of workers across HIV programmes lost their jobs. MatCH, an organisation that provides vital HIV services, entered business rescue. ANOVA, also a major service provider, retrenched 2,000 staff. TAC/Ritshidze, which monitors the HIV programme, retrenched 75% of its team. And 230,000 doses of long-acting injectable medicines that prevent HIV transmission have not been released due to the funding freeze’.7 If this is the situation in South Africa—a relatively well-resourced country—the outlook for poorer nations in the Global South is even more dire.</p><p>Even if one were to accept the US government's ‘America First’ doctrine as morally defensible, the global nature of infectious disease transmission renders such isolationist policies self-defeating. Interruptions in treatments increase the likelihood of drug-resistant HIV variants emerging—variants that will not respect national borders. From a purely pragmatic, self-interested standpoint, the dismantling of PEPFAR is a high-risk gamble with global as well as US national health.</p><p>The funding-related collapse of testing programs further compounds the crisis. In high-prevalence regions, fewer people will be diagnosed and initiated on treatment. This not only endangers their lives but also increases the risk of onward transmission, as effective treatment today renders individuals virtually noninfectious.8</p><p>It is worth noting that the individual reportedly responsible for orchestrating these cuts is Elon Musk, a South African-born billionaire and the world's richest person, who briefly led a government agency tasked with reducing public expenditure. The irony of a billionaire presiding over cuts that disproportionately harm the world's poorest and most vulnerable is difficult to ignore.9</p><p>This editorial would be incomplete without reflecting on the ethical dimensions of these developments. While it is doubtful that ethical arguments will sway the current administration, they remain essential for the historical record.</p><p>Christopher Lowry and I have outlined in a paper published a few years ago in <i>Public Health Ethics</i> how two paradigmatic models of global health ethics support, for different moral reasons, the view that the US has health aid obligations toward the global south (as do other countries, including countries in Europe).10 The humanitarian model defends the view that affluent countries have a moral obligation to prevent avoidable human suffering because it is morally desirable to do so, if the cost isn't unreasonably high. 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引用次数: 0

Abstract

It is difficult to offer a comprehensive account of the current US government's impact on global HIV/AIDS efforts. However, two particularly troubling developments merit urgent ethical scrutiny due to their immediate and long-term consequences for people living with HIV and for the future trajectory of the pandemic in the Global South.

At the core of both developments lies the United States’ unilateral decision to terminate support for PEPFAR (the President's Emergency Plan for AIDS Relief), a cornerstone of global HIV/AIDS funding for treatment, prevention, and research. Interestingly, PEPFAR was the brainchild of another Republican administration, albeit led by a different President, George W. Bush. In March 2025, the US Agency for International Development (USAID) was effectively dismantled by a newly appointed government efficiency czar, resulting in the abrupt cessation of financial support for these programmes. Simultaneously, the National Institutes of Health (NIH) implemented sweeping changes to its research funding policies, effectively ending its capacity to subcontract research to institutions in the Global South.

According to UNAIDS, the termination of PEPFAR could result in up to 4.2 million HIV-related deaths by 2029, assuming affected national governments are unable or unwilling to replace the lost funding.1 UNAIDS has also provided detailed country-level assessments of the impact of these cuts, which underscore the scale of the unfolding crisis.2

The second major consequence of these policy shifts is the widespread disruption—and in many cases, termination—of ongoing HIV vaccine and therapeutic research in the Global South. These projects, often midstream, were halted without prior warning, undermining years of scientific progress and infrastructure development.3

The harmful effects of these funding cuts then, in terms of life-years lost, are both immediate, in that people with HIV lose access to life-preserving drugs, as well as long-term, given that they undermine the development of a preventive vaccine. Glenda Gray, a globally leading HIV researcher in South Africa, lays out the immediate practical implications of the policy changes implemented by the US government. She writes, ‘basically you lose the knowledge or the value of understanding HIV prevention, HIV vaccines or therapeutics. We [in South Africa] have the infrastructure, we have the burden of disease, and we have the ability to answer these questions. And so it's going to take much longer to answer these questions than if you had South Africa there’.4 Gray's colleague, Francoise Venter, offers an equally sobering assessment: ‘We're watching the largest HIV treatment programme in the world unravelling in real time’.5

In Gray's considered view South Africa, a middle-income country, doesn't have the financial capacity to continue funding the existing projects and infrastructure. She puts it in these stark terms, ‘I'm going from bankrupt to absolutely bankrupt in terms of our ability to do work’.6 Venter's predictions are similarly dire, he writes, ‘we are about to see a wave of new HIV infections, sickness and death, with children born infected in record numbers. We will see our public hospitals further overwhelmed, and our hard-won victories against TB reversed. … In South Africa, NGO-led clinics closed overnight, stockouts were reported of antiretrovirals, and thousands of workers across HIV programmes lost their jobs. MatCH, an organisation that provides vital HIV services, entered business rescue. ANOVA, also a major service provider, retrenched 2,000 staff. TAC/Ritshidze, which monitors the HIV programme, retrenched 75% of its team. And 230,000 doses of long-acting injectable medicines that prevent HIV transmission have not been released due to the funding freeze’.7 If this is the situation in South Africa—a relatively well-resourced country—the outlook for poorer nations in the Global South is even more dire.

Even if one were to accept the US government's ‘America First’ doctrine as morally defensible, the global nature of infectious disease transmission renders such isolationist policies self-defeating. Interruptions in treatments increase the likelihood of drug-resistant HIV variants emerging—variants that will not respect national borders. From a purely pragmatic, self-interested standpoint, the dismantling of PEPFAR is a high-risk gamble with global as well as US national health.

The funding-related collapse of testing programs further compounds the crisis. In high-prevalence regions, fewer people will be diagnosed and initiated on treatment. This not only endangers their lives but also increases the risk of onward transmission, as effective treatment today renders individuals virtually noninfectious.8

It is worth noting that the individual reportedly responsible for orchestrating these cuts is Elon Musk, a South African-born billionaire and the world's richest person, who briefly led a government agency tasked with reducing public expenditure. The irony of a billionaire presiding over cuts that disproportionately harm the world's poorest and most vulnerable is difficult to ignore.9

This editorial would be incomplete without reflecting on the ethical dimensions of these developments. While it is doubtful that ethical arguments will sway the current administration, they remain essential for the historical record.

Christopher Lowry and I have outlined in a paper published a few years ago in Public Health Ethics how two paradigmatic models of global health ethics support, for different moral reasons, the view that the US has health aid obligations toward the global south (as do other countries, including countries in Europe).10 The humanitarian model defends the view that affluent countries have a moral obligation to prevent avoidable human suffering because it is morally desirable to do so, if the cost isn't unreasonably high. The political model defends that view that such global health aid is morally obligatory because it sees the poorest citizens of countries of the Global South as vulnerable as a result of harmful-state-to-state actions that benefitted those in the Global North and harmed those in the Global South.

By either standard, the current US administration's policies constitute a profound ethical failure. If unchanged, they will result in millions of preventable deaths—primarily in the Global South, but eventually also in the Global North, as the unchecked spread of HIV continues. As Venter's vivid account of the situation in South Africa illustrates, time is of the essence. The speed and severity of the cuts have left little room for mitigation. The unfolding catastrophe demands a coordinated response from other high-income countries and private funders with the capacity to act. The moral and practical stakes could not be higher.

The withdrawal of funding from projects benefiting people in the Global South by funders based in the Global North should not be taken as an automatic indication of ethical failings. One could take issue, for instance, with Gray's claim that a country as relatively wealthy as South Africa is truly unable to shoulder a significantly greater financial share of its responsibility towards its HIV infected citizens.11 Perhaps it should, and more pressure should be applied on the government to provide the necessary funding. One could also question why other wealthy countries (particularly in Europe) aren't readily stepping into the breach to assist. Be that as it may, however, if such unilateral withdrawal decisions are considered, reasonable efforts aimed at minimizing any resulting harm should be made. That entails giving sufficient advance notice to local authorities in the affected countries and communities to enable them to implement mitigation measures. Undertaking actions such as those described in this editorial, without providing advance warning, demonstrates a concerning lack of respect for the peoples of the Global South and a callous disregard for the harms inflicted on those directly affected by the withdrawal of vital health care services.

Finally, the abrupt withdrawal of research funding mid-trial raises also serious questions about the ethical governance of international research. It may be time for ethics review boards to revisit the conditions under which such funding is granted—and withdrawn. Extraneous conditions along the lines of changing policy outlooks by the granting agency, or the political powers of the day, should not be permitted to end an otherwise successfully proceeding clinical trial.

The author declares no conflicts of interest.

《当紧缩致死:美国艾滋病政策的伦理成本转变》。
很难全面描述当前美国政府对全球艾滋病毒/艾滋病努力的影响。然而,有两个特别令人不安的事态发展值得紧急进行伦理审查,因为它们对艾滋病毒感染者和这一流行病在全球南方的未来发展轨迹产生了直接和长期的影响。这两个事态发展的核心是美国单方面决定终止对总统艾滋病紧急救援计划(PEPFAR)的支持,该计划是全球艾滋病毒/艾滋病治疗、预防和研究资金的基石。有趣的是,PEPFAR是另一届共和党政府的创意,尽管由另一位总统乔治·w·布什领导。2025年3月,美国国际开发署(USAID)实际上被新任命的政府效率沙皇解散,导致对这些项目的财政支持突然停止。与此同时,美国国立卫生研究院(NIH)对其研究资助政策进行了全面改革,有效地终止了将研究分包给南半球国家机构的能力。据联合国艾滋病规划署称,如果受影响的国家政府不能或不愿弥补损失的资金,到2029年,终止总统防治艾滋病紧急救援计划可能会导致多达420万人死于艾滋病联合国艾滋病规划署还提供了对这些削减的影响的详细国家一级评估,这强调了正在发生的危机的规模。2 .这些政策转变的第二个主要后果是,全球南方国家正在进行的艾滋病毒疫苗和治疗研究受到广泛干扰,在许多情况下甚至终止。这些项目往往处于中游,在没有事先警告的情况下被叫停,破坏了多年来的科学进步和基础设施建设。3 .因此,这些资金削减的有害影响,就失去的生命年数而言,既是立即的,因为艾滋病毒感染者无法获得维持生命的药物;又是长期的,因为它们破坏了预防性疫苗的研制。格伦达·格雷(Glenda Gray)是南非一位全球领先的艾滋病研究人员,她列出了美国政府实施的政策变化的直接实际影响。她写道,“基本上你失去了了解艾滋病毒预防、艾滋病毒疫苗或治疗方法的知识或价值。我们(在南非)有基础设施,我们有疾病负担,我们有能力回答这些问题。因此,回答这些问题要比回答南非的问题要长得多格雷的同事弗朗索瓦丝·文特尔(Francoise Venter)给出了一个同样发人深思的评估:“我们正在看着世界上最大的艾滋病治疗项目实时瓦解。”在格雷深思熟虑的观点中,南非是一个中等收入国家,没有财力继续为现有的项目和基础设施提供资金。她直截了当地说:“就我们的工作能力而言,我正从破产走向彻底破产。文特尔的预测同样可怕,他写道:“我们即将看到一波新的艾滋病毒感染、疾病和死亡浪潮,出生时感染艾滋病毒的儿童数量将达到创纪录的水平。”我们将看到我们的公立医院进一步不堪重负,我们在抗击结核病方面来之不易的胜利被逆转。在南非,非政府组织领导的诊所一夜之间关闭,据报道抗逆转录病毒药物短缺,数千名艾滋病毒项目的工作人员失去了工作。提供重要艾滋病服务的机构MatCH进入了商业救援。ANOVA也是一家主要的服务提供商,它裁减了2000名员工。负责监督艾滋病项目的TAC/Ritshidze裁减了75%的团队成员。由于资金冻结,23万剂预防艾滋病毒传播的长效注射药物没有发放如果这就是南非这个资源相对丰富的国家的情况,那么南半球较贫穷国家的前景就更加可怕了。即使人们认为美国政府的“美国优先”原则在道德上是站得住的,传染病传播的全球性质也会使这种孤立主义政策弄巧成拙。治疗中断增加了耐药艾滋病毒变体出现的可能性——这些变体不受国界限制。从纯粹务实、利己的角度来看,取消PEPFAR是一场高风险的赌博,赌的是全球和美国的国民健康。与资金有关的测试项目的崩溃进一步加剧了危机。在高患病率地区,被诊断并开始接受治疗的人数较少。这不仅危及他们的生命,而且还增加了进一步传播的风险,因为今天的有效治疗使个人几乎没有传染性。 值得注意的是,据报道,负责协调这些削减的个人是埃隆·马斯克,他是南非出生的亿万富翁,也是世界上最富有的人,他曾短暂领导过一个负责削减公共开支的政府机构。一个亿万富翁主持的削减计划对世界上最贫穷和最脆弱的群体造成了不成比例的伤害,这种讽刺意味很难被忽视。如果不反思这些发展的伦理层面,这篇社论将是不完整的。虽然道德争论是否会影响现任政府还值得怀疑,但它们对历史记录来说仍然至关重要。Christopher Lowry和我在几年前发表在《公共卫生伦理学》上的一篇论文中概述了全球卫生伦理学的两种范式是如何基于不同的道德原因支持这样一种观点,即美国对全球南方负有卫生援助义务(其他国家,包括欧洲国家也是如此)人道主义模式支持这样一种观点,即富裕国家有道德义务防止可避免的人类苦难,因为如果代价不是高得不合理的话,这样做在道德上是可取的。这种政治模式为这种观点辩护,认为这种全球卫生援助在道义上是有义务的,因为它认为全球南方国家最贫穷的公民是脆弱的,因为国与国之间的有害行为使全球北方国家受益,而损害了全球南方国家的公民。无论以哪一种标准衡量,当前美国政府的政策都构成了严重的道德失败。如果不改变,它们将导致数以百万计的可预防的死亡——主要是在全球南方,但最终也会在全球北方,因为艾滋病毒继续不受控制地传播。文特尔对南非局势的生动描述表明,时间是至关重要的。削减的速度和力度几乎没有留下缓解的余地。这场正在上演的灾难要求其他高收入国家和有能力采取行动的私人资助者采取协调一致的应对措施。道德和实际的利害关系不能再高了。全球北方的资助者撤回对全球南方人民受益的项目的资助,不应被视为道德失败的自动迹象。例如,人们可以对格雷的说法提出异议,他认为一个像南非这样相对富裕的国家,确实无法为其感染艾滋病毒的公民承担更大的经济责任也许应该,而且应该向政府施加更大的压力,要求其提供必要的资金。人们也可能会质疑,为什么其他富裕国家(尤其是欧洲国家)不愿意挺身而出提供帮助。然而,尽管如此,如果考虑这种单方面的退出决定,应作出合理的努力,尽量减少由此造成的损害。这就需要充分提前通知受影响国家和社区的地方当局,使其能够实施缓解措施。在没有事先警告的情况下采取本社论所述的行动,表明对全球南方人民缺乏尊重,对那些因撤出重要保健服务而直接受影响的人所受的伤害漠不关心,令人担忧。最后,在试验中途突然撤回研究经费也引发了关于国际研究伦理治理的严重问题。也许是时候让伦理审查委员会重新审视这些资金的发放和撤回条件了。不应该允许批准机构或当时的政治权力改变政策前景的外来条件结束原本正在成功进行的临床试验。作者声明无利益冲突。
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来源期刊
Developing World Bioethics
Developing World Bioethics 医学-医学:伦理
CiteScore
4.50
自引率
4.50%
发文量
48
审稿时长
>12 weeks
期刊介绍: Developing World Bioethics provides long needed case studies, teaching materials, news in brief, and legal backgrounds to bioethics scholars and students in developing and developed countries alike. This companion journal to Bioethics also features high-quality peer reviewed original articles. It is edited by well-known bioethicists who are working in developing countries, yet it will also be open to contributions and commentary from developed countries'' authors. Developing World Bioethics is the only journal in the field dedicated exclusively to developing countries'' bioethics issues. The journal is an essential resource for all those concerned about bioethical issues in the developing world. Members of Ethics Committees in developing countries will highly value a special section dedicated to their work.
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