{"title":"When Austerity Kills: The Ethical Cost of US HIV/AIDS Policy Shifts","authors":"Udo Schüklenk","doi":"10.1111/dewb.70000","DOIUrl":null,"url":null,"abstract":"<p>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.</p><p>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.</p><p>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</p><p>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</p><p>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 [<i>in South Africa</i>] 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</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. 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.</p><p>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.</p><p>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.</p><p>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.</p><p>The author declares no conflicts of interest.</p>","PeriodicalId":50590,"journal":{"name":"Developing World Bioethics","volume":"25 3","pages":"167-168"},"PeriodicalIF":1.0000,"publicationDate":"2025-07-07","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://onlinelibrary.wiley.com/doi/epdf/10.1111/dewb.70000","citationCount":"0","resultStr":null,"platform":"Semanticscholar","paperid":null,"PeriodicalName":"Developing World Bioethics","FirstCategoryId":"98","ListUrlMain":"https://onlinelibrary.wiley.com/doi/10.1111/dewb.70000","RegionNum":3,"RegionCategory":"哲学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":null,"EPubDate":"","PubModel":"","JCR":"Q3","JCRName":"ETHICS","Score":null,"Total":0}
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.
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.