Trump aid cuts deal a blow to HIV prevention in Africa

By Robbie Corey-Boulet

(Reuters) -Emmanuel Cherem, a 25-year-old gay man in Nigeria, tested positive for HIV two months after U.S. President Donald Trump's administration cut access for at-risk groups like gay men and injecting drug users to medication that prevents infection. 

Cherem admits he should have been more careful about practicing safe sex but had become accustomed to using the U.S.-supplied pharmaceutical. The drug - known as Pre-Exposure Prophylaxis, or PrEP - is typically taken daily as a tablet and can reduce the risk of contracting HIV through sex by 99%.

"I blame myself... Taking care of myself is my first duty as a person," Cherem said at his gym in Awka, the capital of Nigeria's southeastern state of Anambra.

"I equally blame the Trump administration because, you know, these things were available, and then, without prior notice, these things were cut off."

Trump ordered a 90-day pause on foreign aid after taking office in January and halted grants by the U.S. Agency for International Development (USAID). The agency was responsible for implementing the bulk of the assistance under the President's Emergency Plan for AIDS Relief (PEPFAR), the world's leading HIV/AIDS initiative. 

Sub-Saharan Africa remains the epicenter of the AIDS pandemic. Trump's cuts have restricted the availability of drugs that millions of Africans have taken to prevent infection - particularly vulnerable communities such as gay men and sex workers - as aid groups and public health systems in Africa strove to roll back the disease. 

The number of initiations, or people who have taken at least one dose of the drug, rose in Africa from fewer than 700 in 2016 to more than 6 million by late 2024, according to PrEPWatch, a global tracker. More than 90% of new initiations last year were financed by PEPFAR, using cheap generic versions of the drug. 

Sub-Saharan Africa had 390,000 AIDS-related deaths in 2023, or 62% of the global total, according to UNAIDS, the United Nations AIDS agency. However, progress has been made: that death toll was down by 56% from 2010, according to the World Health Organization.

Now, some of those who've lost access to the preventative medication because of U.S. cutbacks are already testing positive, according to 10 patients, health officials and activists.

Restrictions on PrEP have coincided with dwindling supplies of more widely used HIV prevention tools like condoms and lubricants "because of the US funding cuts", according to a UNAIDS fact sheet from May. The combination is creating what nine activists and three medical experts described as a major threat to prevention across the continent.

"I just see this as incredibly short-sighted because we were on a winning path," said Linda-Gail Bekker, an HIV expert at the University of Cape Town.

She said that many African governments did not have the resources to spend on PrEP drugs on top of treatment for HIV infections, risking a worsening of the pandemic.

"It's as predictable as if you take your eye off a smouldering bushfire and the wind is blowing: a bushfire will come back."

Trump has said that the United States pays disproportionately for foreign aid and he wants other countries to shoulder more of the burden, as he seeks to reduce U.S. government spending across the board. The U.S. disbursed $65 billion in foreign assistance last year, nearly half of it via USAID, according to government data.

"It's a question of who has primary responsibility for the health needs of citizens of other countries, and it's their own governments," said Max Primorac, a former senior USAID official who is now senior research fellow at The Heritage Foundation's Margaret Thatcher Center for Freedom.

"We all know, and this is a bipartisan issue, that aid dependency doesn't help these people - that the best solution is for these countries to be able to take over the responsibility of these programs."

A RISE IN CASES

UNAIDS says the permanent discontinuation of PEPFAR-supported prevention and treatment programs could lead to an additional 2,300 new HIV cases globally per day. There were 3,500 new cases per day in 2023.

Reuters spoke to 23 health workers, PrEP users and activists, nearly all of whom said that the increase in HIV infections since the funding cuts was impossible to quantify because many organisations working with vulnerable populations have been defunded.

A State Department waiver issued on February 1 allowed some PEPFAR activities to restart, but only covered HIV prevention for mother-to-child transmission.

That means PEPFAR-financed PrEP is no longer available for gay and bisexual men, sex workers and injecting drug users who are especially exposed to the virus. Many African governments had specifically targeted these groups in their PrEP programs. 

A spokesperson for the State Department, which oversees USAID and the PEPFAR program, told Reuters it "continues to support lifesaving HIV testing, care and treatment, and prevention of mother to child transmission services approved by the Secretary of State."

"All other PEPFAR-funded services are being reviewed for assessment of programmatic efficiencies and consistency with United States foreign policy," the spokesperson said. 

The spokesperson did not directly respond to a question about why the waiver had excluded vulnerable groups from PrEP distribution. 

In East and Southern Africa, the sub-region that accounts for more than half of all people living with HIV, the U.S. had been funding nearly 45% of HIV prevention programming, UNAIDS said in March. 

Some countries like Malawi, Zimbabwe and Mozambique were almost entirely dependent on PEPFAR for their HIV prevention programs, the agency said. In some wealthier nations, like South Africa and Kenya, PEPFAR represented less than 25% of spending on HIV prevention.

Russell Vought, the director of the U.S. Office of Management and Budget, told a Congressional committee on June 4 that, due to high U.S. debt levels, Africa needed to shoulder more of the burden in fighting AIDS.

Asked specifically about restrictions on HIV prevention programs, Vought said: "We believe that many of these nonprofits are not geared toward the viewpoints of the administration." His office did not respond to a request for further details.

'I PRAY TRUMP CHANGES HIS POLICY' 

Reuters spoke to four PrEP users in Nigeria, all gay or bisexual men, who have tested positive for HIV since January when they stopped being able to obtain more pills, after practicing unsafe sex.   

Hearty Empowerment and Rights (HER) Initiative, a community-based organisation in southeastern Nigeria, worked with other groups that provide HIV/AIDS services to confirm the men's diagnosis and help secure treatment for them, said executive director Festus Alex Chinaza. 

In Asaba, the capital of Nigeria's Delta state, Echezona, a 30-year-old gay man who took PrEP pills daily for more than three years, is struggling to come to terms with his HIV-positive test result, which he received in early May. He regrets that he had unprotected sex.

"I just pray and wish that Trump actually changes his policy and everything comes back to normal so that the spread and transmission of the virus would be reduced," said Echezona, who asked to be identified only by his first name for fear of stigma.

Like the other three men, he described being told by staff at community-based clinics that PrEP was only available to pregnant and lactating women, in line with the Trump administration guidelines.

Nigeria has an adult HIV prevalence rate of 1.3% and an estimated 2 million people living with HIV, the fourth-highest total globally, according to UNAIDS.

But for so-called key populations, the rates are much higher: 25% for men who have sex with men, according to a survey completed in 2021.

The Nigerian health ministry did not respond to a request for comment on the effects of the Trump administration's cuts to HIV prevention services. 

South Africa – which has an estimated 7.7 million people living with HIV, according to UNAIDS, the highest number in the world - pays for its own PrEP pills.

But some clinics where so-called key populations obtained them relied on PEPFAR grants and have been forced to close in recent months. 

PrEP is also available for free at public health centers, but gay men and sex workers often avoid such facilities, fearing discrimination and harassment, nine activists said.

Francois Venter, executive director of the Ezintsha medical research center at the University of the Witwatersrand in Johannesburg, said PrEP distribution from public sector clinics in the city had shown almost no increase since the Trump cuts.

Foster Mohale, spokesperson for South Africa's health ministry, said the ministry was "not aware" of reports that key populations were avoiding health facilities due to stigma.

"We have sensitized health officials across the country to create (a) conducive environment for all healthcare seekers/clients to access the service without feeling judged or discriminated against," he said.

(Reporting and writing by Robbie Corey-BouletAdditional reporting by Seun Sanni in Awka, Nigeria, Nellie Peyton in Johannesburg, Amindeh Blaise Atabong in Yaounde, Ange Adihe Kasongo in Kinshasa, Maxwell Akalaare Adombila in Accra and Jennifer Rigby in London. Editing by Daniel Flynn)