A little over two decades ago, addressing the HIV crisis in Nigeria was one of the main priorities of US President George W. Bush. The most populous country in Africa had 3.5 million cases of HIV, and the disease threatened to destabilize the region and, ultimately, compromise US interests.
These interests included ensuring access to Nigeria’s substantial oil reserves, maintaining regional military stability and protecting commercial alliances valued at billions of dollars.
After years of agitation by AIDS activists, Bush launched in 2003 the president’s emergency plan for AIDS relief, or Pepfar. Since then, this HIV treatment program led by the United States has saved dozens of millions of lives worldwide.
While living in Nigeria for labor issues, Kathryn Rhine, a medical anthropologist, witnessed the launch of Pepfar and saw first hand how the powerful therapies that offered transformed the life of the Nigerians.
The women he worked with, told him that they could finally leave behind the fear of death or abandonment that consumed them.
Instead, they could focus on an even broader possibilities horizon: develop a professional career, find love and have healthy children. However, now a serious threat to the prevention and treatment of HIV worldwide.
The decision of the Trump administration to substantially restrict access to a vital tool for HIV prevention – the pre -exposition prophylaxis (PREP) funded by Pepfar – would interrupt the current treatment of millions of people and block the future access of innumerable people who need this protection.
The moment is devastating: scientists recently achieved an important advance in HIV prevention. Appointed the progress of the year 2024 by the magazine Science. The Lenacapavir drug, offers six months of HIV protection with a single injection.
Unlike the previous PREP options that required daily pills, which created important barriers for constant access and adherence, this semiannual injection drastically simplifies prevention.
By undermining access to an essential treatment to reduce HIV rates, the new Trump administration restrictions threaten two decades of bipartisan investment for the elimination of HIV worldwide. The consequences extend far beyond individual lives.
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Kathryn Rhine in Nigeria; beyond help
“Some people who have it choose to be evil and simply spread it,” Elizabeth confessed to me, a woman I interviewed during my stay in Nigeria. I use a pseudonym to protect your privacy. “They say: ‘Someone infected me, so I will spread it too.’ But if they knew they can live positively with the virus, their bad thoughts would decrease.”
Elizabeth’s words reveal a worrying dynamic: when hope of treatment disappears, a dangerous despair may arise. Patients who feel abandoned by health systems could lose motivation to protect others from HIV. They could also stop looking for medical attention, abandoning prevention measures and rejecting future aid.
Cultural anthropologists use the phrase “beyond aid” to describe what happens after the withdrawal or drastic reduction of global aid programs. The communities remain not only without resources, but with a lasting sensation of betrayal that weakens their willingness to seek help, creating cycles of skepticism that can persist for generations.
Treatment as hope
In my field work, I have witnessed how to manage life with the virus implies much more than taking medications. It requires carefully managing personal relationships, family obligations, cultural expectations and hopes for the future.
Many of the women I worked with had contracted the HIV of their husbands or boyfriends. Some even suspected that their partners were positive HIV, but could not protect themselves. Before these medications, women, both HIV positive and HIV negative, had to choose between the risk of rejection or the risk of transmission.
Elizabeth and David’s story illustrates these challenges. They had been together for more than a year when David proposed.
“When I felt that I was serious about marriage, I knew I had to say my situation,” Elizabeth told me during one of our many conversations. Although at first he was surprised, he maintained his commitment to the relationship.
Elizabeth had maintained a decade of strict adherence to her HIV treatment, but the couple still had difficulties to use the condom constantly. David described the use of condom as something similar to “eating a candy with the wrapping.”
I was also anxious to have a baby. While the PREP had considerably reduced the risk of transmission, the responsibility for protecting her husband fell on Elizabeth.
The path that Elizabeth traveled shows how Nigerian cultural expectations complicated their situation. Although demonstrating fertility is usually considered essential to establish gender identity, pressure to have unprotected sex generated additional tension.
In addition, Elizabeth’s need to balance her own health needs with her husband’s wishes reflected the delicate negotiation faced by many Nigerian women between personal well -being and marriage.
While Elizabeth prepared for her son’s birth, he expressed both joy and anxiety: “Now I have to stay healthy for both.”
Politicize world health
The previous interruptions in help anticipate what is at stake when changes in the political priorities of the United States compromise world health financing.
Consider the global increase in maternal and infant mortality when President Ronald Reagan instituted the policy of Mexico City, often called the “Global Gag Law.” This prevented American financing from all international non -governmental organizations that provided or even derived abortion services.
This policy has been repeatedly implemented by Republican Administrations, including those of George Hw Bush, George W. Bush and Donald Trump during their first mandate, and subsequently revoked by Democratic presidents, creating a disruptive cycle of financial uncertainty. Among these affected organizations are Pepfar fund receivers.
The human cost of this political pendulum is measurable and significant. Researchers have discovered that, when this law is promulgated, nations around the world suffer an increase in the mortality rates of newborns and mothers, as well as an increase in HIV cases.
In countries with a strong dependence on American aid, the policy of Mexico City has caused approximately 80 additional children’s deaths and nine additional maternal deaths per 100,000 live births per year, and approximately an additional HIV infection for every 10,000 uninfected people.
My research in Nigeria also reveals the fragile progress that now hangs from a thread. Before the arrival of treatments, HIV devastated Nigerian communities. In 2001, almost 6% of the population had HIV, which represented a total of around 3.5 million people.
The Hausa language reflected this trauma: the terms for AIDS also meant “lifeless body” and “nearby tomb.”
After the implementation of HIV treatments, the cases in Nigeria decreased dramatically: by 2010, the prevalence had dropped to 4.1%. The decrease continued constantly as access to treatment expanded from 360 thousand people in 2010 to more than one million in 2018.
This progress depended largely on international support, since Pepfar and other international donors contributed more than 80% of the 6,200 million US dollars for the fight against HIV in Nigeria between 2005 and 2018.
In 2019, around 1.3% of the population had HIV, that is, 1.9 million people.
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Of personal choice to global security
What is at stake is not just the increase in HIV rates. The reductions of foreign aid imposed by the Trump administration threaten to dismantle more than two decades of US investment in global security and economic growth.
Public health crises are rarely limited to national borders. When health systems fail in West Africa, diseases can spread rapidly abroad and require expensive emergency responses.
The 2014 Ebola outbreak demonstrated this reality, when the cases arrived in the United States and caused an emergency response of 5.4 billion dollars. Similarly, 2009 H1N1 flu pandemic, which infected about 60 million Americans, showed the speed with which infectious diseases spread throughout the world when surveillance and containment systems are inappropriate.
The inconsistent help, in turn, undermines American global leadership and creates opportunities for rival powers to establish their influence. China has actively exploited these gaps, establishing a bilateral trade with Africa that reached 295 billion dollars in 2024.
Although the United States reduced its commitment to global health during previous administrations, China expanded its global health diplomacy, collaborating on issues that cover from the prevention and control of infectious diseases to the response to health emergency and innovation in health technologies.
Meanwhile, restrictions on access to PREP run the risk of recreating the same impossible options that women faced at the beginning of the epidemic: choosing to reveal their serological state and run the risk of being abandoned, accepting sexual relations without protection and running the risk of transmission, or rejecting sexual relations without protection and running the risk of violence or losing economic support.
I think the result is a much less safe world, where avoidable suffering continues, hard progress is crumbled and the promise of a free -free generation is still not fulfilled.
*Kathryn Rhine She is an attached professor of General Internal Medicine of the Anschutz Medical Campus at the University of Colorado
This article was originally published in The Conversation
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