Trump's aid freeze hits HIV care for gay men, trans people

NAIROBI-U.S. President Donald Trump's suspension of foreign assistance has crippled humanitarian relief efforts around the world, and the President's Emergency Plan for AIDS Relief, or PEPFAR, has not been spared.

A limited waiver permitted some PEPFAR services to resume during the 90-day freeze, but pre-exposure prophylaxis (PrEP), medicine that helps the prevention of HIV/AIDS, remains curtailed for most people.

This has led to fears that HIV prevalence may surge and that millions of lives are at risk.

In sub-Saharan Africa, the arc of the pandemic is shifting. New infections are becoming concentrated in harder-to-reach marginalised populations, with men who have sex with men (MSM) and transgender people disproportionately affected.

PEPFAR has focused on these vulnerable groups in its global fight against the disease that has saved 26 million lives and prevented millions of infections over the last two decades.

Now those gains are imperilled.

How does PEPFAR funding reach local health services, and what services are provided?

PEPFAR is managed and overseen by the U.S. State Department and implemented by multiple government agencies.

Funding reaches local health services through implementing partners, which include foreign governments, large nonprofit groups and private contractors.

"These organisations then provide grants or contract out work to local groups delivering HIV/AIDS services on the ground," explains Solomon Wambua, national coordinator at the Key Population Consortium of Kenya, a nongovernmental organisation that works to get marginalised communities receive HIV/AIDS treatment.

Key populations are defined as groups at increased risk of HIV infection and include gay men and other MSM, sex workers, transgender people, people who inject drugs and incarcerated people.

On the prevention front, PEPFAR offers PrEP, voluntary medical male circumcision, condom distribution and HIV testing services. For those who have contracted the disease, it provides antiretroviral therapy.

It may also fund medically assisted therapy, such as methadone, for people who inject drugs.

PEPFAR has helped train more than 300,000 healthcare workers to deliver HIV and other services, including counsellors, peer educators and home-based caregivers, many of whom have been integrated into national health systems.

The programme supports more than 70,000 health centres, including 3,000 laboratories, and these ultimately improve the overall capacity to deliver care. 

How do these services reach LGBTQ+ populations, and what happens in countries where their identities are criminalised?

Key populations and their sex partners accounted for an estimated 80% of new infections outside of sub-Saharan Africa and 25% of new infections in sub-Saharan Africa in 2022, according to UNAIDS, the United Nations' programme on HIV/AIDs.

In countries where sex work or LGBTQ+ activities are criminalised, these people can face violence, discrimination and difficulty accessing basic HIV services. That is why PEPFAR gave priority funding to community-led groups able to foster trust and confidentiality to deliver care.

The groups tread a thin line in places where homosexuality is illegal and LGBTQ+ identities are policed.

In Kenya, for example, same-sex activity is a punishable offence, but the Health Ministry acknowledges the need to address LGBTQ+ people's vulnerability to HIV as part of the national response.

"Even if we are criminalised, (the government) actually sees key populations as people who require healthcare services and acknowledges that if key populations are not part and parcel of the HIV response, we'll get cross infections, prevalence rates rising and the work we've done over the years will be eroded," says Wambua.

How is PEPFAR likely to change with Trump in the White House?

Trump signed an executive order after his inauguration on Jan. 20 to freeze all foreign aid for three months.

A subsequent exemption in February for PEPFAR says only pregnant and breastfeeding women (PBFW) may receive preventive medicine.    

"People other than PBFW who may be at high risk of HIV infection or were previously initiated on a PrEP option cannot be offered PEPFAR-funded PrEP during this pause," the State Department ordered.

Complicating matters for PEPFAR is the U.S. Congress' refusal to grant the programme its typical five-year authorisation, instead providing it with a short-term mandate. Its current authorisation expires on March 25.

"What happens after this point is uncertain and likely to be affected by the ongoing Trump administration actions related to global health as well as the current complex outlook for PEPFAR," according to a brief from KFF, a U.S.-based nonprofit global health policy organisation.

In the meantime, aid workers and U.N. officials report that clinics are closing, confusion about what medicine can be distributed and fears that U.S. funding may never be restored. 

This story is part of a series supported by Hivos's Free to Be Me programme.

(Editing by Ayla Jean Yackley)