More than two decades ago, solving the HIV crisis in Nigeria was a priority for U.S. President George W. Bush. Africa's most populous country suffers from 3.5 million HIV cases, a disease that threatens stability in the region and ultimately harms the interests of the United States. These benefits include ensuring access to large oil reserves in Nigeria, maintaining regional military stability and protecting multi-billion dollar trade partnerships.
After years of inciting by AIDS activists, Bush launched the president's AIDS relief emergency program in 2003, or Pepfar. The U.S.-led HIV treatment program has since saved tens of millions of lives around the world.
While living in Nigeria as a medical anthropologist, I witnessed the launch of Pepfar and first-hand how it brings powerful therapies to life in Nigeria. The women I worked with told me that they could eventually abandon their fear of death or abandonment that consumed their days. Instead, they can focus on a newly expanded horizon of possibilities: building a career, finding love, having children.
However, now, prevent and treat the serious threat of HIV worldwide. The Trump administration’s decision essentially limits access to important HIV prevention tools – PEPFAR-funded prevention or preparation can cut off ongoing treatment of millions of people and block future access to countless others who need such protection.
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The timing is devastating: scientists have made significant progress in preventing HIV recently. Lenacapavir drug Lenacapavir was named the 2024 annual breakthrough by Magazine and has provided six months of HIV protection. Unlike the preparatory options that previously required daily pill preparation options (which creates significant barriers to consistent access and compliance), twice-year injections greatly simplify prevention.
By undermining opportunities for treatments that are critical to reducing HIV rates, new restrictions by the Trump administration have the potential to differentiate bipartisan investments in global elimination of HIV. The consequences far exceed personal life.
Aid for the afterlife
“There are people who own it, they choose to be evil and just spread around,” said Elizabeth, a woman I interviewed while in Nigeria. I'm using a pseudonym to protect her privacy. "They said, 'Someone gave it to me, so I'm going to spread it too.' But if they know they can live actively with the virus, that'll reduce their evil thoughts."
Elizabeth’s words reveal a dynamic saying: dangerous despair can be replaced when hope for treatment disappears. Patients who feel abandoned by the health care system may lose the motivation to protect others from HIV. They may also stop seeking health care, abandon preventive measures and get rid of future aid.
Cultural anthropologists use the term “Aid Afterlife” to describe what happens after the global aid program is withdrawn or drastically reduced. Not only is the community without resources, it has a lasting sense of betrayal, which undermines their willingness to seek help, creating a skepticism that can last for generations.
Treatment as hope
In my field work, I have witnessed that virus management life is far more than taking medication. It requires a careful look at personal relationships, family obligations, cultural expectations, and hope for the future.
Many of the women I work with have contracted HIV from their husbands or boyfriends. Some people even doubt their partner’s positive status but cannot protect themselves. Before these drugs, women (HIV-positive and HIV-negative) must choose between risking rejection or risking transmission.
The stories of Elizabeth and David illustrate these challenges. David proposed for more than a year and they were together for more than a year. “When I felt he was serious about marriage, I knew I had to tell him who I was,” Elizabeth told me in many of our conversations. Despite initial shock, he remains committed to their relationship.
Elizabeth has maintained a decade of careful compliance with her HIV treatment, but the couple is still struggling with condoms that are being used ongoing. David described the use of condoms as similar to "eating candies with wrapping paper." He also longs for a child. Although the transmission risk of Prep is greatly reduced, it bears the full burden of protecting her husband in Elizabeth.
The roads Elizabeth navigated highlights how Nigerian cultural expectations complicate their situation. When proving one's fertility is often considered critical to establishing gender identity, the stress of unprotected sexual behavior creates additional tension. Furthermore, Elizabeth needs to balance her health needs with her husband’s desires, reflecting the delicate negotiations many Nigerian women face between personal well-being and marriage.
As Elizabeth prepares for the birth of her child, she expresses joy and anxiety: “I have to stay healthy for both of them now.”
Politicalizing global health
Previous disruptions in aid presuppose danger when the shift in U.S. political priorities hurt global health funding.
When Ronald Reagan formulated Mexico City policy, it was often called "global gag rule" considering the global surge in maternal and child mortality. It prevents us from funding to all international NGOs that provide or even refer abortion services.
The Republican administration has repeatedly enforced this policy – including George HW Bush, George W. Bush and Donald Trump’s first term and was subsequently revoked by the Democratic president, creating a devastating cycle of funding uncertainty. Among these affected organizations, they are the recipients of PEPFAR funds.
The labor cost of the policy pendulum is measurable and important. When the law was enacted, countries around the world suffered from mortality rates in newborns and mothers as well as jumps in HIV cases. Among countries heavily reliant on U.S. aid, Mexico City policy causes 80 more deaths per 100,000 births per 100,000 births per 100,000 uninfected people, and 80 more deaths per 100,000 pregnant women.
My research in Nigeria also reveals the fragile progress that is now open. Before treatment arrived, HIV destroyed Nigerian communities. In 2001, nearly 6% of the population suffered from HIV, totaling about 3.5 million. Hausa reflects this trauma: the term AIDS also means “an inanimate body” and “a nearby grave.”
Cases in Nigeria have dropped sharply after the introduction of HIV treatments - by 2010, the prevalence has dropped to 4.1%. As treatment visits expanded from 360,000 in 2010 to 1 million in 2018, the decline has steadily declined. This progress depends largely on international support, with Pepfar and other global donors over 80% of the $6.2 billion that competed with HIV in Nigeria between 2005 and 2018.
In 2019, about 1.3% of the population suffered from HIV, or 1.9 million people.
From personal choice to global security
It is not just about increasing the HIV rate. The Trump administration's reduction in foreign aid has threatened U.S. investment in global security and economic growth for two decades.
Public health crises are rarely retained within national borders. When health systems fail in West Africa, the disease can spread rapidly overseas and require expensive emergency responses. The 2014 Ebola outbreak proved this reality when the case arrived in the United States and a $5.4 billion emergency response was proposed. Similarly, the 2009 H1N1 flu pandemic that infected about 60 million Americans, the faster the infectious disease is when the system is insufficient.
In turn, inconsistent aid undermines US global leadership and creates vacancies for building competitiveness influentiality. China has actively exploited these gaps to establish bilateral trade with Africa in 2024, reaching US$295 billion in 2024. Although the United States reduced its global health participation during the last administration, China expanded its global health diplomacy to cover the scope of disease prevention and control to health emergency response and health emergency technology and health technology innovation.
At the same time, when the pandemic emerges, the restrictions on access risk are limited, i.e. choosing the same impossible choice between disclosing one's status and abandoning the risk; accepting unprotected gender and risking spread, rejecting unprotected sexual behavior, and risking violence or losing financial support.
I think the result is a less secure world that can prevent suffering, difficult progress has been revealed, and hopes for the AIDS-free generation are still not realized.