Ending HIV: a reality check
Article Info
Publication History:
Published July 11, 2026
DOI: 10.1016/S0140-6736(26)01375-9 External LinkAlso available on ScienceDirect External Link
Copyright: © 2026 Elsevier Ltd. All rights are reserved, including those for text and data mining, AI training, and similar technologies.
Linked Articles
The fifth UN High-Level Meeting on HIV/AIDS (June 22–23) saw the agreement of a new Political Declaration on HIV/AIDS. In it, countries expressed commitments to end AIDS as a public health threat by 2030, mobilise adequate resources, achieve the 95–95–95 targets, and accelerate equitable access to comprehensive HIV prevention, among other provisions. Speaking to the press ahead of the meeting, Winnie Byanyima, Executive Director of UNAIDS, identified the four foundations of global HIV control that she hoped countries would support: multilateralism, sustained financing, protection of rights, and access to innovations. The difficulty for the Declaration is that each of these four dimensions is facing stark opposition, if not outright reversal.
Multilateralism is embattled. The UN system is undergoing steep budget cuts and layoffs, and its legitimacy is being undermined. As part of these changes, UNAIDS looks set to end, or at least be greatly weakened. A plan to transfer the agency's activities to other UN bodies is due to be announced in October and implemented in 2027. Bilateral extractive global health arrangements are becoming normalised, with HIV policy dictated by foreign politicians rather than scientific best practice. Funding and programmatic cuts have been deep and wide. The abrupt gutting of the US Agency for International Development and cutbacks at the US Centers for Disease Control and Prevention caused huge disruption. Affected countries largely managed to maintain HIV treatment programmes at the expense of prevention, testing, and community-led services for key populations. Data from 62 countries show that the number of people receiving pre-exposure prophylaxis at least once fell by 38% between 2024 and 2025. Moreover, the USA has recently announced that it will withdraw PEPFAR support for South Africa—the country with the world's largest HIV epidemic. The decision is likely to hamper the provision of services to key populations, including drug users, men who have sex with men, sex workers, and transgender females. The USA is not alone in enacting shortsighted aid cuts. Total overseas development assistance has plummeted, falling by 6·1% in 2024 and 23·1% in 2025; it is now below 2019 levels.
There is increasing pushback on gender equality, sexual and reproductive health and rights, and the rights of LGBTQI+ people in many countries. In Russia, persecution has shuttered services and is discouraging LGBTQI+ individuals from engaging with health care. Earlier this year, Senegal's President Bassirou Diomaye Faye signed a law doubling to 10 years the maximum prison term for sexual acts by same-sex couples. Both countries voted against the new UN Declaration. And despite major innovations in HIV science, corporate interests continue to condemn many people to preventable illness. Lenacapavir offers highly efficacious protection against HIV through a twice yearly injection and has been hailed as the next best thing to a vaccine. In 2025, Gilead, the drug's maker, announced a deal with generic manufacturers to produce low-cost versions for 120 high-incidence countries where it could help curb the epidemic. But the limited nature of the deal leaves many middle-income countries unable to afford a potentially transformative and much needed tool for HIV. In Latin America, for example, new infections have increased by 13% since 2010.
The overall progress in controlling HIV/AIDS over the past 25 years is nothing short of incredible. Equally, the pandemic unarguably remains a major threat to health. An estimated 40·9 million people live with HIV, with 1·2 million new infections in 2025. 570 000 people died from AIDS last year. And yes, we have the countermeasures and know-how to end HIV. But the systematic undermining and deprioritisation of HIV control will almost certainly result in more cases, more illness, more deaths, and more harm to those with HIV and their families, friends, and communities. Just last year, UNAIDS estimated that cuts to PEPFAR alone could lead to an additional 6·6 million new HIV infections and 4·2 million AIDS-related deaths by 2029. Talk, therefore, of ending the threat of HIV to public health in the next 4 years risks reinforcing the stereotype of global health as the plaything of Geneva technocrats, out of touch with reality. It also risks letting off the hook the architects of these devastating setbacks.
Setting ambitious targets is a hallmark of global health. The drive to meet them shapes political, economic, and health agendas and they have helped to spur some of the most transformative advances in human wellbeing. But care is needed to avoid a sliding from the ambitious into the unrealistic. We need to do all we can to bring HIV/AIDS under control. The challenges to that aim will not be overcome without a serious injection of honesty into discussions of where the community now is and where it goes from here.