現在是砍愛滋防治經費最糟糕的時機
—— 當新藥可能終結愛滋時，為什麼我們卻阻礙它的推廣？
作者：Jackie Flynn Mogensen、Sam Van Pykeren
出處：Mother Jones
瑞貝卡・丹尼森（Rebecca Denison）從未想過自己會活這麼久。
她在1980年代就感染了HIV，並於1990年被正式診斷。她在舊金山的傳染病會議中回憶：
「當時我們都知道，會死。」
但六年後，一切都改變了。
新一代的蛋白酶抑制劑，搭配其他藥物，能讓病毒量變得幾乎測不到，大幅提高HIV感染者活到老年的機會。
「你們的工作救了我一命。」現在是愛滋感染女性倡議者的她，對在場專家說。
她並不孤單。
過去三十年來，預防性藥物的開發、檢測與治療的進步，使全球每年新增感染數下降了60%。
現在，只要在可能暴露HIV前服藥（PrEP），可將性行為傳染風險降低至99%。
她感嘆：「我們終於有機會真的終結HIV了。」
2023年，研究人員宣布另一項重大突破：
在非洲逾5000位女性的臨床試驗中，一種名為Lenacapavir的半年一針型PrEP，能100%預防感染。
另一個橫跨七國、3000人參與的研究中，99.9%接受注射的人都未感染HIV。
這麼有效、使用又方便的藥物，前所未見。
這讓曾任美國國際開發署（USAID）分析師的安娜・卡托姆斯基（Anna Katomski）當場落淚。
雖然Lenacapavir不是疫苗，但《科學》雜誌稱其為「下一個最佳選擇」，
還給了它「2024年度突破」的榮譽。她說：「天啊，我們真的可能終結HIV。」
但現在，這一切都岌岌可危。
丹尼森在會上警告：曾說HIV來自「同志生活方式」與「快樂丸」的羅伯特・甘迺迪小（Robert F. Kennedy Jr.）如今掌管美國衛生與公共服務部；
USAID被馬斯克領導的「政府效率部」關閉，連帶影響抗瘧疾、抗小兒麻痺、抗肺結核與愛滋等全球醫療行動；
而美國政府也正在考慮削減CDC對國內HIV防治的經費。
尤其PEPFAR（總統愛滋緊急救援計畫）更是首當其衝。
該計畫自2003年由小布希總統創立，已拯救2600萬人生命。
川普上任後簽署行政命令，要求全面審查對外援助，PEPFAR工作也被迫暫停，
僅有針對孕婦與哺乳婦女的部分PrEP項目獲准繼續，LGBTQI與性工作者族群則遭排除。
前USAID高層波里（Nidhi Bouri）表示：
「未來是否還有資金支持PEPFAR，現在根本不知道。」
舊金山加州大學的愛滋研究中心主任甘地醫師（Dr. Monica Gandhi）直言：
「這會是災難。」
她警告，若病人因資源短缺而間斷服藥或共用藥物，恐造成HIV對藥物產生抗藥性，
「這樣會讓病毒回來得更強。」
此外，包括MATRIX與MOSAIC等大型臨床試驗也因川普命令而腰斬，
中斷了女性用PrEP產品（如陰道膜、藥膜、環狀避孕器）的研究。
其中參與MATRIX試驗的婦產科醫師查普爾（Dr. Catherine Chappell）批評：
「我們還在收集數據，參與者還有環狀產品在體內，就被叫停，這根本不道德。」
卡托姆斯基說：
「這不只是對研究倫理的背叛，也是在浪費納稅人的錢。」
她曾計劃進行Lenacapavir的臨床試驗，現在也被迫終止。
PEPFAR過去一直獲得美國兩黨支持。2023年，共和黨參議員林賽・葛蘭姆等人還在《The Hill》撰文呼籲重啟PEPFAR：
「我們必須再次團結起來，把愛滋在2030年前終結為公共衛生威脅。」
而即使是現任國務卿盧比歐，也曾多次讚揚USAID的工作。
總結來說：我們花了幾十年，終於擁有史上最有效的愛滋預防藥物，
而美國卻選擇在此刻抽手、停止援助。
這不只是道德上的失職，也是對自己國家利益的背叛。
防疫一向是「軟實力」的展現，能提升國際信任，
也能防止病毒回到美國本土。
前NIAID所長佛奇醫師也透過影片在會議中說：
「我們有資源，也有能力終結全球愛滋疫情。現在絕對不是放棄的時候，否則歷史將嚴厲審判我們。」
Now Is a Uniquely Terrible Time to Cut Funding for HIV
New breakthrough drugs could eradicate AIDS. Why are we hobbling their distribution?
Mother Jones; Getty
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Rebecca Denison expected to have a short life. She’d acquired HIV as a college student in the 1980s, she told the audience at an infectious disease conference in San Francisco earlier this month, and got an official diagnosis in 1990. “Back then,” she said matter of factly, “it was understood we were all going to die.” Within six years, that all changed. A new generation of drugs called protease inhibitors, when combined with other drugs, made the virus virtually undetectable in people with HIV, giving them a much greater chance of living to old age.
“Your work saved my life,” Denison, now an advocate for HIV-positive women, told the room.
She’s not alone. Over the last three decades, the development of preventative medicines, along with better testing and treatment, has cut new annual HIV infections by a staggering 60 percent globally. Now, a strategy of taking drugs before an HIV encounter—pre-exposure prophylaxis, or PrEP—can reduce the risk of transmission during sex by up to 99 percent.
“It’s like, oh my God, we might have this tool that can really put an end to HIV.”
Then last year, scientists unveiled another critical development: In a clinical trial of more than 5,000 girls and young women in Africa, a twice-annual shot called lenacapavir, administered as PrEP, blocked HIV infection for 100 percent of the more than 2,000 participants who’d received it. Shortly after, in a 3,000-person multigender study across seven countries, 99.9 percent of participants who got lenacapavir did not acquire HIV. A drug that worked this well (and required an injection just once every six months, no less) had never been seen before.
“I was sobbing,” Anna Katomski, a former program analyst at the United States Agency for International Development, recalls when she first saw the results presented at a conference. Lenacapavir isn’t a vaccine; such a thing has eluded scientists for decades. But as Science put it in an article naming the drug its 2024 “Breakthrough of the Year,” it may be the “next best thing”—a long-lasting, injectable, highly efficacious preventative. “There was just such a feeling of optimism,” Katomski says, adding, “It’s like, oh my God, we might have this tool that can really put an end to HIV.”
But now, that’s all at risk. As Denison warned in her speech at the conference in San Francisco, Robert F. Kennedy Jr., who once said HIV was caused by the “gay lifestyle” and “poppers,” now leads the Department of Health and Human Services; thousands of government workers, including Katomski, have seen their jobs terminated or funding cut, and the so-called Department of Government Efficiency, led by tech billionaire Elon Musk, shuttered USAID, a decision that officials say will hamper the country’s ability to fight malaria, polio, tuberculosis, HIV/AIDS, and other diseases across the world. The clawbacks don’t end there: Last week, the Wall Street Journal reported that the Trump administration is considering cutting funds at the Centers for Disease Control and Prevention for domestic HIV prevention, too.
Particularly worrisome for HIV researchers is the threat to PEPFAR—the US President’s Emergency Plan for AIDS Relief—a program created in 2003 by Republican President George W. Bush to bring HIV treatments to the world, largely delivered through USAID. On January 20, President Donald Trump issued an executive order to “reevaluate and realign” the country’s foreign aid policies and called for a 90-day review of related programs. Shortly after, the Trump administration ordered the shutdown of operations at USAID, including work on PEPFAR. The administration has since backtracked, issuing a waiver allowing some PEPFAR programs to continue, including PrEP for pregnant and lactating women, but not for other “key populations” like LGBTQI people and sex workers, says Nidhi Bouri, the former deputy assistant administrator for global health at USAID. With foreign aid now under review through April 19, PEPFAR’s future is unclear.
This is a program that, throughout its 20-plus-year history, has saved an estimated 26 million lives. “It is the greatest act of humanity in the history of fighting infectious diseases that the world has ever known,” former PEPFAR head John Nkengasong recently told Science magazine.
Without a renewal of US aid, the world could see more than six times more new HIV infections by 2029.
So what would it mean to walk away from this great act of humanity? In short, says Dr. Monica Gandhi, who directs the University of California, San Francisco-Bay Area Center for AIDS Research, it would be a “disaster.” Without a renewal of US aid, UNAIDS Executive Director Winnie Byanyima told the Associated Press last month, the world could see more than six times more new HIV infections by 2029 and a tenfold increase in deaths, to more than 6 million. Quite literally, it’s death by a thousand cuts.
Gandhi also worries about the possibility of HIV gaining resistance to drugs. As she explains, effectively treating HIV requires a daily combination of antiretroviral drugs. Without reliable access to clinics and aid, she warns, people may try to stretch their pill supply, taking medicine less often or sharing with family members. “If you do this kind of rationing, what it leads to is drug resistance.”
And PEPFAR isn’t the only HIV program at risk. Several high-profile studies have also shut down in response to Trump’s order. One set of trials known as the MATRIX study, a $125 million endeavor funded by USAID, was designed to evaluate new HIV prevention products for women, including a dissolvable vaginal film, a dissolvable vaginal insert, and a vaginal ring meant to prevent pregnancy and HIV transmission. Dr. Catherine Chappell, an assistant professor and OB-GYN at the University of Pittsburgh who helped lead the trial for the vaginal ring, says Trump’s order meant her phase I clinical trial was abruptly ended mid-data collection. “We had participants in South Africa that still had these [placebo] rings in their vaginas,” she says. Chappell worries that dropping the study midway through could have “irreparably damaged” researchers’ relationship with the community. “It is just completely unethical,” she says.
Similarly, Katomski, the former USAID analyst, had been in the midst of data analysis on the MOSAIC study, a three-part trial intended to evaluate various forms of PrEP (oral, injectable, and vaginal ring) in women and girls. When the study stopped, so did Katomski and her colleagues’ analysis and data dissemination to partners and participants. “It not only is such a violation of ethics codes that we follow as researchers,” she says, “but also, from a scientific standpoint, it’s just such a waste of US taxpayers’ dollars.” Before losing her job at USAID, Katomski’s research division was considering trials for lenacapavir, the 2024 “breakthrough” drug. “All of that’s just been cut off,” she says.
It’s unclear how, exactly, this recent shift in priorities happened. Over the last 20 years, PEPFAR has seen wide bipartisan support. In a 2023 op-ed published in The Hill, a group of senators, including Lindsey Graham (R-S.C.), one of Trump’s most vocal supporters, urged the reauthorization of PEPFAR, writing: “We must come together once again to reauthorize PEPFAR and work to end AIDS as a public health threat by 2030. Now is the time to remind the world what American leadership can accomplish when we put our minds and hearts to it.” Even former Sen. Marco Rubio, now Trump’s secretary of state—who oversaw the purging of USAID—praised the agency’s work on “more than two dozen occasions” over the years, according to fact-checking site PolitiFact, “from hurricane relief to battling infectious diseases to aiding refugees.”
In short, after decades of research, science delivered the most effective preventative HIV drugs the world has ever seen—and the US is throwing up its hands and abandoning efforts to share them with those most in need. That isn’t just a moral failing, experts say, but also goes against the country’s self-interest. For decades, officials have seen foreign disease prevention as a form of “soft power”—it engenders trust within the global community while ensuring fewer infections both abroad and, ultimately, at home. “When you prevent disease transmission—whether that be HIV, whether that be tuberculosis, whether that be malaria—in one area of the world,” Katomski says, “it prevents that disease from coming back to the United States.”
All of this is to say, now is a uniquely bad time to walk away from HIV research and aid. As Dr. Anthony Fauci, the former head of the National Institute of Allergy and Infectious Diseases, told conference attendees via video in San Francisco: “We can end the global HIV epidemic. We have the resources to do so.”
“Now is not the time to pull back,” he said, “for history will judge us harshly if we squander the opportunity that is before us.”
