www.thelancet.com 第 405 卷，2025 年 4 月 26 日
有些病人你永遠不會忘記。有些是因為你和他們本人或他們的故事有著超乎尋常的深厚聯繫；有些是因為你可能看到自己或你所愛的人處於他們的境地，躺在輪床上，承受著那種痛苦。 20 世紀 80 年代，我作為一名醫學生在美國紐約州東弗拉特布什的金斯縣醫院進行兒科輪值，其中一個小組負責照顧一名一個蹣跚學步的孩子慢慢屈服於愛滋病的幼兒。和那些可怕的歲月裡的許多孤兒一樣，他也是個孤兒，床邊的病歷上寫著「嬰兒 M」。這個孩子的身體狀況一直不太好，而且發育一直在倒退，失去里程碑。首先是能夠坐起來，然後是抬起小腦袋，吃固體食物，最後是呼吸。我有一個難忘的任務，試圖從他殘廢的四肢中抽血——他幾乎發不出聲音，但仍然在尖叫。我記得幾個月後，在同一家醫院再次輪班時，得知他已經過世了。仁慈，然後得知他的照護團隊自豪地報告說他在該病房存活了創紀錄的幾個月。這或許是臨床上的進步，但對 M 寶寶來說，這只會延長痛苦。
幾個月來，這個男孩那張瘦小而枯槁的臉一直清晰地縈繞在我的腦海裡。創傷記憶就是這樣 ——它更敏銳地將我們帶回我們的大腦、身體或心靈幾十年來一直隱藏的創傷之中。
但讓這段記憶、這段創傷如此難以承受的原因是，在 20 世紀 80 年代，沒有任何有效的治療方法可以治療任何感染愛滋病毒/愛滋病的人——無論是成人、兒童還是嬰兒。當然，如今愛滋病毒感染者可以獲得有效的抗病毒療法。這就是為什麼美國總統川普政府突然削減對外援助，包括無理地暫停美國總統愛滋病緊急救援計畫（PEFPAR）90天，會造成如此大的創傷。
美國總統防治愛滋病緊急救援計畫（PEPFAR）實施了約21年，是全球衛生史上針對單一疾病的最大規模承諾。截至 2025 年 1 月 20 日美國政策發生變化時，PEPFAR 已為全球約 2,100 萬名愛滋病毒感染者（包括 50 多萬名兒童）提供治療。該計畫自實施以來一直得到美國兩黨政界的支持。我與同事們以及華盛頓大學的建模師 Khai Hoan Tram 合作，於 2025 年 2 月發表了對 PEPFAR 資金暫停 90 天對隨後 12 個月可能產生的影響的估計；我們估計，愛滋病毒相關死亡人數會超過 100,000 人，周產期愛滋病毒傳播人數將超過 135,000 人。一種本應可以預防的新生兒感染，而且幾乎是可以預防的，卻又捲土重來。這是因為，在全球愛滋病毒感染率最高的地區──東部和南部非洲，大多數愛滋病毒感染者都是育齡婦女。獲得愛滋病毒治療使她們的生育希望成為現實；確保自身和出生時不會感染愛滋病毒之嬰兒的健康。當我看到模型結果——估計有 135,000 例可預防的嬰兒之感染病例時，我的腦海中閃過 M 寶寶的臉。從那時起我就無法清除它；我繼續地看到它。
2025年1月，美國總統川普暫停實施防治愛滋病緊急救援計畫的呼聲立即高漲。 48 小時內，負責監督該計畫的美國國務卿馬可·盧比奧 (Marco Rubio) 發布了「挽救生命的治療和預防母嬰傳播」的豁免。但實際上，這項豁免意義不大，因為美國國際開發署（USAID）——總統防治愛滋病緊急救援計畫在非洲的主要實施者——已經因削減開支和大規模裁員而陷入困境。美國國際開發署的資金削減導致 PEFPAR 失去了其最重要的執行機構，擾亂了藥品和商品的供應鏈以及診所用品的採購，中斷了數據系統和監控，並削弱了對脆弱的衛生系統的支持。盧比歐隨後向美國國際開發署所有工作人員發送了一份備忘錄，要求他們報告豁免條款是否有效。過去和現在都不是這樣的，暫停實施 PEPFAR 意味著美國政府手上沾滿了難以洗刷的血。
長期的傳染病控制運動為全球衛生界教導了許多慘痛的教訓。一個是專案中斷（最常見的原因是資金削減）可能很快導致疾病復發蔓延。這種影響在瘧疾、結核病和性傳播感染中已得到充分證實。在愛滋病毒防治方面，先前從未發生過如此大規模的計畫中斷。但現在愛滋病毒防治計畫已經中斷，需要強調的是，無論是個人或族群中愛滋病毒感染的特殊性。
HIV 治療可以有效率地長期抑制病毒血症，讓 HIV 得到良好控制的患者不再對其性伴侶具有傳染性。然而，中斷愛滋病毒治療，病毒很快就會恢復到非常高的水平。在抗病毒水平低於治療水平且病毒再次複製的期間，該人再次具有傳染性，並且可能對抗病毒藥物產生抗藥性。中斷整個社區、國家或地區的治療，這個現實可能很快就會導致疫情再次蔓延，發病率和死亡率隨之上升。數十年的成就可能很快就會化為烏有。這些潛在影響在 2025 年 3 月《刺胳針愛滋病毒》上 Debra ten Brink 及其同事的建模研究中得到了清晰的展示；他們估計，國際援助的減少加上 PEPFAR 支持的停止，可能導致 2025 年至 2030 年間新增 443萬至1,075 萬愛滋病毒感染病例和和 77萬至293 萬愛滋病毒導致之死亡病例。
2025 年的黑暗春天可能會被人們銘記為第二輪愛滋病毒大流行的開始——這是一場可以預防的大流行——但對人類大家庭的破壞性卻絲毫不減。
很難理解這種程度的破壞背後的動機，極度缺乏同情心。削減成本一直是美國政府的主要解釋。但可以說，其意義更為深刻。全球衛生和國際發展援助的基礎是所有人的生命都具有同等價值的原則，而世界上的富人對最貧窮的人負有義務。川普在第二任總統任期的首次國情咨文演說中嘲笑向非洲國家賴索托提供援助的想法，「賴索托是一個從未有人聽說過的國家」。毋庸置疑，賴索托長期以來一直是 PEPFAR 的重點國家。總統防治愛滋病緊急救援計畫 (PEPFAR) 在賴索託的投資正在獲得回報。 2016 年和 2020 年所進行基於人口的評估顯示，愛滋病毒感染率下降，人們對愛滋病毒狀況的認識提高，或許最重要的是，抗反轉錄病毒療法的覆蓋率從知曉自身狀況的人群中的 91.8% 提高到 96.9%。賴索托目前已受到美國貿易關稅的打擊，但對美國經濟這方面的影響不大 ，但卻可能會對這個小國產生嚴重影響。動機是什麼？懲罰或憤怒似乎是唯一可能的解釋。
隨著川普政府繼續將頂尖科學家和公共衛生領導人從美國衛生機構和組織的職位上趕走，很明顯，在小羅伯特·F·甘迺迪的新領導下，現任美國政府的政策確實在倒退。
美國衛生與公眾服務部部長彼得·馬克斯被迫辭職，他曾任美國食品藥物管理局生物製品評估與研究中心主任，在新冠疫苗研發成功中發揮了重要作用。然而，小羅伯特·甘迺迪任命了一位未經訓練且不合格的疫苗懷疑論者（此人曾在馬裡蘭州無證行醫）來領導一項由聯邦政府委託的疫苗與自閉症研究。
我們正處於美國在應對愛滋病毒和疫苗方面倒退的時刻。美國國際開發署的大幅削減意味著美國政府也未能履行對糧食不安全人群（包括難民和因戰爭和衝突而流離失所的人）的承諾。取消產婦保健計畫的重大撥款意味著我們在安全孕產方面正在倒退。諸如此類的例子還有很多。這些都是故意造成的傷害，這讓它們更難以承受。
其他富裕國家會為全球公共衛生事業出力嗎？法國、德國和英國都在減少對全球健康的承諾。歐洲面臨增加國防開支的壓力。儘管許多遭受重創的非洲國家可以做得更多，並正在努力加強國內衛生支出以及與全球南方其他夥伴的聯盟，但大規模官方發展援助和美國總統防治愛滋病緊急救援計畫 (PEPFAR) 等重要計畫的突然停止讓這些國家陷入困境。對於世界上最脆弱的衛生系統所服務的人來說，這些損失幾乎肯定在幾年甚至幾十年內都無法逆轉。
我們將如何面對這新現實？我們中的許多人都經歷了從愛滋病毒出現到有效治療方法問世之間漫長的15年，並且承受著早年那些年的創傷。但我們也知道，愛滋病毒防治是我們這個時代全球團結的偉大事蹟之一。我們在糟糕的治理、匱乏的資金、否認愛滋病、恐懼和無知以及對受影響人群和社區的歧視中磨練自己。我們在全世界愛滋病毒治療和預防方面面臨著巨大的差異，但透過全球團結、創新夥伴關係和熟練的宣傳，我們克服了許多雖不是全部的差異。我們將竭盡全力阻止自己回到早年那個時代。事實上，創傷和痛苦，以及 「嬰兒 M」 和其他許多像他一樣的人的面孔，可以產生一種激發內心的火焰。我看到「嬰兒 M」，又為他的痛苦而哭泣，我們知道我們不能也不會放棄這場戰鬥。
克里斯·貝雷爾 (Chris Beyrer) 我是國際愛滋病協會的前任主席。本文所表達的觀點僅代表我個人的觀點，不代表我所屬的任何機構的觀點。
參考文獻：
Brink DT、Martin-Hughes R、Bowring AL 等人。國際愛滋病資金危機對中低收入國家愛滋病感染和死亡率的影響：一項建模研究。《刺胳針愛滋病毒2025》；3 月 26 日線上發表。 https://doi。org/10.1016/S2352-3018(25)00074-8
Casey M, Perrone M. 頂尖疫苗官員辭去 FDA 職務，批評羅伯特甘迺迪推動「錯誤訊息和謊言」。美聯社。2025 年 3 月 29 日。 https://apnews。 com/article/fda-vaccine-chief-peter-marks-resign-rfk-kennedy-7743be11cec4e4e22c50c2ddbcb6bcd8（2025 年 4 月 4 日瀏覽）
Farahani M、Farley SM、Smart TF 等人。賴索託在2016 年至 2020 年實現聯合國愛滋病規劃署 95-95-95 目標方面取得的進展：基於人口的愛滋病毒影響評估比較。《刺胳針愛滋病毒2025》；12：e51–59
Jewett C、Baumgaertner Nunn E、Gay Stolberg S. Kennedy。 向一位名譽掃地的疫苗懷疑論者求助自閉症研究。《紐約時報》。 2025 年 3 月 27 日。 https://www.nytimes.com/2025/03/27/health/rfk-jr-autism-vaccines.html（2025 年 4 月 4 日瀏覽）
Miolene E、Saldinger A。盧比歐「救命」豁免內部的混亂。《Devex》。 2025 年 2 月 17 日。
Tram KH、Ratevosian J、Beyrer C。根據行政命令：暫停 PEPFAR 資金 90 天可能帶來致命後果。《 J Int AIDS Soc 2025》； 28：e26431
The art of medicine
On going backwards
www.thelancet.com Vol 405 April 26, 2025
There are patients you can never forget. Some because you connected unusually deeply with them as people or with their stories—some because you may have seen yourself or a loved one in their shoes, on that gurney, in that pain. On a paediatric rotation as a medical student at Kings County Hospital in East Flatbush, NY, USA, during the 1980s, I was part of team that took care of a toddler slowly succumbing to AIDS. An orphan, as so many were in those terrible years, his bedside chart read Baby M. This child had never been well and was steadily going backwards in development. Losing milestones. First the ability to sit up, then to lift his little head, to eat solids, eventually to breathe. I had the unforgettable task of trying to draw blood from his wasted limbs—he could barely make a sound but was still visibly screaming. I remember months later, on another rotation in the same hospital, learning that he had died. A mercy. And then learning that his care team had proudly reported he had survived a record number of months on that ward. Perhaps a clinical advance, but only prolonged suffering for Baby M.
The small, withered face of this boy has been haunting me these past months with astonishing vividness. Traumatic memory is like that—all the more sharp for bringing us back into the traumas that our brains, or bodies, or hearts, can hold in abeyance for decades.
But what makes this memory, this trauma, so hard to bear is that in the 1980s there were no effective therapies for anyone—adults, children, or infants—living with HIV/ AIDS. Today, of course, effective antiretroviral therapies are available for people living with HIV. And this is why the abrupt cuts by the administration of US President Donald Trump to foreign assistance, including an unconscionable 90-day pause on The US President’s Emergency Plan for AIDS Relief (PEFPAR), is so traumatic.
PEPFAR, for some 21 years, was the largest commitment to a single disease in global health history. Up to Jan 20, 2025, and the change in US policy, PEPFAR, which had since its inception received bipartisan support among US politicians, was supporting care for some 21 million people living with HIV worldwide, including more than half a million children. With colleagues I worked with a modeller at the University of Washington, Khai Hoan Tram, and published, in February, 2025, an estimate of the likely impact of the 90-day pause in PEPFAR funding on the subsequent 12 months; we estimated about 100 000 excess HIV-related deaths, and 135 000 excess perinatal HIV transmissions. What should be, and nearly was, a preventable infection in newborn babies could come roaring back. And this is because in the highest prevalence regions for HIV worldwide— eastern and southern Africa—most people living with HIV are women of reproductive age. And access to HIV treatment had made their reproductive hopes come true; health for themselves and babies born free of HIV. When I saw the modelling outcomes—that estimate of 135 000 preventable infant infections, Baby M’s face flashed across my mind’s eye. I have not been able to clear it since; I continue to see it.
The outcry over the PEPFAR pause in January, 2025, was immediate. Within 48 hours, US Secretary of State Marco Rubio, whose bureau oversees the programme, had issued a waiver for “life-saving treatment and prevention of mother to child transmission”. But in the event, the waiver meant little, since the United States Agency for International Development (USAID), the principal implementer of PEPFAR across Africa, had already been gutted by spending cuts and mass firings. The cuts to USAID left PEFPAR without its most important implementation arm, disrupting supply chains for drugs and commodities and purchasing of clinic supplies, interrupting data systems and monitoring, and undermining support for fragile health systems. Rubio subsequently sent a memo to all USAID staff requiring them to report that the waiver was working. It was not and is not, and in putting PEPFAR on pause, this US administration has blood on its hands which will not easily wash away.
The long history of infectious disease control campaigns has taught the global health community several hard lessons. One is that programme interruptions, most commonly those driven by funding cuts, can quickly lead to recrudescent disease spread. This impact has been well documented in malaria, tuberculosis, and in sexually transmitted infections. In HIV there have not previously been programme interruptions on this massive scale. But now that HIV programmes have been disrupted, special characteristics of HIV infection, both for individuals and populations, need to be emphasised.
HIV treatment can be highly effective in long-term suppression of viraemia, rendering patients who have well controlled HIV no longer infectious for their sexual partners. Interrupt HIV treatment, however, and the virus quickly comes back to very high levels. The person is again infectious and could also have developed resistance to antivirals in the period where their antiviral levels were subtherapeutic and viral replication is underway again.
Interrupt treatment for a whole community, country, or region and this reality can quickly lead to a return of epidemic spread with subsequent rising morbidity andmortality. Decades of achievement can be swiftly lost. These potential impacts were starkly shown in Debra ten Brink and colleagues’ modelling study in The Lancet HIV in March, 2025; they estimated that international aid reductions together with discontinued PEPFAR support could cause an additional 4·43–10·75 million new HIV infections and 0·77–2·93 million HIV-related deaths between 2025 and 2030.
The dark spring of 2025 may well be remembered as the start of the second round of the HIV pandemic—a preventable one—but no less devastating for our human family.
It is difficult to understand the motivations behind this level of destruction. This vast lack of compassion. Cost-cutting has been the principal explanation from the US Government. But it arguably goes much deeper. Underpinning all of global health and international development assistance is the principle that all human lives are of equal value—and that the wealthy of the world have an obligation to the poorest of the poor. In the first State of the Union address of his second presidency, Trump mocked the concept of aid to the African nation of Lesotho “a country nobody has ever heard of”. It need hardly be said that Lesotho has long been a PEPFAR focus country. And the PEPFAR investments in Lesotho were paying off. Population-based assessments done in 2016 and again in 2020 showed declines in incident HIV infections, increasing awareness of HIV status, and perhaps most importantly, an increase in antiretroviral therapy coverage from 91·8% among those who knew their status, to 96·9%. Lesotho has now been hit by US trade tariffs, which will have little impact on the US
economy, but could have grave implications for this small state. The motivation? Punishment or pique seem the only likely explanations.
As the Trump administration continues to drive leading scientists and public health leaders from their positions in US health agencies and organisations, it is clear that the policies of the current US Government are, indeed, going backwards. Under Robert F Kennedy Jr’s new
leadership as the US Secretary of Health and Human Services, Peter Marks, who had directed the Center for Biologics Evaluation and Research within the US Food and Drug Administration and had vital roles in the COVID-19 vaccine successes, was forced to resign. Yet Kennedy Jr has appointed an untrained and unqualified vaccine sceptic (who has a history of practising medicine without a licence in Maryland) to lead a federally commissioned study of vaccines and autism.
We are at a moment when the USA is moving backwards on the response to HIV and backwards on vaccines. The massive cuts to USAID mean the US Government is also going backwards on its commitments to food insecure populations, including refugees and those displaced by war and conflict. The cancellation of major grants for maternal health programmes means we are going backwards on safe motherhood. And the list goes on. That these are deliberately inflicted wounds makes them all the more difficult to bear.
Will other wealthy nations step into the breach for global public health? France, Germany, and the UK are all reducing their commitments to global health. Europe is pressed to spend more on defence. And while many hard-hit African countries could do more and are working to strengthen domestic spending on health and alliances with other partners in the Global South, the abrupt cessation of massive levels of official development assistance and crucial programmes such as PEPFAR have left them scrambling. For the people served by the most fragile health systems in the world, these losses will almost certainly not be reversed for years, if not decades.
How will we live with this new reality? Many of us who worked through the 15 long years between the emergence of HIV and the advent of effective treatment carry the traumas of those early years. But we also know that the HIV response is one of the great stories of global solidarity in our time. We cut our teeth on bad governance, little funding, AIDS denialism, fear and ignorance, and stigma against affected people and communities. We have faced enormous disparities in treatment and prevention access for HIV worldwide, and overcame many, but not all, through global solidarity, innovative partnerships, and skilled advocacy.
And we will resist going backward to those early years with all we have. Indeed, the trauma and the pain, the faces of Baby M and so many others like him, can yield a kind of
energising inner fire. I see Baby M and I weep again for his pain, and I know we cannot and will not give up this fight.
Chris Beyrer
I am a Past President of the International AIDS Society. The views expressed in this essay are my personal views and not those of any institution with which I am affiliated.
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