The year 2025 has been a rollercoaster for the HIV community, with a mix of advancements and challenges that have left many concerned about the future. Despite some progress, the year has been defined by setbacks and controversial decisions that threaten to undermine the hard-fought gains in HIV treatment and prevention.
Since its identification in 1981, HIV has seen remarkable strides in both treatment and prevention. Thanks to these advancements, individuals living with HIV can now expect similar life expectancies to those without the virus, provided they receive prompt and consistent treatment. However, the year 2025 has brought about a series of changes that have cast a shadow over these achievements.
The Trump administration's arrival in January 2025 brought with it a wave of changes to HIV policies. One of the most significant moves was the imposition of a stop-work order on global health funding, including the US President's Emergency Plan for AIDS Relief (PEPFAR). This decision, justified as a review of foreign aid contributions to align with the new president's foreign policy, had immediate and devastating consequences.
"The cuts to PEPFAR have destabilized HIV treatment and prevention programs in the 55 supported countries, undoing the progress made over the last two decades in combating HIV as a public health threat," explained Kimberly Powers, PhD, an associate professor of epidemiology at the UNC Gillings School of Global Public Health. The disruption in services and infrastructure has caused irreparable harm, and continued cuts to PEPFAR have proven detrimental to foreign countries, with studies predicting a rise in HIV-related deaths in South Africa alone.
Marshall Glesby, MD, PhD, associate chief of the Division of Infectious Diseases and director of the Cornell HIV Clinical Trials Unit at the Weill Cornell Medical College, highlighted the impact of cuts to the US Agency for International Development (USAID). "USAID has historically funded the infrastructure needed to implement PEPFAR. The near elimination of USAID has led to disruptions in HIV diagnostic, prevention, and treatment services worldwide. PEPFAR is a vital initiative, supporting over 20 million people in over 50 countries by providing antiretroviral therapy and essential services to vulnerable populations. It has saved an estimated 26 million lives."
The pausing or ending of research grants, including those focused on HIV, has also disrupted care and research into potential advancements. Glesby stated that the disruptions to NIH funding will likely have widespread effects on HIV research, particularly in areas like HIV vaccine research, which is gaining traction with newer approaches using mRNA technology.
Despite these challenges, there were some bright spots in HIV research and treatment this year. One notable advancement was the FDA approval of lenacapavir (Yeztugo; Gilead Sciences), a long-acting injectable form of pre-exposure prophylaxis (PrEP) that only needs to be taken twice a year, a significant reduction compared to cabotegravir, which requires six injections per year. The approval was based on the PURPOSE trials, which found nearly 100% efficacy in preventing HIV in those who received the injection.
Glesby explained, "We've had long-acting injectable HIV medications for about five years now. The original combination regimen of injectable cabotegravir and rilpivirine was approved as monthly injections and then ultimately bimonthly injections. While this combination has become popular for some patients, there are logistical challenges to scaling up intramuscular injections in clinical settings. Lenacapavir represents a significant advancement, as it only needs to be taken every six months."
Powers agreed that lenacapavir is an exciting advance that adds to the tools available to address HIV and overcome barriers related to oral PrEP. However, she noted that the disruptions in care could pose a significant barrier to distributing the treatment, raising concerns about its potential impact in a dysfunctional healthcare system.
Despite these challenges, the promise of lenacapavir to curb HIV incidence is encouraging and could pave the way for future research into long-acting injectables, potentially extending the time between injections even further.
Looking ahead to 2026 and beyond, the future of HIV treatment and prevention remains promising, albeit with some significant challenges on the horizon. Glesby noted that drug development in HIV is an exciting area, with small studies testing the efficacy of once-yearly lenacapavir, once-weekly oral pills, and monoclonal antibodies injected every six months. Powers finds solace in the availability of existing treatment options for the millions living with HIV.
However, both experts highlighted the potential cuts to the Ryan White HIV/AIDS Program, the nation's safety net for HIV care and treatment, as a significant concern. The Trump administration is reportedly looking to cut funding for this program, which would effectively eliminate the AIDS Education and Training Centers, a vital program that educates healthcare providers and clinicians on treating HIV.
"While there have been some bright spots and reversals of lost funding, it's hard to feel like we're out of the woods or that the situation is likely to remain anything but difficult for the foreseeable future," said Powers. "But I believe that those working in this space are resourceful and persistent, and I hope that the situation will ultimately improve."
The year 2025 has been a challenging one for the HIV community, but with continued dedication and innovation, there is hope for a brighter future.
