Advocates warn proposed cuts to HIV/Aids prevention programmes and strategy shift could stall progress against epidemic.

While US officials celebrate the work that has been done for HIV prevention, global advocacy groups and activists warn that US President Donald Trump‘s policies and approach may stall any future progress.

“We honour those who have lost their lives to Aids, we celebrate the remarkable progress we have made in combatting this disease, and we reaffirm our ongoing commitment to end Aids as a public health threat,” Trump said in a proclamation, which did not mention the LGBT community, marking World Aids Day.

But 38 advocacy organisations submitted a letter to congressional leaders on Friday voicing a “profound concern about the direction the executive branch appears to be taking in the global response to the HIV/Aids epidemic“.

The letter referred to Trump’s proposed budget, which would have cut $800m for programmes like the President’s Emergency Plan for AIDS Relief (PEPFAR) and the Global Fund to Fight AIDS, Tuberculosis and Malaria.

The organisations expressed their “profound concern,” saying recent actions by the Trump administration have caused them to “doubt the White House’s commitment to fighting the epidemic”.

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A report released this week by ONE, a global advocacy organisation, said that the president’s proposed budget cut could have led to more than four million deaths and 26 million new infections in sub-Saharan Africa over the next 15 years if it had been enacted.

“Slowing US efforts to fight HIV/AIDS for three years could set the global response back nine years and squander much of the $64bn that the US has invested over that time,” the report said.

Funding from the US has been critical to combatting HIV/Aids globally, health experts and activists say.

Started in 2003 under former President George W Bush, PEPFAR currently provides treatment to more than 13 million people globally.

The US is also the biggest donor to the Global Fund, and has contributed more than $13bn over the past 15 years.

Reductions in US foreign aid for these programmes, advocates say, could do irreparable damage to stemming the tide of new infections.

New strategy: ‘Risk is enormous’

While the proposed cuts were ultimately rejected by Congress, which is yet to pass its final budget, health experts and advocates say the administration’s shift in strategy on HIV/Aids prevention may still have dire effects for the 36.7 million people living with HIV.

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The PEPFAR Strategy for Accelerating HIV/AIDS Epidemic Control (2017-2020), announced in September by the US Department of State, named 13 priority countries where the US will focus its HIV/Aids funding.

These countries are those closest to bringing the epidemic under control, but are not necessarily the ones with the highest rates of infection, advocates say.

South Africa, the country with the highest percentage of the population infected with HIV, was left off the list.

Advocates like Brian Honermann of amFAR, the Foundation for AIDS Research, worry that with these shifting priorities and possible budget cuts, the epidemic could resurge.

“The thing that keeps me up at night is population growth,” he told Al Jazeera, referring to the massive boom in the youth population in sub-Saharan Africa, or the “youth bulge.”

The UN estimates that by 2030, there will be more than 300 million young people in Africa.

“Even if we’ve been successful at reducing the rate of infection, if we don’t stay ahead of the epidemic, the risk having HIV entrenched in a whole new generation is enormous,” Honermann said.

Although the number of deaths each year due to HIV/AIDS has declined significantly over the last decade, the number of cumulative infections continues to rise.

Honermann said he also worries about the expansion of the Mexico City Policy, or the “Global Gag Rule”, which prohibits foreign NGO’s from utilising other donors’ money for the provision of or advocacy for abortion.

While the policy previously only applied to programmes funded through USAID, the Trump administration has expanded it to apply to programmes funded by PEPFAR.

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“Historically, we’ve seen this mean that health centres lose funding and shut down,” Honermann said.

“And when that happens, we could see HIV rates going up again as people lose access to services,” he added.

Deborah Birx, the US global Aids coordinator and special representative for global health diplomacy, said in a press conference on Thursday that “efficiency and effectiveness” led to “dramatically increased results” despite no increase in funding in 2017.

But Ian Koski, director of communications for ONE, pointed out that, in the future, the cheapest programmes may not always be the most effective.

“There’s only so much you can do with efficiency,” he said.

“You can’t grow the number of people added to treatment simply through efficiencies”

Both Koski and Honermann agreed that increasing the number of people on treatment is the most effective way to keep the virus from spreading.

And while the proposed congressional budget has kept the funding for now, Koski said, “that’s no guarantee”.