In 2016, the US gave about $6.6-billion in international HIV funding making it one of the largest funders of HIV programmes globally, according to the US-based health research organisation the Kaiser Family Foundation. For some countries like South Africa, this aid is in the form of funding for HIV vaccine research and medical male circumcision to reduce men's chances of contracting HIV. In the past, the US also heavily funded antiretrovirals. In countries like Angola, assistance still translates into life-saving antiretroviral treatment in patients' hands through the US President's Emergency Fund for Aids Relief (Pepfar) programme.
But in the red, white and blue aftermath of one of the country’s most divisive presidential campaigns, many are wondering what a Trump administration will mean for global health. The answer may be far from clear, but activists are likely to keep a close watch on the science guiding policy, HIV funding and generic medicines.
“President-elect Trump made one statement on the campaign trail about Pepfar and it was supportive,” says Matthew Kavanagh, senior policy analyst for the global HIV group Health GAP. “We hope he will stand up to those in his party that want to recklessly slash and burn the federal budget and take us backwards in the fight against Aids.
“The campaign did continue with a number of xenophobic and misogynist statements, so people are worried. Some of president-elect Trump’s backers have some very problematic views. The question is whether Trump and [vice-president elect Mike] Pence will support the hugely-effective, bi-partisan effort to fight global Aids with science – or do what right-wing Washington, DC think tanks want him to do.”
Mark Heywood is the executive director of the public interest law organisation Section27 and co-founder of South Africa's largest HIV activism organisation, the Treatment Action Campaign.
"Obviously, we are very concerned. The Pepfar programme, despite all its warts...has been very important in terms of infusing money globally into Aids programmes," he says.
Heywood says that under US President Barack Obama's administration, Pepfar backtracked on its previous decision to scale down support of South Africa's HIV programme. The country now receives about $500-million in annual Pepfar funding.
But Trump's xenophobic remarks have made Heywood fearful that Pepfar could become an easy target as some Republican politicians have clearly signalled desires to cut budgets.
"We need funding to stay at that level. Pepfar could be a low-hanging fruit for him or congress to chop," he says.
Trump's inner circle holds a poor record on reproductive rightsAmong Trumps' backers is Ken Blackwell, a senior fellow for human rights and constitutional governance at the anti-abortion and pro-marriage organisation the Family Research Council. Trump has selected Blackwell to head up domestic policy as part of the team helping him transition into the White House but his previous statements about lesbian, gay, bisexual and transgender people and others have caused concern among many groups.
The presence of people like Blackwell in Trump’s “inner circle” may conjure up bitter memories among activists. In 2006, conservative politicians were able to introduce new Pepfar funding requirements that mandated that at least a third of HIV prevention dollars be spent on abstinence-only or “fidelity” programmes. A 2008 review of research published in the journal Science found there was little evidence to support the effectiveness of such programming.
Pepfar’s “abstinence only” clause was later removed but could the US global health policies take a similar turn now?
“The helpful signs are that the Trump campaign was not about cutting foreign aid. He also did not campaign on some of the 'cultural war' elements from the 1980s and 1990s that fed into the early 2000 fights over Pepfar,” Kavanagh says.
“The Trump administration needs to focus on making things work, and so there may be far less stomach for repeating wars.”
Pence has also supported Pepfar, notes Laurie Garret, a senior fellow for global health at the US think tank the Council on Foreign Relations in a recent analysis.
Faced with rising narcotic use in his home state, Pence was also recently forced to introduce needle exchange programmes. Some UK studies have shown that these programmes can reduce HIV infections by about 5%, according to a 2013 review published in the journal Aids and Behaviour.
But Garret writes Pence has also consistently "promoted very far-right policies on women’s reproductive rights", including a full ban on abortion in cases where fetuses have abnormalities.
Could Trump's party put the Global Fund in the firing line?In 2004, the US Republicans mounted an unsuccessful attack to cut support to the international financing mechanism the Global Fund to Fight Aids, TB and Malaria in part because of the fund's support of scientifically-based HIV prevention efforts like needle exchanges and condoms.
Kavanagh says that just a year prior, Republican President George W Bush had created Pepfar in part to counter the Fund's calls for greater access to generic medicine. Bush later proposed a paltry pledge of $200-million to the multi-billion dollar mechanism.
Today, the US is the largest contributor to the Global Fund, which supports more than half of all people with HIV globally. In many countries is one of the few donors working with marginalised, high-risk populations like men who have sex with men and sex workers.
If Trump’s administration were to set its sites on cutting Global Fund support, it would be disastrous for an international mechanism already underfunded, Kavanagh warns.
Heywood says that a US decision to decreased Global Fund support could set a dangerous precedent.
"US leadership has, at times, in the global Aids response set the tone for other countries. If the US waters down its leadership, this could have a knock on effect particularly if European governments shift to the right in the next few years and there is a danger of that happening," he says.
Attacks on generic medicine access may be likelyActivists are also likely to be keeping a close eye on Trump’s stance on generic medicines. He’s signalled his intention to leave the Trans-Pacific Partnership Agreement trade deal undertaken by the US with 11 Pacific Rim countries including Malaysia, Mexico and Vietnam.
International humanitarian organisation Doctors Without Borders slammed the agreement for prioritising aggressive patent protection over access to medicines.
Kavanagh says: “One of the things that we have seen lately is [the idea] to scrap the Trans-Pacific Partnership Agreement, which is very good news but for largely the wrong reasons. We should not mistake this good news for good news for access to medicines.”
"I think we are likely to see attacks on generic drugs,” he warns.
But these decisions will not all be made by Trump; who fills positions of secretary of state and head of health and human services will also play important roles in deciding US global health policy in months to come.
And the world may take comfort in knowing that American politics was designed to move at almost a glacial speed.
"It’s important to note that all of this will play out over years. It’s not immediate," Kavanagh says.
On December 1, the globe marks World Aids Day. Activists may use the day to send a strong message to America’s new president-elect about their expectations.
“Trump is a wild card. The question is where will the administration go. I would argue that we have some power in dictating that,” Kavanagh says.
Heywood says the world will be watching to see how Americans hold Trump to account.
He says: "Outside the US, we are relatively powerless. The real job lies with US citizens and activists to do much more on every front to ensure the accountability of their government."
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