The 4 I’s: How HIV Prevention, Treatment Can Move Forward in Challenging Times

The past year in the HIV space has been challenging across the country and the globe, as the Trump administration has introduced budget cuts that specifically affected global HIV aid,¹ research grants were put on pause or halted altogether, and research into HIV vaccines was stopped indefinitely due to funding cuts.² However, even as the HIV space sees all of these challenges, the epidemic continues to be a top health priority, as millions still live with the potentially deadly virus.

Ilesh Jani, PhD, from the Mozambique National Institute of Health in Maputo, Mozambique, began the first full day of the Conference on Retroviruses and Opportunistic Infections 2026 by going over the progress that has been made in HIV over the past 30 years, describing the challenges the past year has brought, and outlining his plan, highlighting 4 I’s, for how experts around the world should move forward.

HIV Treatment, Prevention Has Improved Leaps and Bounds in 30 Years

Jani began his lecture by recognizing how much progress has been made in treating and preventing HIV in the past 30 years, specifically when it comes to increasing the percentage of people with HIV receiving treatment from near 0% in 2000 to nearly 80% in 2024.³ This has ultimately led to a significant reduction in the number of deaths related to AIDS, with a peak of about 2 million in 2004 to a little more than 500,000 each year by 2024. There’s also been a 40% reduction in new HIV cases from 2010 to 2024. However, he noted, this is still not nearly enough to meet the 2025 goal set forth by the Joint United Nations Programme on HIV/AIDS (UNAIDS) and is on track to miss the 2030 target.

The reduction in HIV cases was primarily driven by progress made in eastern and southern Africa and western and central Africa, totaling a 56% and 55% reduction, respectively, whereas the Middle East and North Africa saw a 94% increase in cases between 2010 and 2024. Deaths have also been reduced by 54% between 2010 and 2024, although eastern Europe and central Asia saw a 48% increase in deaths in that same time.

UNAIDS estimates that the highest distribution of unmet need for antiretroviral therapy (ART) was in eastern and southern Africa (36%), followed closely by Asia and the Pacific (24%) and western and central Africa (13%), which makes it important to invest in HIV responses, said Jani. Study results have also found that investments in HIV response have strengthened health systems overall, he said, as laboratories supported by the US President’s Emergency Plan for AIDS Relief made up 42% of nationally conducted COVID-19 testing.⁴

Jani emphasized that it is important to also make sure that prevention methods are not neglected in favor of promising ART treatments alone.

Funding Decline Has Had Profound Effect Worldwide

Total funding assistance for health has declined since 2020 and has now reached similar levels to those of 2010, according to a graph presented by Jani.⁵ Development assistance peaked during the pandemic in 2020 and has seen steady declines starting in 2022-2023, with the most notable decreases coming in the past year due to the US cutting back on worldwide funding.

These cutbacks in funding, said Jani, primarily affect countries with a high HIV burden, particularly in sub-Saharan Africa. The decreases in funding have led to the restrictions of use for community-based care, among others. Jani also revealed data from a study that found that the global funding cuts will lead to more HIV infections and more deaths related to AIDS as the funding levels stand.⁶ This, he said, would be a reversal of public health gains.

The 4 I’s: How to Meet the Moment

With the new landscape of HIV in the US and around the world, the response to the HIV pandemic needs to change too. Jani proposed the 4 I’s method: focusing on integration, inclusion, innovation, and impact.

When it comes to integration, all 6 building blocks of the health system should be considered when integrating HIV into primary health care. These building blocks are service delivery, health workforce, health information system, access to essential medicines, financing, and leadership and governance. Integrating health services across different levels and sites to meet client needs is important in making sure that the patient is receiving necessary care. When HIV care has been integrated, it has improved health outcomes overall, especially when it came to starting ART in mothers and retaining them for at least 12 weeks.

For inclusivity, community-based care, developed through community engagement, can help to establish health programming that is sustainable and inclusive. Health outcomes were improved and health services were more efficient when patients were engaged in care through their community, Jani said. Community-led services can also help to expand access to demographics who need it the most.

Innovation has been coming in the mode of service delivery, with new, long-acting injectables for use as pre-exposure prophylaxis, such as cabotegravir and lenacapavir, that can also transform the way that HIV is treated. The PURPOSE trials of lenacapavir have shown nearly 100% efficacy in preventing infection of HIV, which can help slash transmission in the areas where HIV is highly prevalent. Digital health may also help to increase access and quality of health services for those in health deserts or for young adults and adolescents who may not be able to get to the doctor by themselves. Lastly, countries that saw the highest budget cuts will need to be innovative in how they use the money they have to maximize health outcomes in those of highest need, Jani said, which ties into the last I of impact.

Doctors and researchers need to tailor their health services to areas that will have the most impact on preventing HIV, including through prevention interventions that are tailored to the contexts of the country’s epidemiological and economic status. Health impact and program ownership are both helped by strengthening the governance of a country. Jani suggested that each country needs to develop an evidence-to-impact ecosystem that informs policy making and resource allocation, including prioritizing immunization programs and putting together a task force to assess the impact of the budget cuts.

Jani concluded that the past 30 years have seen public health gains in HIV that can leave a generational legacy, but treating and preventing HIV needs to evolve with the current landscape. Jani called on countries to make the difficult choices about what services need to be prioritized and how available resources should be allocated to best stem the HIV epidemic and continue the downward trend in HIV cases and deaths related to AIDS.

References

1. Bonavitacola J. HIV in 2025 defined by challenges throughout the year, despite some advances. AJMC^®. December 16, 2025. Accessed February 23, 2026. https://www.ajmc.com/view/hiv-in-2025-defined-by-challenges-throughout-the-year-despite-some-advances
2. Bonavitacola J. Cuts to HIV vaccine research come amid challenges to other vaccines, treatment. AJMC. June 13, 2025. Accessed February 23, 2026. https://www.ajmc.com/view/cuts-to-hiv-vaccine-research-come-amid-challenges-to-other-vaccines-treatment
3. UNAIDS. AIDS, crisis and the power to transform: UNAIDS global AIDS update 2025. Geneva: Joint United Nations Programme on HIV/AIDS. 2025. Accessed February 23, 2026. https://www.unaids.org/sites/default/files/2025-07/2025-global-aids-update-JC3153_en.pdf
4. Romano ER, Sleeman K, Hall-Eidson P, et al. Contribution of PEPFAR-supported HIV and TB molecular diagnostic networks to COVID-19 testing preparedness in 16 countries. Emerg Infect Dis. 2022;28(13):S59-S68. doi:10.3201/eid2813.220789
5. Apeagyei A, Bariş E, Dieleman J, et al. Financing global health 2025: cuts in aid and future outlook. Institute for Health Metrics and Evaluation. July 15, 2025. Accessed February 23, 2026. https://www.healthdata.org/research-analysis/library/financing-global-health-2025-cuts-aid-and-future-outlook 
6. Brink DT, Martin-Hughes R, Bowring AL, et al. Impact of an international HIV funding crisis on HIV infections and mortality in low-income and middle-income countries: a modelling study. Lancet HIV. 2025;12(5):e346-e354. doi:10.1016/S2352-3018(25)00074-8