Conflicting signals from Trump could disrupt HIV meds. What’s the impact?

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After abruptly pausing PEPFAR on Tuesday — the U.S.-led HIV/AIDS program created in 2003 and credited with saving 25 million lives globally — the Trump administration issued an ambiguous waiver for programs that provide lifesaving humanitarian assistance earlier this week. It wasn’t immediately clear whether PEPFAR qualifies for the waiver in full or in part.

Either way, the off-again, on-again messaging has created waves of confusion, including in South Africa, which has the largest PEPFAR portfolio in the world. At a a press conference on Wednesday, health minister Dr. Aaron Motsoaledi said, “So far, we haven’t received any letter from the American government. Tried to contact the embassy of the US. We couldn’t get them.”

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Some HIV clinics in the country have already shut down until they receive further clarity, such as Engage Men’s Health that provides HIV treatment including crucial life-saving drugs that prevent HIV from replicating. Their website now states that they “regret to announce that, due to an immediate ‘stop-work order’ issued by our funder, we cannot provide any services until further notice.”

Other groups have sounded the alarm as well. “We are seeing interruptions in medication supply, clinics are scaling back services and community health workers have literally been losing their livelihoods,” says Ling Sheperd with the Triangle Project , the oldest LGTBIQ+ organization in Africa. “We risk undoing decades of progress, especially in communities that are already structurally marginalized.”

And the confusion isn’t limited to South Africa. In Uganda, Dr. Adolf Alinaitwe , a clinical HIV researcher at the Joint Clinical Research Centre, says, “I for one have received many calls from my patients asking what their fate is.”

Motsoaledi dreads what stopping the distribution of antiretroviral drugs, or ARVs, would mean. “Nobody must stop taking ARVs because that would be devastating,” he said. “It will be completely dangerous. When you are on ARVs and you stop, there will be serious trouble.”

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Here’s what that trouble would look like.

The power of antiretrovirals

HIV was once a death sentence. But antiretroviral medications, taken as a single tablet each day, now allow people to live reasonably healthy lives.

“It doesn’t mean that you’re cured of HIV,” says Dr. Susan Cu-Uvin , the director of the Providence/Boston Center for AIDS Research, “but it controls the amount of virus in your body so that you don’t get very sick.”

She says the drugs kill the virus at different points of its life cycle and keep it from making copies of itself. They’re so effective that HIV transmission has plummeted between sexual partners and from mothers to children. By providing these drugs to clinics around the world, PEPFAR has helped lower global HIV rates and save millions of lives.

When Cu-Uvin started out as a medical doctor, all her HIV-positive patients were dying in their 20s and 30s. Today, her oldest patient is 90. (The woman discovered she had HIV in her late 60’s and likely contracted it earlier.) Because of these drugs, “any person who has HIV has been given a life,” says Cu-Uvin. “Stopping antiretroviral therapy means death, means sickness.”

HIV lies in wait

Once someone stops taking antiretrovirals, the levels of these protective drugs begin to drop in their body. That’s when HIV comes out from hiding.

“There are viral reservoirs of HIV in the body,” says Dr. Chris Beyrer , the director of the Duke Global Health Institute. “We don’t know where all of them are. We know some of them are in lymph nodes and in other tissues. Some may be in the brain. But either way, the virus will come back.”

This means that within days or weeks, the patient will come down with what feels like a dreadful flu. “You’re achy, you have night sweats, you have fever,” says Beyrer. “And some people may feel like they’re acquiring HIV all over again with rash and high fever, headaches, nausea.”

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The disease will then progress. The speed of that progression depends on a variety of factors, but becoming immunocompromised — in which the immune system is weakened and no longer able to fight off infections — is pretty much inevitable.

“Eventually, all those people will develop clinical AIDS and the very serious complications like opportunistic infections that a healthy immune system protects you from,” Beyrer says.

Those infections include everything from shingles to fungal and parasitic infections to — especially in Africa and Asia — tuberculosis. Any of these can kill someone without a functioning immune system.

The grave danger of resistance

There’s another problem with stopping antiretroviral treatment. The period when drug levels in the body are declining and viral levels are growing is when the virus is most likely to become resistant.

“You are selecting for resistant virus because you don’t have enough drug in the body to fully suppress replication,” explains Beyrer. “And if you develop resistance to one of these antivirals, you generally are resistant to the whole class.”

That forces someone to move onto a second or third line regimen of drugs that are pricier and harder to get. Plus, “if you do have a resistant virus, you can transmit it,” says Beyrer.

These are the reasons why public health experts are so worried.

“Without antiretroviral therapy,” says Cu-Uvin, “the amount of virus in your body will bounce back immediately. The virus comes back in revenge.”

And without intervention, she says death from AIDS is all but certain.

Freelance journalist Kate Bartlett, in South Africa, contributed to this story.

How Trump’s travel ban could disrupt the way knowledge about health is shared

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Abdul-Rahman Edward Koroma was supposed to be in New York last week.

For months, the disability rights activist from Sierra Leone had been looking forward to his trip to the United Nations session. He had a busy schedule of meetings and official events talking about the challenges of living with a disability in his country, including showcasing a documentary about how the disability community is especially vulnerable to flooding and landslides associated with climate change.

But on June 5, he learned he couldn’t come. Sierra Leone was one of 19 countries where President Trump had banned or restricted the ability to travel to the U.S.

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“Honestly, for me, it’s quite painful, and it’s quite disappointing,” says Koroma. “I hope the U.S. government will reconsider. The world is a global village, we all need each other, one way or the other.”

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Why is Sierra Leone on the list? The Trump administration cites high levels of visitors to the U.S. who’ve overstayed their visa as the reason. Other countries were selected for national security reasons.

“We will restore the travel ban, some people call it the Trump travel ban, and keep the radical Islamic terrorists out of our country that was upheld by the Supreme Court,” President Trump said in a statement .

The administration banned travelers from Afghanistan, Myanmar, Chad, the Republic of the Congo, Equatorial Guinea, Eritrea, Haiti, Iran, Libya, Somalia, Sudan and Yemen. Travelers from Burundi, Cuba, Laos, Sierra Leone, Togo, Turkmenistan and Venezuela also face some restrictions.

More bans may be coming. A State Department memo first reported by the Washington Post and confirmed by NPR suggests the administration may add 36 more countries, largely in Africa, to the banned or restricted list.

Consequences of the ban

Stories like Koroma’s will likely accumulate over the coming weeks and months, as global health researchers, workers and advocates from these countries are barred from coming to the U.S. to learn — and to share their expertise. Some global health specialists say the restrictions will ultimately harm U.S. interests by reducing our engagement with the world.

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“We are closing ourselves off from the active participation of potential allies,” says Judd Walson , an epidemiologist at Johns Hopkins University. “That will only lead to negative consequences in the long term.”

Closing the U.S. off could ultimately open it up more to global health threats, says Walson.

The ban follows the administration’s cancellation of foreign aid and withdrawal of U.S. membership from the World Health Organization. Walson says these decisions are upending many of the institutions designed to detect and respond to disease threats worldwide.

“As we think about the new architecture of global health and how it can respond to the many crises that emerge around the world, participation from all these countries is critical,” says Walson, and ultimately benefits Americans.

He notes that new infectious disease threats could emerge from any of the banned countries.

“Our inability to engage with partners from those places, who can serve as eyes and ears on the ground to identify threats. just hampers our ability to have a coordinated response,”

Abraar Karan, an infectious disease physician at Stanford University, is concerned future bans could hamper his team’s research on Marburg, a hemorrhagic fever virus. It’s normally found in bats, but can spillover into humans, sparking deadly outbreaks.

Karan and his team are trying to understand those spillover dynamics, in part by studying antibodies in people who live near past outbreaks along the Uganda-Kenya border.

“Part of the testing we’d do involves a test where there’s expertise in Uganda, at the Ugandan Viral Research Institute,” says Karan.

Uganda is among the 36 countries under consideration for future restrictions. If that happens, Karan worries his team may have restricted access to that expertise. While such restrictions wouldn’t preclude collaboration via Zoom, Karan says it’s just not the same as in-person.

“Many of the best conversations and ideas that we had happened during our drives, during meals or unplanned moments,” he says of interactions with foreign researchers in person. “Implementing these kinds of bans has a huge effect on research studies and really impedes progress.”

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Scientific conferences often serve as the nexus for that kind of collaboration, where researchers gather to share research and connect with colleagues. Trump’s travel restrictions are already preventing some scientists from being able to travel to the U.S. for conferences.

“We need to have such participation and contact, but it’s now very difficult,” said a biomedical scientist from Yemen who requested anonymity because speaking out could draw negative attention that would cause her university to retaliate. The scientist was planning to travel to California this fall for a conference on cancer management but cannot because of the ban, noting:. “Such an absolute restriction for all people is not wise.”

The U.S. could also lose its global role as a key location for trainings and scientific conferences. The travel bans, coupled with broader tensions around immigration in the U.S., have already led organizers of these events to look elsewhere.

“Our research team decided to host a planning meeting in London as opposed to the U.S. due to concerns with visas and the overall climate,” says Walson. There are economic consequences if U.S. conferences are canceled, he says. And with a likely reduced U.S. presence at conferences held elsewhere, there could be more intangible impacts too.

“Diseases don’t respect borders, and infections travel faster than diplomacy,” says Walson. “Whether we want to or not, we have to understand the reality of the global community as it is today. If we don’t engage, we will suffer the consequences.”

Effective immediately: CDC can’t talk to WHO. What will that mean for world health?

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This week, as officials at World Health Organizations convene meetings discussing everything from Marburg virus in Tanzania to mpox in the Democratic Republic of Congo, there are some empty seats in the room — and fewer attendees at virtual meetings.

Officials from the U.S. Centers for Disease Control and Prevention are missing.

On Monday, public health officials at CDC were told to immediately stop communicating with the World Health Organization in a memo that was sent to division directors, their deputies and others by John Nkengasong, the deputy director for global health at CDC.

The order comes on the heels of President Trump’s inauguration day announcement that he was starting the process of withdrawing from the WHO , a U.N. agency that the U.S. helped found in 1948. In Trump’s executive order , he recalled all U.S. personnel who work at WHO. The order explained that the U.S. is leaving because of WHO’s “mishandling of the COVID-19 pandemic,” unequal payments from member states and an “inability to demonstrate independence from the inappropriate political influence of WHO member states.”

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According to the official process for the U.S. to terminate membership, the country must give a one-year notice. However, this ban on communication takes effect immediately and does not allow for a transition period.

What the ban could mean

Officials inside the CDC and global health specialists outside of the organization are trying to understand the ramifications of this order both for the U.S. and for the world.

“This is unprecedented,” says Javier Guzman , the director of global health policy at the Center for Global Development.

CDC collaborates with WHO on a wide range of health efforts, including the ongoing efforts to quash a major mpox outbreak in parts of Africa and an outbreak of Marburg virus , which is Ebola’s cousin, in Tanzania. The U.S. has donated more than a million vaccines to these efforts and sent expert teams to support the local response.

Asked to comment on the future of these collaborative efforts, a spokesperson for WHO wrote in an email to NPR, “we are analyzing developments and do not have further information at this time.”

“There are a lot of people who are looking forward to further clarification and direction from the incoming administration,” said a CDC official, who asked for anonymity because they are not authorized to speak to the press. They said they can’t remember another presidential transition that included a directive similar to this. “I am not aware of any sort of communication that’s gone out to CDC employees like this one.”

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A request for comment from CDC’s media team was referred to the Health and Human Services media team, which has not responded.

How they’ve worked together

Among many other collaborations, the two agencies also work together on worldwide efforts to monitor and contain influenza. WHO runs the Global Influenza Surveillance Network. Josh Michaud , the associate director for global health policy at KFF, says that it may be challenging for the U.S. to develop flu vaccines each year tailored to the current strains of the virus that are circulating if scientists don’t have access to the samples provided through the WHO system.

“There might be third parties which could create some communication channels and U.S. pharmaceutical companies on the private side could continue to have some kind of contact,” he says. “But it definitely throws a wrench a little bit in the works of what had been a system which is really important – not just for global health security, but for U.S. health as well.”

“It’s absolutely vital that the CDC and WHO are talking to each other about what’s happening. So a ban on that? I just can’t see what benefit it has, but I see that it has a massive downside,” say Dr. Chandy John , director of Indiana University School of Medicine’s Ryan White Center for Infectious Diseases and Global Health.

Others agree. “It’s very hard for me to see any U.S. national interest that’s being advanced here. And quite the contrary, I just think it’s making it very hazardous for Americans,” says Lawrence Gostin , professor of global health law at Georgetown University and director of WHO’s Center on Global Health Law.

For example, he says, WHO is convening an international meeting of experts who will discuss bird flu, among other things. Bird flu has been circulating widely in livestock and wildlife in the U.S. Without CDC representatives at the meeting, he says, CDC will be unable to examine the shared data from other countries where bird flu has been identified and understand how the virus is evolving and spreading across species. Gostin says this new clampdown on communications could hinder the country’s ability to prevent humans from being infected as well as to develop medications and vaccines to combat bird flu.

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“Not only is it reckless, but I think it’s lawless,” Gostin adds, explaining that even with the Trump administration’s announcements, the U.S. is a party to the International Health Regulations and obliged to follow its guidelines. This is a legally-binding agreement managed by WHO that requires states to monitor health threats and report them to the WHO. However, there is not a strong enforcement mechanism for countries that don’t comply.

“We criticize China relentlessly for failing to abide by [IHR] in rapid reporting and communicating of the Wuhan outbreak,” says Gostin. “Why we would want to be in the company of China or Russia, that violates these international global health norms, certainly beats me.”

In addition to withdrawing from WHO and halting communication between CDC and WHO, Trump has paused almost all foreign aid, including many health programs . Taken all together, KFF’s Michaud calls the moment “incredibly precarious.” And, he says, “for global health, it could mark a turning point” in how the U.S. contributes to the international effort to tackle diseases.

The Women Of Peru Are Suffering From A ‘Shadow Pandemic’

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It’s a grim roster of alerts. A woman, age 19, last spotted in July wearing sky blue jeans, a black sweater and black sneakers. A 16-year-girl missing since she left her home one morning in July. A 14-year-girl last seen heading to the supermarket at the end of June; she was wearing blue shoes.

Such are the reports of missing women and girls that can be found on the Facebook page of Mujeres Desaparecidas, or Missing Women, a Peruvian advocacy and support group for families. The case reports are shared by distraught families and friends seeking help from the public in their search for loved ones who have been caught up in a grim statistic: Thousands of women — many of them girls and adolescents — have gone missing in Peru since January, including at least 1,423 reported missing since the country entered a state of emergency amid the COVID-19 pandemic in mid-March.

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“These aren’t just numbers. They are real women being erased,” says Katherine Soto, who founded Mujeres Desaparecidas after a close friend went missing four years ago.

As much of the world entered lockdown this spring, the United Nations in April warned of a “shadow pandemic” – a global increase in violence against women and girls, particularly domestic violence. Even during normal times, violence against women is high globally, with 1 in 3 women experiencing physical or sexual violence during their lifetime, according to the U.N. But evidence from past pandemics and humanitarian crises has shown that the stress from economic hardship, social isolation and restricted movement can exacerbate the problem, with many victims trapped at home with their abusers, with limited access to services that could help them.

“This confinement and restriction can exacerbate violence within homes. That’s what we’re seeing throughout this pandemic,” says Isabel Ortiz, a human rights lawyer with the women’s rights office of Peru’s National Ombudsman’s office, an independent group that monitors the country’s human rights.

Many of the missing women and girls are feared dead, Ortiz says, given earlier research from the Ombudsman’s office that found a sizable portion of women reported missing are later discovered to be victims of femicide.

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“So far this year [January 1 to August 21] there have been 75 cases of femicide and 35 violent deaths of women, of which 18% [19 cases] were previously reported as missing,” says Eliana Revollar, who heads the women’s rights division of the Ombudsman’s office. She says 38 cases of femicide and 19 deaths have occurred since mid-March.

But it’s not just disappearances and femicides. Calls to a national hotline for victims of domestic and sexual violence also skyrocketed between March and the end of July to 104,000 – more than double the calls fielded during the same time period the previous year, according to data from Peru’s Ministry for Women and Vulnerable Populations (MIMP), which runs the hotline. And MIMP’s emergency-response workers attended to nearly 1,000 victims of rape, including 703 girls and adolescents, during this same time period.

“All of this is really troubling,” says Clea Guerra Romero, a human rights lawyer with the Flora Tristan Center for the Peruvian Woman, a feminist organization.

Guerra Romero says she’s received calls during the pandemic from women whose landlords offered them breaks on rent in exchange for sex, as well as from women experiencing increased violence from their partner after one or both of them lost their job.

Peru is far from the only country where reports suggest that fears about increasing violence against women and children have come to fruition: From Tunisia to Argentina to the United States, calls to domestic abuse helplines spiked during the early days of confinement, according to the U.N. For example, calls to the U.K.’s National Domestic Abuse hotline spiked by 25% in the first week of lockdown, and France reported a 30 percent increase in domestic abuse cases, according to the U.N.

Violence against women is pervasive across Latin America as a whole, in part because of the region’s history of political and military sexual violence against women that hasn’t really been addressed, says Jelke Boesten of King’s College London, who has spent years researching gender-based violence in Peru.

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In Peru, domestic violence against women was a longstanding problem before the pandemic, with 5 women and girls reported missing each day on average, according to the Ombudsman’s office. The fact that the figures remain so high during the pandemic is striking, given that Peru enacted some of the strictest lockdown measures in the world back in mid-March, with police and armed soldiers on the streets enforcing stay-at-home orders and nighttime curfews.

“How is it possible that women disappear even during lockdown in such high numbers? It is shocking,” says Boesten. “How can women still disappear if we’re all behind closed doors?”

“It seems to me that this proves the fact that the majority of these missing women are [victims of] domestic disputes,” Boesten says. “Women disappear, get killed. This is intimate partner violence or family violence.”

Boesten and Ortiz note that reports of both femicides and disappearances were down somewhat in the first months of the pandemic compared to the same time period last year. “It’s not because cases have really decreased,” Ortiz says, “but rather, given the restrictions on freedom, it’s harder for victims or their relatives to file complaints [with authorities]. People were still getting used to this new normal.”

Indeed, Peru saw a jump in missing women reports after it eased some of its pandemic restrictions at the start of July: 508 women and girls were reported missing in July, compared with 358 the prior month, according to the Ombudsman’s office.

This pandemic has exposed “another emergency that’s been made invisible for decades, and that’s the emergency women live inside their own homes, with multiple forms of violence,” says Soto.

Soto and others note that it’s impossible to know for sure the fate of the women reported missing. That’s because Peru lacks an up-to-date, national database for tracking missing women, even though a law requiring the creation of such a database has been on the books since 2003. That means there’s no way to track information like the circumstances under which they disappeared or whether they were later found alive or dead, women’s rights advocates say. Last month, Peruvian Prime MinisterWalter Martos promised the country’s congress that the database would finally be operational in October. Soto says she welcomes the news but notes that it comes after 17 years of such government promises.

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But Guerra Romero says that while the pandemic has forced the issue of violence against women and girls back onto the political agenda, it has also made it harder for victims of that violence to get the physical and mental health services they need from the government. Most health services “are currently primarily focused on COVID care,” says Guerra Romero. Peru has one of the highest death rates per capita in the world from the coronavirus — 90.87 deaths per 100,000 inhabitants as of Sept. 3, according to data from Johns Hopkins University. “So many health services, even sexual and reproductive health services, in practice have been neglected,” she says.

The Peruvian government operates emergency centers for women (Centros Emergencia Mujer, or CEM) that offer legal help and counseling for victims of violence, but in practice, these centers haven’t been able to do much for all but the worst cases, says a worker with one of these centers who asked not to be named because of fears of losing her job for speaking out.

“I know we are only addressing urgent, emergency calls, for example sexual violence or attempted femicide or physical violence,” the CEM worker told NPR. But more moderate cases of assault – such as verbal assault or pushing — aren’t being attended to, she says. “They are being told that they will get a visit when lockdown measures ease more. Can you imagine? I mean, we’re so many months into this already.”

She tells me about a case emblematic of the obstacles victims of violence face: a 12-year-old girl who was assaulted and raped while walking home in late May in the Vilcashuamán province of Ayacucho, a region in south-central Peru. The girl reported the rape, but the health workers who examined her failed to give her the emergency health kit that victims of sexual violence are supposed to receive under Peruvian law. The kit includes the emergency birth control drug levonorgestrel. The girl later found out she was pregnant. Two men were charged in the case, but relatives of one man testified that the girl was in fact his girlfriend, while the relative of the second man vouched for his whereabouts at the time of the rape. A judge eventually let both men go free, with some restrictions on their movement. Meanwhile, the girl is in a state shelter, according to Peruvian news reports.

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Boesten says that while Peru has passed several laws in the last two decades to address violence against women and girls, in practice, there’s no actual infrastructure. “And that means that one can report violence, but nothing will happen.” For example, she says the police in practice do not enforce restraining orders against men reported for domestic violence. And cases of physical abuse are classified as misdemeanors, not criminal offenses, unless the victim is deemed injured enough to be incapacitated for at least 10 days, she says.

Guerra Romero of the Peruvian feminist group Flora Tristan says at the heart of the problem is a deeply ingrained culture of machismo. She points to a 2019 survey from the Peruvian government that found nearly 53 percent of Peruvians think a woman’s job is to focus first on her role as a mother and wife, and only after that on “her dreams.” She says these attitudes pervade Peruvian society, including government officials tasked with applying the law.

“This type of data tells us how hard it is to fight against societal prejudices,” Guerra Romero says. “It’s a huge problem throughout the civil service. We’re talking about police, courts, prosecutors.”