Opinion: The next US administration's legacy can be to end HIV worldwide

The first Donald Trump administration’s initiative to end the HIV epidemic in the United States by 2030 was a bold and visionary goal, and, if his next administration follows through, will be a legacy that will rank among the most important American public health achievements. Achieving this goal in the U.S. also offers a rare historic opportunity to clench a global legacy that will create lasting health, economic, and social impacts for generations to come: the beginning of the first AIDS-free generation in 50 years. Both these domestic and global goals are achievable if American leadership and financial innovators step up. There are three major reasons why the next administration should prioritize eliminating HIV worldwide and redouble efforts to secure a global health legacy: saving millions of lives and ending HIV as a public health threat; driving economic growth and resilience; and investing in health systems to safeguard public health beyond HIV. To get there, we need not only scientific advancements and greater innovation in service delivery, but innovative financing mechanisms, such as public-private “HIV bonds” that build on groundbreaking government and philanthropic investments such as the United States President's Emergency Plan for AIDS Relief, Global Fund to Fight AIDS, Tuberculosis and Malaria, and Gavi, the Vaccine Alliance. An HIV bond could be issued by the Global Fund — or another appropriate global financing institution — to private investors, with proceeds distributed to low- and middle-income countries for HIV and other health care investments. Countries will repay the bond with interest over time using savings generated from improved health outcomes, increased tax revenue due to higher economic growth, and other government revenue streams. This can not only end HIV as a public health threat by helping millions of people access the latest in medical innovation, it can also demonstrate the positive power of American financial innovation. The potential of the HIV bond Despite significant progress, HIV/AIDS claimed over 630,000 lives and there were 1.3 million new infections in 2023 alone. An estimated 15 million people globally are still not being treated. While U.S. progress against HIV offers a model for controlling hot spots and saving lives at home, ending HIV globally requires regional approaches and tailored strategies to address the unique drivers of the epidemic in different contexts. PEPFAR, which was launched in 2003 by former U.S. President George W. Bush, has saved 25 million lives and strengthened health systems across the countries in which it operates. Building on this progress, we can help evolve the fight against HIV just as the epidemiology has evolved. Financing through HIV bonds would amplify these outcomes, enabling countries to reinvest their own resources in public health, reducing dependency on development assistance, and, ultimately, repaying bondholders. Modeled after the International Finance Facility for Immunisation, which has already raised nearly $10 billion for vaccination programs, HIV bonds can provide upfront capital to rapidly expand access to antiretroviral therapy and preexposure prophylaxis. Guaranteed by the U.S. government and philanthropies, and aligned with the U.N. Sustainable Development Goals, HIV bonds can offer attractive and stable returns for long-term investors such as pension funds, private equity firms, and sovereign wealth funds seeking to diversify portfolios while limiting risk. HIV bonds will enable governments to aggressively finance treatment and prevention programs today. As new infections decline, long-term health care savings will increase, enabling a virtuous cycle of reinvestment in healthcare systems, further bolstering economic stability and resilience. This ripple effect bolsters geostrategic interests as well, offering a rare opportunity to build bridges with countries critical to global stability. Strengthening cooperation with countries the U.S may disagree with politically but agree with in areas such as global health and healthy populations is not only smart, it is essential if we are to move toward greater stability and avoid global catastrophe. Broad benefits Investing in ending HIV also creates broader benefits for health systems struggling to fight other society-sapping diseases such as malaria and tuberculosis. As COVID-19 demonstrated, a resilient health care infrastructure is essential for addressing future health challenges. Lessons from HIV informed how countries fought COVID-19. Investing in one part of the health care system builds capacity across the system, in areas like workforce training, disease surveillance, resilient supply chains, and knowledge transfer — all of which enhance health security and global cooperation. Scientific advancements in HIV prevention and treatment are at their pinnacle, offering unmatched confidence in medical outcomes, and new tools to transform how HIV and other diseases are fought. Taking advantage of these powerful innovations requires sustainable financing free of political uncertainty. Experts estimate LMICs need almost $30 billion, on top of what has already been pledged by governments, to end HIV as a public health threat by 2030. Traditional government funding models and philanthropy cannot fill this gap, but innovative financing mechanisms like HIV bonds can. Nearly 45 years after the first HIV diagnosis, the question is no longer whether we can end HIV but whether we have the vision, political leadership, and financial tools to do so. The global scientific and financial response to HIV has been unprecedented — raising an additional $30 billion to finish the job is both feasible and necessary. By expanding the global coalition fighting HIV to include new private financiers and innovators committed to impact, a successful pilot HIV bond program could set a target of raising $7 billion, almost equivalent to the annual U.S. global HIV spending requested for FY2025. Its success could encourage other G7 and G20 countries to adopt similar models tailored to their unique financial systems and investors, ultimately filling the $30 billion gap. The next Trump administration has an opportunity to reaffirm American leadership and secure a historic legacy decades in the making. As former President Bush said when launching PEPFAR: “To whom much is given, much is required.” Now is the moment for great countries and leaders to meet their historic responsibility, turning the dream of an AIDS-free generation into a reality at home and around the globe.