On June 5, 1981, the Centers for Disease Control and Prevention published a brief clinical report in its Morbidity and Mortality Weekly Report five young people in Los Angeles who had contracted a rare and dangerous form of pneumonia.
Writing, not a long page, run in the middle report on dengue transmission among US travelers and evaluation of measles cases. No one who read it would have known that this was the first chapter of the worst infectious disease epidemic since the flu of 1918 – which would kill the estimates. 44 million people around the world and reshaped medicine, politics and culture in ways that we still consider. It would eventually be called the human immunodeficiency virus, or HIV.
For the next 15 years, an HIV diagnosis was, in effect, a death sentence, as the immune system was exposed to slow progression to full-blown AIDS. The virus evolved so quickly that every early attempt at a treatment felt like trying to aim at a moving target in the dark. And darkness was where many of the early victims were forced to live, stigmatized by society. It took until September 1985 for President Ronald Reagan even saying the word “AIDS” in publicat what point About 6,000 Americans he was already dead.
By 1993, HIV was leading cause of death for all Americans ages 25 to 44. Not just gays. Not just intravenous drug users. Everyone in the quality of his life. In 1995, at the height of the American crisis, 50,628 people he died of AIDS within a year. Globally, new infections peak the following year around 3.4 million. In the most affected cities of sub-Saharan Africa, one in five adults had HIV. All generations of parents were destroyed. By 2000, AIDS was leading cause of death in the African continent.
The story could have ended there: The virus won while the world looked away. But it didn’t. What happened instead, through a combination of activist fury, scientific ingenuity, and an act of bipartisan political will that still seems impossible in retrospect, is one of the greatest revolutions in medical history. It is a narrative that gives hope not only that we can one day reach zero and eradicating HIV, but that the world can overcome what may seem like hopeless challenges.
Miracle drugs – and a society that would not die
For the first decade of the pandemic, the US government’s response was defined by indifference, until activists decided to make it impossible. Group Act Up it turned unimaginable grief into political powerraiding the Food and Drug Administration, shutting down Wall Street, and turning funerals into protests. They were loud and angry and provocative – and effective: Act Up and partner organizations push the FDA in creating fast-track drug approval pathways and drug companies shying away from expanding access to experimental HIV treatments.
The clinical revolution came in 1996 International AIDS Conference in Vancouver. Researchers including Dr. David Ho presented data on combination antiretroviral therapy – what would become known as HAART. The scientists mixed several drugs into the cockroach that attacked HIV at different stages of its life cycle – basically around the virus it had no place to change.
The results were astounding: 60 percent to 80 percent of AIDS rates, deaths, and hospitalizations decreased. Patients who had been dead for several days recovered so well that doctors called it “The Lazarus Effect.” One doctor’s practice went out 37 patient deaths in 1995 to zero in 1998. Nationally, AIDS deaths in the United States it decreased by 63 percent in three years. HIV has dropped from The number 1 killer of America’s youth to No. 5 by 1997 – the most unprecedented decline for any major cause of death in modern history.
But the effect of Lazarus had a cruel star. The upfront cost of antiretroviral therapy $10,000 to $15,000 per patient per year. For many Americans living with HIV, that was made possible by a combination of insurance and government funding. For the tens of millions infected in sub-Saharan Africa – where the epidemic was worse than in the West – such life-saving drugs were not available. In January 2003, nearly a decade after antiretrovirals became widespread in the United States, just about. 50,000 people in sub-Saharan Africa were on those drugs. Thirty million were infected. Approx 12 million Africans died of AIDS between 1997 and 2006 when high costs and supply constraints put life-saving treatments out of reach.
It is not difficult to imagine an alternative history in which this balance of death continued. After all, we firmly acknowledge these entrenched inequalities in many other areas, from extreme poverty to child mortality.
But that’s not what happened. The same activist energy that forced the FDA’s hand in the 1990s turned its attention to global treatment gapjoined by an unlikely coalition of evangelical Christians motivated in faith, public health officials who saw a security threat, and the president who gave an example example of the Good Samaritan.
In his 2003 State of the Union address, President George W. Bush pledged $15 billion for five years to fight AIDS abroad through what he called the President’s Emergency Plan for AIDS Relief, or PEPFAR. Parliament passed the law created PEPFAR 375-41, a sign of how broad the alliance behind him was.
In April 2004, a 34-year-old man in Uganda was called John Robert Engole was the first person in the world to receive antiretroviral therapy supported by PEPFAR. By the end of 2005, approximately 400,000 people were in treatment through the program. By 2008, it was 2 million worldwide – a 40-fold increase from 50,000 Africans on ART When Bush gave his speech.
Since then PEPFAR has invested more than $120 billion and, by its own estimates, it saved the lives of 26 million people. The cost of treating one patient in a low-income country fell from about $1,200 a year in 2003 to $58 by 2023. Like my old colleague Dylan Matthews once he wrotePEPFAR is “one of the most effective federal programs in American history.”
The downstream effects of PEPFAR and other advances in HIV treatment and prevention are remarkable.
Annual AIDS deaths in the world have decreased from a peak of 2.1 million in 2004 to 630,000 in 2024 – a 70 percent reduction. Some 30.7 million people in low- and middle-income countries are now on antiretroviral therapy around the world, from a few more than 400,000 two decades ago. That’s almost an 80-fold increase.
What all this means is that a person diagnosed with HIV today who receives treatment can expect a near-normal life, an outcome that would have been unthinkable for anyone living in the 1980s and early 1990s.
On top of better treatment, tools to prevent people from getting HIV in the first place have become more effective, which has helped cause new infections to drop by more than 60 percent from 3.4 million in 1996 to 1.3 million. PrEP – a daily pill that reduces the risk of contracting HIV by up to 99 percent – has been available since 2012, and more than 3.5 million people all over the world have taken it at least once. Last year the FDA approved lenacapavir, a twice-yearly injection that the journal Science named its own 2024 successful year. In a PURPOSE 1 trial of the drug, among more than 2,100 women in South Africa and Uganda, no HIV infection. It’s not a low number. Zero.
HIV treatments have, in principle, become so effective that they now act as prophylaxis as well. HIV experts call it Undetectable is the same as Unpassable, or U=U. Inclusive studies more than 100,000 acts of sex without a condom where one partner has HIV and the other has zero infection. This means that a person living with suppressed HIV cannot transmit the virus sexually, which is a step towards reversing the once feared disease and further reducing the epidemic. And these tools can work at scale: SEARCH test it showed that community health workers in rural areas in Kenya and Uganda, with smartphone apps and the ability to provide life-prolonging treatment immediately to anyone who gets infected, reduce new infections by 70 percent.
Turbulence that can kill
And yet, more than 630,000 people they are still dying of AIDS every year – about one every minute. Some 9.2 million people who need treatment are still not receiving it. Children are worst off: only 55 percent of those under 14 with HIV are receiving treatment, compared to 78 percent of adults. And the burden of this epidemic falls on the most marginalized: sex workers, men who have sex with men, people who inject drugs, and transgender people now account for more than 55 percent of all new infections worldwide – from 44 percent in 2010.
Two thirds of all people living with HIV located in the South of the Sahara Desertwhere external funding funds nearly 80 percent of prevention programs. That has left them vulnerable as the global HIV response faces its biggest funding threat in decades.
PEPFAR’s statutory authorization expired in March 2025 without the approval of the parliament. A January 2025 cease-and-desist order halted the program worldwide. Efficiency the dissolution of USAID – with 90 percent of contracts canceled – has destroyed the software infrastructure. The effectiveness of UNAIDS suggests that if this disruption is sustained, the result could be more than 6 million infections and another 4 million deaths by 2029. Only South Africa has already been laid off about 8,000 health workers due to funding cuts.
And the threat isn’t just overseas: More than 20 US states are now taking note cuts to the AIDS Drug Assistance Programa safety net that covers a quarter of all Americans living with HIV – including Florida, where 16,000 people lost their vaccinations shortly before the emergency fix that only lasts through the summer. A recent Johns Hopkins study estimated that removing major software laws could increase new infections in America’s largest cities by nearly 50 percent by 2030.
For the first time in the 45-year history of this epidemic, we have effective tools to stop it: drugs, pills and injections that prevent, even the hope of a possible vaccine. The gap between where we are and where we need to be is no longer a matter of science. It’s a matter of money and political will — the same forces that, two decades ago, helped produce the most effective global health program in American history.
The story of HIV is the story of what humanity can accomplish when it decides something important enough. We have made that decision before. The question is whether we will do it again.
A version of this story originally appeared in Habari Njema magazine. Register here!
