The 2030 Countdown to reduce new HIV infections by 90% is at risk
In 2019, the U.S. federal government launched the Ending the HIV Epidemic (EHE) initiative, aiming to reduce new HIV infections by 90% by 2030. This year’s U.S. Conference on HIV and AIDS (USCHA), focused on aging with HIV, marked not only the five-year milestone since the initiative’s launch but also the halfway point to the 2030 target. That goal could remain within reach if scientific breakthroughs such as long-acting injectable treatment and PrEP are made widely available; if community-based delivery models expand to offer safer and more affirming access points; and if syndemic frameworks advance to reflect the complexity of HIV risk.
Yet this year’s USCHA carried a sharper sense of urgency. Amid a shifting political landscape, the HIV community confronted the fragility of its progress and the risk of regression from the 2030 milestone. If past decades were defined by discovery and innovation, the next five years must be about adaptability, coordination, and resistance to ensure the multi-generational HIV community not only survives but thrives. The standing-room-only policy sessions underscored that urgency: advocates are preparing to lead another movement, one focused on defending hard-won gains and ensuring scientific innovation becomes lived success.
An evolving policy environment is challenging the HIV care landscape
The federal budget remains the most pressing policy battleground for HIV programs. While FY2025 appropriations largely maintained level funding, program freezes and reductions in federal HIV staff mean stability is no longer guaranteed. Cuts have already materialized in the form of canceled HIV research grants. The pause in early 2025 of U.S. foreign assistance through the President’s Emergency Plan for AIDS Relief (PEPFAR) led to immediate global declines in testing, prevention and treatment access abroad. Domestically, HIV programs face risks to their structure and funding; House proposals for FY2026 target core HIV initiatives, including eliminating nearly $2 billion for EHE, Ryan White Parts C–F, and the Minority HIV/AIDS Program. Communities have historically relied on these appropriated dollars for sustaining frontline HIV services, including testing, prevention, treatment, and wraparound support programs that would otherwise be inaccessible without federal investment.
The work of the Ryan White HIV/AIDS Program is critical as it serves a majority of people aging with HIV and supports over 500,000 in the HIV community. Safeguarding the strong infrastructure of clinical and support services built by the Ryan White Program requires more than preserving its budget; it demands adapting services to address evolving needs such as long-term care, housing stability, mental health support, and geriatric expertise. Without this evolution, the promise of innovation risks being outpaced by the reality of unmet needs.
These policy shifts mean advocacy must continue to build Congressional and presidential support for the HIV response. Yet, funding is too often under-supported for advocacy and for educating policy makers on the cost effectiveness of HIV prevention, treatment and care. Adequate appropriation levels for maintaining our HIV response and legislation that affirms and supports people living with and vulnerable to HIV will not happen without robust community advocacy.
Lived impact: from community to individual
Federal policy sets the stage, but access is ultimately experienced in the community and affects the lives of individuals. Community-based organizations and peer networks have long led the response to ensure individuals find their way to trusted entry points to care. Syringe service programs connect clients to testing, PrEP and HIV care, while peer navigators help instill confidence among those previously excluded from health systems. These models are essential, but their stability depends largely on federal funding. As policy shifts and federal HIV budgets are reduced, community organizations that have sustained access for decades will be forced to scale back or close, leaving fewer safe and reliable pathways to prevention and treatment. States will need to understand their populations’ needs and work with community organizations to ensure access is not scaled back or lost, so that safe and reliable pathways to prevention and treatment remain.
For individuals, this instability translates into real consequences. People aging with HIV, many managing multiple chronic conditions, face growing challenges with housing, geriatric care, and mental health. Younger people considering prevention often encounter cost barriers, stigma, or provider bias that place innovation out of reach. Recent declines in testing and treatment initiation signal how quickly policy uncertainty can ripple down to daily life.
The result is a dual burden: communities absorbing financial shocks while individuals shoulder the cost of disrupted care. Success cannot be measured solely by the existence of new biomedical tools. It must be measured by whether those tools are consistently reaching those in need and delivered in ways that people can trust and use.
Call to Action: Building financial resilience for the HIV response
At USCHA, the urgency was unmistakable: defending existing federal funding is necessary but is not sufficient alone. The conversation must be widened and new supporters and funders involved. HIV response must also pursue innovative financial models that can withstand political volatility and ensure the promise of innovation reaches people’s lives. Several approaches already show promise:
Integration of HIV funding within public health and insurance systems
Federal appropriations remain the backbone of the U.S. response, but long-term resilience requires stronger roles for Medicaid, Medicare, and state budgets. Medicaid already covers about 40 percent of people living with HIV in the U.S., and states that expanded Medicaid eligibility have reported higher rates of viral suppression compared to those that have not. However, new Medicaid requirements may put many living with and vulnerable to HIV at risk of losing coverage. State-level commitments such as New York’s Ending the Epidemic initiative and California’s PrEP Assistance Program demonstrate how targeted investments can expand access beyond what federal dollars alone could support. Yet, several states in the South where the HIV epidemic is severe put no state funding into their state’s HIV response. As more than half of people living with HIV are now over age 50, Medicare is also becoming central to care, yet its structures were not designed for long-term HIV management. Embedding HIV supportive strategies into Medicaid, Medicare, and into broader chronic care frameworks will help ensure that HIV prevention and treatment are protected from political swings and aligned with the realities of the most vulnerable and people aging with HIV.
Innovative Financing mechanisms
Globally, blended financing has combined donor grants with loans and private capital to sustain HIV programs. In the U.S., a parallel approach could mean pooling resources from domestic donors, pharmaceutical companies, social investors, and philanthropic foundations into shared investment vehicles. These funds could help maintain core HIV care and prevention structures and help underwrite fragile community-based services such as syringe service programs, peer navigation, and mobile clinics and other non-traditional site clinics that are vulnerable to federal cuts but are central to providing equitable access. Beyond philanthropy, partnering with social investment organizations could support more sustainable financing structures, using debt or equity models, that incentivize business growth while channeling returns into HIV services.
Private sector and workplace health partnerships
Employer-based health schemes have been leveraged globally to expand HIV services, particularly in high-burden countries with corporate workforces. In the U.S., similar opportunities exist through insurers and employers. Despite ACA coverage requirements, barriers such as co-pays and prior authorization continue to limit PrEP uptake. Currently only one in three who could benefit are on it, with uptake lowest among Black and Latino MSM. Employers and insurers could help close this gap by promoting and assuring the availability of their HIV prevention benefits and expanding their partnerships with community-led providers. Models already exist such as Walgreens’ partnerships with community organizations to expand HIV testing, and multinational corporations embedding HIV services in employee health packages. Scaling these approaches could reduce reliance on federal programs for working-age adults and normalize HIV prevention and treatment as standard care.
Together, these models point toward a more resilient financing backbone for the HIV response. The lesson from USCHA is clear: progress cannot hinge solely on federal appropriations. To thrive toward and beyond 2030, the HIV community must continue its advocacy and embrace a diversified financing strategy that blends public, private, and community-driven resources to protect individuals and sustain access, no matter the policy climate.