Rio and the Reckoning: HIV, Health Equity, and the Trump Era
As the world gathers for AIDS 2026 in Brazil, debates over funding, Medicaid, NIH research cuts, PrEP access, antiretroviral therapy (ART), and social justice underscore a pivotal moment in the global
By Robert Antonacci, M.D, David A. Miller, Jodi Sahlin and Felipe Recalde
When thousands of scientists, activists, policymakers, healthcare workers, and people living with HIV/AIDS (PLWHA) gather in Rio de Janeiro this July for AIDS 2026, the 26th International AIDS Conference, they will do so against the backdrop of one of the most uncertain periods in the modern history of the HIV response.
The conference theme—Rethink. Rebuild. Rise.—captures a growing concern shared by researchers and advocates worldwide: progress against HIV is no longer guaranteed. Funding pressures, political polarization, healthcare inequities, and threats to public health infrastructure are forcing governments and communities to confront difficult questions about the future of prevention, treatment, and care.
The global HIV movement spent four decades transforming what was once a near-certain death sentence into a manageable chronic condition for millions. Yet the benefits of scientific progress remain unevenly distributed. As delegates arrive in Rio, the central question will not be whether the science exists to end the epidemic, but whether political systems are willing to deliver that science equitably.
One of the most pressing concerns heading into the conference is the growing instability of HIV funding worldwide.
Advocates and public health leaders have raised alarms about reductions in HIV program funding and uncertainty surrounding future commitments from major donors. These concerns are especially acute in low- and middle-income countries where treatment programs often depend on a combination of domestic spending and international assistance.
The consequences are not theoretical. Interruptions in prevention services, testing programs, outreach efforts, and medication access can quickly reverse years of progress. HIV remains a disease deeply tied to social determinants of health, meaning that cuts to housing support, mental health services, transportation assistance, and community-based care often have a direct impact on treatment outcomes.
Beyond concerns about treatment access and prevention programs,researchers at AIDS 2026 will be focused on a less visible but equally consequential issue: the future of HIV research itself.
Recent reductions and proposed constraints on federal biomedical research funding have raised alarms throughout the HIV scientific community. Funding pressures affecting the National Institutes of Health (NIH), which has long served as the cornerstone of HIV research in the United States and a major driver of global HIV scientific progress.
For decades, NIH investigators produced the breakthroughs that transformed HIV from a fatal disease into a manageable chronic condition. These investments have supportedl ART drug development and viral load monitoring to advances in prevention,vaccine research, and cure strategies.
Researchers warned funding instability threatens both basic science and clinical research infrastructure. Basic HIV research often requires years of sustained investment before practical applications emerge. Discoveries involving viral replication, immune function, viral reservoirs, and drug resistance have formed the foundation of modern HIV treatment.
Among the most significant concerns is the future of the AIDS Clinical Trials Group (ACTG), one of the world’s premier HIV clinical research networks. For nearly four decades, ACTG investigators have conducted many of the landmark studies that established today’s standards of HIV care. The network has been instrumental in evaluating new therapies, optimizing treatment strategies, addressing HIV-associated comorbidities, and improving care for women, children, and the aged with PLWHA..
Scientists argue that weakening support for networks such as ACTG could slow innovation precisely when new opportunities are emerging. Long-acting injectable therapies, broadly neutralizing antibodies, HIV cure research, and next-generation prevention technologies all depend upon robust clinical trial infrastructure and sustained federal investment.
The implications extend beyond HIV. The research platforms developed through decades of HIV funding have repeatedly been leveraged to address other infectious disease threats, including COVID-19, mpox, tuberculosis, hpv, syphilis, and emerging pathogens. Many experts view HIV research funding not simply as an investment in one disease, but as a cornerstone of the broader biomedical research ecosystem
The history of HIV has always been inseparable from questions of human rights and social justice. From the earliest years of the epidemic, marginalized communities carried a disproportionate burden of infection while simultaneously facing discrimination, stigma, and inadequate access to healthcare. Those inequities persist today.
Globally, gay and bisexual men, transgender individuals, sex workers, people who use drugs, incarcerated populations, veterans, migrants, and racial and ethnic minorities continue to experience higher rates of HIV infection and barriers to care. In many countries, criminalization and discriminatory policies discourage people from seeking testing or treatment.
Advocates attending the conference are expected to emphasize that ending HIV requires more than biomedical innovation. It requires dismantling structural barriers that prevent people from accessing care in the first place.
Housing instability, food insecurity, poverty, and lack of insurance coverage remain powerful predictors of HIV outcomes. Even the most effective medications cannot achieve their full impact when patients are unable to maintain stable housing, obtain transportation, or access culturally competent healthcare.
Although the conference is international in scope, domestic policy debates in the United States are likely to receive significant attention.
For PLWHA in the US, Medicaid is the nation’s most important source of healthcare. Medicaid finances physician visits, laboratory monitoring, mental health services, prescription drugs, and supportive services that help patients remain engaged in care. Among the most consequential is the ongoing discussion surrounding Medicaideligibility formulas, enrollment requirements, or funding mechanisms.Even modest barriers to enrollment can lead to treatment interruptions, delayed diagnoses, and reduced access to preventive services.
Beyond PLWHA. Medicaid also supports access to pre-exposure prophylaxis (PrEP), one of the most effective HIV prevention tools available. Consistent PrEP access requires regular physician visits, laboratory testing, and prescription coverage. Reductions in coverage could disproportionately affect low-income communities already facing elevated HIV risk.
Access to ARV’s is also affected. ARV’s have transformed life expectancy and quality of life for millions, but uninterrupted access remains essential. Coverage disruptions can lead to viral rebound, increased transmission risk, and the emergence of drug resistance.
Although the conference is international in scope, domestic policy debates in the United States are also likely to receive significant attention.
For the approximately 1.2 million Americans living with HIV, Medicaid remains one of the nation’s most important sources of healthcare coverage. Medicaid finances physician visits, laboratory monitoring, mental health services, prescription drugs, and supportive services that help patients remain engaged in care. Proposed changes involving Medicaid eligibility formulas, enrollment requirements, or funding mechanisms have generated concern among HIV advocates, who note that even modest barriers to enrollment can lead to treatment interruptions, delayed diagnoses, and reduced access to preventive services.
Beyond people living with HIV, Medicaid also supports access to pre-exposure prophylaxis (PrEP), one of the most effective HIV prevention tools available. Consistent PrEP access requires regular physician visits, laboratory testing, and prescription coverage. Reductions in coverage could disproportionately affect low-income communities already facing elevated HIV risk.
Advocates are also closely monitoring the future of the Ryan White HIV/AIDS Program, which serves as the nation’s safety net for people living with HIV who are uninsured or underinsured. Established in 1990, the program currently receives approximately $2.6 billion in federal funding and provides medical care, medications, case management, and support services to more than half of Americans diagnosed with HIV each year. Ryan White-funded programs frequently work alongside Medicaid and local healthcare providers to help patients remain engaged in treatment and achieve viral suppression.
While no specific reductions have been enacted, public health organizations warn that broader efforts to reduce domestic discretionary spending could place Ryan White funding under pressure. Depending on the scope of future federal budget reductions, cuts ranging from 5% to 20% could translate into losses of roughly $130 million to more than $500 million annually. Advocates argue that reductions of that magnitude could weaken AIDS Drug Assistance Programs (ADAP), medical case management, and support services that help vulnerable patients remain connected to care.
Access to antiretroviral therapy (ART) is similarly dependent on stable healthcare coverage. ART has transformed life expectancy and quality of life for millions, but uninterrupted access remains essential. Coverage disruptions can lead to viral rebound, increased transmission risk, and the emergence of drug-resistant virus. As policymakers debate healthcare spending priorities, advocates are expected to emphasize that maintaining continuous access to treatment remains one of the most cost-effective and successful public health interventions ever developed.
Despite the policy concerns dominating headlines, AIDS 2026 will also highlight remarkable scientific achievements.
Another current federal policy changes include rescheduling of medical cannabis in the US which has renewed conversations about cannabis access for PLWHA. While medical cannabis is not a treatment for HIV itself, some patients use cannabis-based products to help manage chronic pain, nausea, appetite loss, sleep disturbances, and anxiety.
Advocates argue that rescheduling will facilitate rigorous research and create a more consistent regulatory framework for evaluating therapeutic uses. For many patients living with chronic illness, the issue is less about politics than about access to evidence-based options that may improve quality of life.
Despite the policy concerns dominating headlines, AIDS 2026 will also highlight remarkable scientific achievements.
Long-acting injectable therapies continue to reshape HIV treatment and prevention. Researchers are advancing studies involving broadly neutralizing antibodies andnext-generation prevention tools, vaccine candidates, and potential cure strategies.
Yet conference participants are likely to return repeatedly to a familiar lesson: scientific breakthroughs matter only when people can access them. The gap between discovery and delivery remains one of the defining challenges of global health.
The choice of Rio de Janeiro as host city is resonating in the public health sector
Brazil has long been recognized as a global leader in HIV policy, particularly for its commitment to broad access to ART. Its public health system has frequently been cited as an example of how political commitment can expand access even in resource-constrained settings.
Hosting the conference in Brazil highlights the growing importance of perspectives from the Global South. HIV advocates argue that contemporary HIV challenges must increasingly emerge from communities directly affected by the epidemic rather than being dictated solely by wealthier nations.
Every major breakthrough in prevention, treatment, and care emerged because scientists, activists, patients, and communities refused to accept the status quo. AIDS 2026 arrives at a moment when innovation is once again required.
The challenge facing the global HIV movement is not merely scientific. It is political, economic, and moral. Clinicians possess tools capable of dramatically reducing new infections. What remains uncertain is whether governments and institutions will commit the resources necessary to ensure those tools reach everyone who needs them.
As delegates gather in Rio, they will confront a question that has echoed throughout the history of the epidemic: who gets access to care, and when?
The answer will shape not only the future of HIV policy but also the broader global conversation about health equity, human rights, and social justice in the years ahead.
About the Authors
Robert Antonacci, M.D. is a physician, healthcare executive, and public health advocate whose work focuses on healthcare innovation, population health, and improving access to care. He has written extensively on health policy, infectious diseases, and strategies to advance equitable healthcare delivery in the United States and globally.
David A. Miller is an AIDS treatment activist and journalist focused on HIV aging, coinfections, emerging therapies, and policy issues affecting people living with HIV (PLWH). He is the former Co-Chair of the Cornell AIDS Clinical Trials Group Community Advisory Board and has served as Co-Chair of the New York City HIV Planning Council Community Advocacy Group. Miller has also served on the Board of the AIDS Institute and the Bronx HIV CARE Network. A veteran of ACT UP New York, his work emphasizes the intersection of science, access to care, and quality of life for PLWH. He is a member of the International AIDS Society, the American Public Health Association, the International Association of Providers of AIDS Care, the National Minority AIDS Council, the HIV Medicine Association, and the American College of Epidemiology.
Felipe Recalde is a global health advocate and communications strategist whose work centers on health equity, international healthcare policy, patient engagement, and expanding access to evidence-based healthcare. His writing and advocacy focus on strengthening healthcare systems and advancing equitable health outcomes worldwide.