In a clinic in Cape Town earlier this year, a woman rolled up her sleeve and became the first person enrolled in what is one of the most consequential HIV treatment trials ever attempted on African soil.
The researchers watching had spent the better part of a year wondering if this moment would ever come. Fourteen months earlier, the programme – known as BRILLIANT 011, the flagship of an Africa-led consortium of scientists researching a potential HIV vaccine had been days from its original launch when a stop-work order arrived from Washington. Part of Donald Trump’s attempts to slash US aid funding when he returned to the White House, the project ended almost overnight. The $45 million (£33m) grant from the United States Agency for International Development (USAID) that had made the whole thing possible was cancelled. The trial was over before it had begun.
Except it wasn’t. Thanks to a combination of South African government funding, backing from the Gates Foundation (who also provide funding for The Independent’s Rethinking Global Aid project) and the Wellcome Trust – totalling around $33m – the BRILLIANT Consortium rebuilt and the trial is now running.
In her lab in Johannesburg – full of equipment bought with American money, each piece bearing a sticker that reads: “From the American People” – Penny Moore, a virologist at the University of the Witwatersrand working on the trials, explains the knock-on effect of the trial being stopped, even if it has now restarted. “We rely on scientists in the US and across Europe,” she tells The Independent. “Getting reagents from those labs… people who are no longer encouraged to engage with us here in South Africa… has really slowed us down. The training network that got a generation of African scientists to the same level came to an abrupt halt.” She was lucky not to have laid anyone in her lab off, Moore adds, but she is “in the minority” on that.
The stoppage also compounded the difficulties of getting a trial off the ground. “The trials are so difficult to set up, so slow to set up,” Moore says. “Starting and stopping costs far more than you would think, because every new trial needs regulatory approval… so you move sites and you need to restart. That has cost my consortium a whole year.”
‘Every element is slower than I wish it were’
That tension between genuine scientific momentum and the fragility of the systems around it currently runs through the entire global HIV ecosystem. A thousand miles away, in Uganda, a mother living with HIV, who wishes to stay anonymous, describes a different version of the same collapse. She has HIV and by what she calls “God’s grace”, her child does not. She says: “After [Trump’s] aid cuts, I went a long time without my antiretrovirals. It was risking my life and my child’s life. These days we don’t get any follow-up care. We are trying to find where we can and what we can do.”
This is the distance between a scientific breakthrough and its impact, measured not in dollars or agreements, but in a mother rationing antiretrovirals in Kabale while researchers in Johannesburg push to complete a trial around a vaccine that might, one day, mean neither of them has to worry.
The vaccine BRILLIANT 011 is testing works by training the immune system to recognise HIV in a way it would never manage on its own. The virus mutates constantly. Moore describes it as making “every mistake it can, every single day” – which means a conventional vaccine targeting one version of the virus would quickly become useless.
The goal instead is to produce broadly neutralising antibodies which are immune cells powerful enough to recognise HIV strains from across the world, including ones that don’t yet exist. Getting there means one vaccine to activate rare immune precursors, then another to push those cells further, then another, each shot nudging the immune system down a path it wouldn’t find by itself.
“We have vaccinated the first seven”, Moore continues, “It will take a while to get any data on those people and when you get to the business of a sequential vaccine, we don’t yet know what the second will be as we have to wait for preclinical data to catch up and present to the regulator to say: ‘this is what we think the booster will be.’” She pauses, before continuing: “Every element is slower than I wish it were. Always good reasons. But it does mean progress can be slow.”
Africa remains the epicentre of HIV and the continent carries viral strains largely absent from global research. Moore continues: “In South Africa we can go from sequencing a virus to testing in mice and then in larger primates and then humans. Other countries on the continent don’t have that access. USAID were funding every gap in that pipeline… well, not a vast, never-ending budget, but at least making inroads. So yes, now you can really hear how frustrated I am that it’s [the funding] gone… All parts of this vaccine ecosystem are fragile. The clinical trials are the least fragile and they’re in trouble.”
Moore is keen to highlight how everything we know about how the human immune system responds to vaccines has been drawn from white European populations. Her work has exposed how significant that gap is. She says: “South African populations are completely uncharacterised. Everything comes from white Europeans and when we sequenced samples from around thirty people in one small province here, we saw a huge level of genetic diversity which is absent from all databases. There is also equity around making sure these vaccines will actually work in the populations where they’re needed – not just in European and American bodies.”
‘Living life to the full’
At the same moment as the vaccine trial is finding its feet, another breakthrough is being rolled in a number of nations in southern Africa. It offers a drug so effective and so simple that it could plausibly change the course of the epidemic. But that hinges on the systems existing to deliver it and across the region, those systems are in trouble.
It involves lenacapavir, a twice-yearly preventative jab which provides near-total protection from developing the virus. It has been described as the nearest thing we have to an HIV vaccine – and a crucial tool for ending the HIV/AIDs pandemic.
In a dusty field on the outskirts of Zimbabwe’s capital this week, young women queued in the morning heat for the jab. They were among the first people in the world to receive lenacapavir as a public health programme. Some held babies, while others had travelled for hours.
In sub-Saharan Africa, women and girls accounted for 63 per cent of all new HIV infections in 2024, concentrated overwhelmingly in adolescents and young women who are not scheduling clinic appointments. “It’s that period in young people’s lives where you feel invincible, living life to the full and not thinking about dangers”, Professor Quarraisha Abdool Karim, who helped develop the proof of concept behind PrEP – a daily pill taken to prevent contracting HIV – says. She continues: “Experimentation, passion, discovering sex and having relationships – that’s the period where young people across the world do that. And in sub-Saharan Africa, new HIV infections come with that.”
For sex workers who have never managed to take a daily pill of PrEP without someone noticing, or a teenage girl who isn’t sure she’s at risk anyway, there is suddenly a version of prevention that fits into a real life. Zimbabwe’s health minister Douglas Mombeshora said at the launch: “Prevention must fit into real life. If a health solution is too complicated, too demanding, or too visible, people simply won’t use it.”
In September, a deal between the Clinton Health Access Initiative, the Gates Foundation and other partners promised to make lenacapavir available at $40 per person per year across 120 low and middle-income countries. Marking a price reduction of more than 99 per cent from its US launch cost.
One of the major upsides of Lenacapavir is that it only needs to be given twice a year, making community delivery through mobile services, and venues where young people actually are more realistic. Professor Karim says: ”If we are more creative and do delivery through mobile service infrastructure, then we have the potential to make a bigger difference. Clinic access and other venue access could be the game-changer tipping point we need so badly.”
The mother in Uganda knows exactly what that kind of outreach used to mean, saying: “We mothers wish there was community or mobile outreach. They used to teach us how to prepare food for our babies and there were group sessions to share thoughts and concerns.” Those sessions are gone. So is the follow-up care, the support workers and the routine visits that kept women like her on their medication.
‘A transformative tool’
In Kabale, western Uganda, Ismail Harerimana, a community health worker who lost his job when USAID was dismantled and now volunteers without pay, describes the disruption from the inside. He was born with HIV and grew up in the programmes that kept him alive. The clinic where he works once had 3,000 patients and a full team of doctors, nurses and cleaners – all funded through USAID.
When Trump’s stop-work orders came in January 2025, with no warning, they all had to leave, he tells The Independent: “Our clinic had 3,000 patients we had to support and all of them were left with no one to attend to them. Authorities sent doctors who were experts in malaria, but not HIV. People received wrong medicines. People died. When I look at the data of how many have died in my region, in this period… we have lost so many children.”
Rachel Bonnifield, who tracks scientific and financing transitions in global health at the Centre for Global Development, says a worry of hers is HIV prevention for the populations governments have the least political incentive to reach “Programmes are focused on key populations – sex workers, transgender people and gay men – which are politically sensitive.” she says. “There are high rates of HIV in these communities and governments are less eager to serve them.”
Antonio Flores, a senior HIV advisor at Médecins Sans Frontières (MSF), says that even lenacapavir’s licensing deal which is valued as a model of access, leaves gaps. He says: “Regions with significant HIV incidence, like Eastern Europe, Central Asia and most of Latin America, remain entirely outside licensing agreements. Seventeen low and middle-income countries representing an estimated 20 per cent of new HIV infections are excluded.”
It is hoped generic versions will be available sometime in 2027, but until then the global supply depends on a single company. Flores continues: “Lenacapavir demonstrates that scientific breakthroughs do not translate to equitable access without deliberate policy measures. Tools meant to end epidemics cannot be treated as luxury commodities.”
Carolyn Amole, vice president for HIV at the Clinton Health Access Initiative, described lenacapavir as a watershed moment in prevention science. “Lenacapavir is the most significant breakthrough in HIV prevention in history. For the first time, the end of HIV transmission feels not just aspirational but achievable,” she says.
After travelling last week to Zambia and Kenya, Amole says she has seen both political readiness and strong public demand to scale up access. She adds: “Governments have the leadership and vision to scale this product to those who need it.” But affordability alone will not guarantee impact without “coordinated investment” in rollout planning and delivery,
She warns that without that “even the most transformative tool will sit on the shelf.”
In her Johannesburg lab, Moore is also optimistic, but is acutely aware of the work that needs to be done. “The field of HIV/AIDS research] feels like it has made more progress in the last five years than we had for a while,” she says. “But we still acknowledge there is a long way to go.”
This article has been produced as part of The Independent’s Rethinking Global Aid project
