Nicknamed "Liberation Day" by the White House, April 2, 2025 has not only featured a slew of new tariffs, but also mass layoffs and funding cuts at the Department of Health and Human Services. Chris Beyrer, MD, MPH, the director of the Duke Global Health Institute, in Durham, N.C., spoke to Infectious Disease Special Edition about the impacts of these policy changes, specifically on the trajectory of HIV research—the subject of his talk at CROI 2025.
This story has been updated to correct a date; the "Liberation Day" is April 2, not April 1.
This transcription was made with Temi.
Meaghan Lee Callaghan: [I heard] you were having a bad morning?
Chris Beyrer, MD, MPH: Yeah, we've just seen an updated list of the grants and contracts that have been recently canceled. Specifically speaking about the NIH, the National Institutes of Health. This has been going on for some weeks now. We expected that it was going to accelerate once the new NIH director had been named and Dr. Charia has been named, and he has been confirmed, but he has, as far as I know, not been sworn in yet, but nevertheless, the acting director has been very actively cutting a number of grants and contracts.
On the list that I saw this morning is the HIV Prevention Trial Network. That's the Leadership and Operations Center. That's the main NIH network that does HIV prevention trials, primary prevention trials, and has led some of the most important trials in our field.
The absolutely classic HPTN-O52, which showed that in discordant couples—where one person, either the man or the woman was living with virus, and the other was not—that if the partner was virally suppressed, there was a significant reduction in transmission. That trial led to the whole idea of treatment as prevention, and it was an absolute watershed in the field. This is also the network that did the first trial of the long-acting injectable PrEP agent, CAB-LA, long-acting cabotegravir, very much perceived to be one of the major advances moving this field forward.
They also collaborated and participated with the HIV the HIV Vaccine Trials Network, the HVTN on the first large studies of broadly neutralizing antibodies, the AMP trials. So, this has been a super important network that has made really, really substantial advances in HIV prevention, and it is on the list of terminated grants.
I am on the executive committee of the network, and so I had a leadership award through that. And I'm also the co-chair of a large HPTN trial, HPTN-O96 with my co-chair, Laron Nelson at Yale. That study is officially on pause, but if indeed the [Letters of Collaboration (LOC)] has been terminated then it makes it extremely difficult to think about how we would be able to get that study off pause and carry it forward. In addition, a number of studies and trials have been stopped or on the list for termination from what was called the Covid Vaccine Prevention Network, the COVPN and the COVPN was, again, an incredibly important network that was stood up very quickly by NIAID and some of the other NIH institutes as part of Operation Warp Speed.
I worked on it as an epidemiologist, and of course, this network did the extraordinary achievement of conducting five COVID-19 vaccine trials with 30,000 American volunteers each in less than a year. And that delivered us all out of the COVID-19 pandemic. The first trial we did was the Moderna mRNA [vaccine]. So I've continued to be an investigator on that network. I remain, as so many of us who worked on it, just incredibly proud of that achievement.
The current leadership of the NIH and their colleagues, particularly people associated with the Great Barrington Declaration, which includes the incoming NIH director, consider the NIH response to Covid to have been a failure. And I think that is a an absolutely false narrative. It undermines the extraordinary achievements of so many people, and it flies in the face of the evidence, which is that the mRNA vaccines were safe and effective and helped deliver us out of the most severe pandemic since the great influenza of 1918. That is a matter of history. We all saw it. We watched it unfold and no attempt at fictitious narratives can undermine that achievement in my view.
MLC: What do you think you're going do moving forward?
CB: Well, I'm most concerned about junior colleagues. Someone like myself, I have a senior leadership position here at Duke University. I have an endowed professorship. I'm the Gary Hock Distinguished Professor in Global Infectious Diseases. Those are the kinds of things that allow people who are more senior in our field to weather these kinds of storms. What we're much more concerned about, of course, is people, early stage career investigators, people really just beginning their research careers. People who want, for example, to have a research career and [try to answer] some of the great unanswered questions. We don't have an HIV vaccine. We don't have a functional cure. We have no way of sustainably inducing remission in HIV infection. So, we're still in a place where we essentially have a commitment, although the United States is backing away from that commitment to treat some almost 40 million people worldwide over the next many decades with daily oral therapy. We need a vaccine and we need a cure.
And so, I think those are the two great remaining research areas in the HIV field. And you know, the people who've been at this for a long time, like myself, are an aging cohort. And we really have been, all of us have been engaged in nurturing new talent and getting people into the field. And the NIH funding has been essential to do that. It's been absolutely essential to ensuring that people with fresh ideas and new energy have the resources they need to make the breakthroughs.
MLC: Totally. Unless there's something else you wanted to say about this, it does kind of segue into talking about your talk that you gave at CROI 2025. Because you, unless I'm wrong, you were looking at the future of HIV. So, did you have to change your talk a little bit as you were going along?
BC: I have never had a talk and I've done a number of plenaries at a number of international conferences, and, and it's always an honor to be asked, and, you know, you're, you're asked well in advance. So I think the invitation from the organizers came in August of 2024. And at the time, my focus was really to, because 2025 was looming and coming, and was the year that we were supposed to have meddled these targets on reductions in AIDS deaths on reductions in new infections in particular I, I felt that it was very important to interrogate all the available data and really say, okay, are we on this trajectory? And are we in fact approaching what had been declared and accepted as the political goal globally with the WHO and UN AIDS and most other governments, which was to end AIDS as a public health threat by 2030.
You have milestones to meet by 2025 if you're going be on that trajectory, and what the data were showing clearly. And that was sort of the first part of my talk at CROI, was, no, we were not on a trajectory. We were supposed to be under half a million new infections. We were over 1.3 million. So at that rate, you're just adding to the treatment burden. The second thing that we looked at then was the effectiveness of prep and how much pre-exposure prophylaxis we're going have to do if we really wanted to use PrEP to accelerate HIV control. And the numbers very quickly get enormous. So a part of my message was, at least with the current tools, we are not going be able to ‘PrEP’ our way out of this epidemic, and we're not going be able to treat our way out of this epidemic.
We really have to focus in a major way on primary prevention. Then of course, PEPFAR is put on pause and all of prevention is still on pause, except for prevention of mother to child transmission. The only allowable use of pre-exposure prophylaxis is for pregnant and lactating women in the PEPFAR-focused countries. So everybody else, men who have sex with men, trans women, sex workers, heterosexual men, heterosexual women who are not pregnant or breastfeeding, but at risk, all those people had to stop PrEP or find another way to get it paid. So yes, I had to constantly be adapting because you can't really be in a position of calling for a major reinvestment in primary prevention when prevention itself is being gutted.
MLC: The one last thing that I've been thinking of, so all of these cuts, pauses, whatnot—the whole foundational changes that seem to be going on [the current administration’s] idea, I believe, if I'm following, that private industry, private charities or other countries would come in to fill the void. Could you comment about that and how you could see that happening or not happening?
BC: Well, first, in regards other countries, unfortunately, what we're seeing is that the U.S. is not alone in reducing overseas development aid, and particularly in global health. The U.K. has been cutting back—not as publicly and not as sort of a political agenda, but largely because of their own economic challenges related to Brexit and also related to security. France and Germany are also cutting back and those three are the largest donors after the U.S. So overall there are cuts happening across the board for Germany and France. Of course, this again, is because they are under renewed pressure and their own internal pressure to spend more on defense. And that is because obviously of the ground war in Europe, which, you know, we have not had. The Russian invasion of Ukraine really changed that dynamic.
So there's no question that we are not alone in reducing these expenditures. As for the market—private companies and foundations—I think foundations have been very involved in global health, but all of the foundations, including very big ones like Gates, will tell you that foundations and philanthropy cannot replace the federal government; that is too tall in order. [However,] they can cover some very important priority areas. As far as the market goes, I think the fundamental problem there has been and always will be that the private sector is market driven. And in global health, we are driven by a deep commitment to serve the least among us. And that's not how markets work. We're very concerned in global health about the bottom billionth, the people who live on our planet on less than $2 a day.
And there's never going be a great market incentive to provide healthcare to those people, to immunize their children, to ensure that those women have a skilled attendant at birth—which they don't, to ensure that they have access to a toilet, which so many people do not in our world. And those kinds of very, very basic and fundamental aspects can't be left to the market unless we want live in a truly cruel world and go back to a kind of medieval world where the poorest among us have just no access to healthcare. I think that is not a world that any of us want to live in.
MLC: I think that's very well said. Is there anything that I didn't ask you? I mean, there were a lot of things I didn't ask you.
BC: I guess I would say that at this particular moment, it is very hard to see what the future is going to look like. The level of uncertainty is extremely high. What I do know is that the research community and the academic community, the scientific community is full of the most committed, talented, gifted people I have ever known or worked with. And so I take my solace from the fact that this is a resilient community and if anybody can survive this and continue to do the work that we all know we need to do—it's this community.
MLC: Thank you so much for your time.
BC: Been a pleasure talking with you, Meaghan.