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March 20, 2025 · 19 min read

TGEU POLICY BRIEF –  European leadership in global HIV response: Urgent action to safeguard HIV progress and strengthen trans-led healthcare initiatives

Executive summary

The European Union faces a critical moment requiring immediate action to assert its leadership in global healthcare equity and human rights. The recent disruption of international HIV funding streams has created an urgent need to protect essential healthcare services, particularly for trans communities worldwide (Médecins Sans Frontières, 2025; UNAIDS, 2025). The EU must act swiftly and decisively to prevent the collapse of vital trans-led HIV prevention, treatment, and care services while advancing its core values of healthcare access and human dignity.

In Eastern Europe and Central Asia (EECA), where HIV prevalence continues to rise, trans-led healthcare initiatives face immediate risks of service interruption. Without rapid intervention, decades of progress in harm reduction, ART access, and community-led healthcare could be lost. The stakes are particularly high for trans sex workers, trans people in prison settings, trans people who use drugs, and trans migrants, asylum seekers, and refugees who rely on these essential services (GATE, 2025; Williams Institute, 2025).

The current funding crisis presents both an urgent challenge and a strategic opportunity for the EU to strengthen its role in global health governance. Immediate, robust action by the EU to sustain and expand support for trans-led HIV initiatives will not only prevent a humanitarian crisis but also demonstrate European leadership in protecting key populations and advancing public health goals. The time for EU action is now – delays in responding to this critical situation could result in irreversible damage to global HIV response infrastructure and trans communities’ health outcomes. 

Background: The role of US foreign aid in the global HIV response

Since 2003, PEPFAR and USAID have provided billions in funding to sustain HIV services globally, with PEPFAR alone saving over 25 million lives by investing more than US$100 billion in HIV programs and significantly expanding access to life-saving medications such as ART (antiretroviral therapy, which treats HIV, prevents disease progression, and reduces the viral load to undetectable levels, making the virus untransmittable to sexual partners—also known as U=U, or Undetectable = Untransmittable); PrEP (pre-exposure prophylaxis, a medication that prevents HIV infection in at-risk individuals); PEP (post-exposure prophylaxis, an emergency treatment to prevent HIV infection after potential exposure), and other services across the HIV continuum of care (UNAIDS, 2025; U.S. Department of Health & Human Services, 2024). ART has played a pivotal role in reducing AIDS-related complications by 60% to 80%, while PrEP has drastically lowered the risk of HIV infection among key populations by about 99% when taken as prescribed (CDC, 2023; PAHO, 2020). Finally, PEP has proven to be an essential tool in preventing HIV transmission following potential exposure, reducing the risk by more than 80% when started promptly and taken correctly (HIVinfo | NIH, 2023).

Simultaneously, USAID has been instrumental in implementing PEPFAR’s initiatives, allocating and committing approximately 60% of bilateral HIV/AIDS funding—totaling $2.5 billion in fiscal year 2023—to support essential HIV programs worldwide (Kaiser Family Foundation, 2023). This funding is formally obligated, meaning USAID enters into legally binding agreements to ensure the delivery of life-saving HIV prevention, treatment, and care programs (Médecins Sans Frontières, 2025). USAID’s work spans multiple interventions, including HIV testing and counseling, treatment access, prevention services for key populations, mother-to-child transmission prevention, and capacity-building for local healthcare systems (AIDSfonds, 2025). The agency also plays a crucial role in funding community-led HIV responses, harm reduction initiatives, and gender-based violence prevention programs, making it a key pillar of PEPFAR’s global impact (TGEU, 2025; ECOM & EHRA, 2025).

This funding was particularly vital for further marginalised trans people, including sex workers, people who use drugs, asylum seekers, refugees, those in prison settings, and trans feminine and trans masculine people who have sex with men. Some of these groups face significantly higher risks of contracting HIV, with trans feminine people being 66 times and trans masculine people 6.8 times more likely to acquire the virus compared to the general population. The estimated HIV prevalence stands at 19.9% among trans feminine people and 2.6% among trans masculine people (Stutterheim et al., 2021). Because these communities were already excluded from mainstream healthcare, many depended entirely on community-led initiatives for HIV prevention, testing, treatment, and support (Transgender Studies Quarterly, 2024). The loss of this funding has not only disrupted these essential services but has also further isolated these communities from life-saving care, exacerbating existing health disparities and increasing their vulnerability to HIV (GATE, 2025; Nature, 2025).

The freeze’s disproportionate impact on trans communities

The U.S. funding freeze has triggered the collapse of trans-specific HIV services worldwide, cutting off access to every stage of the HIV continuum of care and dismantling combination prevention strategies (ECOM & EHRA, 2025; GATE, 2025; Nature, 2025). This includes harm reduction programs, trans-specific healthcare, comprehensive sex education, psychosocial support, and other essential services—many of which are run by key-population-led organisations. Without sustained funding, stigma and discrimination in healthcare settings have worsened, further alienating trans people, especially those without legal gender recognition or valid identification documents, from accessing ART, PrEP, and PEP. As a result, the disruption of these services has heightened HIV transmission risks, restricted access to life-saving medications, and deepened systemic barriers to healthcare.

The executive order issued under President Trump, which froze U.S. humanitarian aid and specifically targeted programs supporting key populations, has had immediate and devastating consequences for HIV services worldwide (Williams Institute, 2025). Among the hardest-hit regions is Eastern Europe and Central Asia (EECA)—the area with the fastest-growing HIV epidemic outside the African continent (ECOM & EHRA, 2025). According to preliminary data provided by ECOM and EHRA, organisations impacted by the funding suspension reported varying levels of resilience based on their funding sources: while 46.15% relied on other donors and might have been able to mitigate some disruptions, 26.92% were directly funded by PEPFAR and 19.23% by USAID, experiencing immediate programmatic cuts. Additionally, 7.69% of organisations depended on both PEPFAR and USAID, resulting in a compounded crisis across multiple services (ECOM & EHRA, 2025). The suspension resulted in the complete termination of funding for specific projects in 61.54% of organisations, while 38.46% lost all funding, threatening their survival and forcing many to cease operations entirely.

The defunding of mental health and peer-accompaniment programs, which were critical for ART/PrEP adherence, will result in higher HIV infection rates and major setbacks in prevention efforts (GATE, 2025). Additionally, the freeze has cut funding for trans-specific healthcare, particularly hormone replacement therapy (HRT) and gender-affirming surgeries, both of which are proven to improve mental health, economic stability, and overall healthcare utilization by trans people (Médecins Sans Frontières, 2025). Studies show that access to trans-specific healthcare significantly lowers HIV vulnerability by reducing minority stress, stigma and discrimination in healthcare settings, and economic insecurity (UNAIDS, 2025). However, with cuts to these programs, trans communities now face greater exclusion from HIV-related services and worsening economic precarity, often forcing more individuals into sex work, thereby increasing their risk of contracting HIV. Since sex work is criminalized in many regions, these new challenges further expose trans sex workers to heightened policing, legal persecution, and unsafe working conditions.

Harm reduction programs for trans people who use drugs have also been severely impacted, placing them at higher risk of HIV and hepatitis C (HCV) co-infections (Nature, 2025). With syringe exchange programs, overdose prevention services, and safer-use education initiatives shut down, trans people who use drugs are now left without essential harm reduction resources, further increasing their vulnerability to preventable health complications. Organisations that had attempted to extend project timelines or reallocate resources to maintain operations have faced insurmountable challenges, leading to an overall reduction in service offerings. In more severe cases, entire services were discontinued, directly impacting the health and well-being of trans populations who relied on them for survival (ECOM & EHRA, 2025).

The loss of funding has also severely weakened trans-led advocacy for legal protections, reducing engagement in legislative reform, participation in UN mechanisms, and strategic litigation against discriminatory policies. This has been particularly evident in Eastern Europe and Central Asia (EECA), where trans-led advocacy groups in countries such as Russia, Kyrgyzstan, and Kazakhstan have struggled to remain operational due to financial constraints (ECOM & EHRA, 2025; TGEU, 2025). Legal support for the most marginalised trans populations has disappeared, increasing their risk of persecution, criminalization, and violence. In Russia and Georgia, where anti-LGBTQ+ legislation and police crackdowns have intensified, the absence of legal defense mechanisms has left trans people even more vulnerable to arrests, forced detentions, and systemic harassment. All of these factors exacerbate the risk of HIV transmission, as heightened minority stress, mental instability, and criminalization fuel further barriers to care.

With grassroots trans organisations forced to shut down, larger NGOs and service providers that are not community-led—many of which lack the expertise or cultural competence to address trans-specific needs—have failed to bridge the resulting service gaps (European Union, 2023). This has led to a sharp decline in trans-inclusive, community-led HIV services, particularly in Georgia and Armenia, where trans-led HIV prevention programmes have struggled to remain operational amid shifting donor priorities. As a result, gaps in HIV prevention and care are widening, disproportionately impacting trans sex workers, migrants, and people who use drugs.

A February 2025 TGEU survey assessed the impact of U.S. funding cuts on trans-led organising in Eastern Europe and Central Asia (EECA), revealing severe financial losses, service disruptions, and escalating risks for trans communities. Many organisations reported losses of up to $100,000, with some losing their entire budgets. In Kazakhstan, advocacy programmes are expected to shut down by April, with office closures by May. HIV support and HRT access have been severely disrupted in Kyrgyzstan and Uzbekistan, while legal aid and advocacy services in North Macedonia and Slovakia have been drastically reduced, leaving trans people without essential protections in cases of discrimination and violence.

Beyond these service disruptions, the closure of community centres in Hungary and Central Asia has exacerbated social isolation and mental health crises. Political backlash is intensifying, particularly in Kazakhstan, where anti-trans rhetoric has escalated, fuelling calls for restrictive legislation. Meanwhile, economic instability and reduced funding have forced many activists to consider relocation as conditions deteriorate (TGEU, 2025).

To sustain their work, trans-led organisations have turned to crowdfunding, emergency grants, and mutual aid networks, while strengthening coalitions with broader human rights organisations. However, the defunding of trans-led community monitoring programmes has further dismantled oversight mechanisms for HIV services, making it increasingly difficult to track discrimination, measure barriers to care, and advocate for necessary reforms. This is particularly evident in Ukraine and Tajikistan, where trans communities previously led data collection efforts to document discrimination in healthcare settings. Without these programmes, institutional accountability has weakened, deepening HIV disparities and entrenching systemic exclusion from essential healthcare services.

Despite these funding crises, trans communities have mobilised grassroots solutions, establishing mutual aid networks, peer-led HIV services, and emergency response mechanisms. The EU must invest in these community-driven initiatives to ensure the sustainability of HIV prevention and care and uphold its commitment to human rights and inclusive healthcare.

Urgent Policy Recommendations

As a global leader in human rights and healthcare equity, the EU must strengthen its commitment to universal healthcare access through decisive action, founded on its human rights and legal obligations. The EU’s foundational values of human dignity, equality, and fundamental rights position it as the natural champion for advancing global healthcare justice. The EU has legal and human rights obligations to ensure access to healthcare for marginalised populations, as outlined in the EU Charter of Fundamental Rights, the WHO HIV/AIDS strategy, and the UN Sustainable Development Goals. Addressing this global health crisis is not just a matter of humanitarian concern—it is a matter of compliance with international commitments. The EU Charter of Fundamental Rights, WHO HIV/AIDS commitments, UN Sustainable Development Goals (SDG 3: Ensure Healthy Lives and Well-being for All), and the Universal Declaration of Human Rights (UNDHR) all mandate non-discrimination in healthcare.

Funding Efforts: European Commission and EU Member States

  • Building on its position as a global healthcare leader, the European Commission and EU Member States will expand their comprehensive support for trans-led HIV programs worldwide. This initiative advances the EU’s long-standing commitment to healthcare equality and human dignity.The EU’s Global Health Strategy must explicitly prioritize trans-specific healthcare, recognizing that strengthening access to trans-led and key-population healthcare drives broader improvements in healthcare systems, benefiting everyone, including women. This requires securing sustainable, flexible funding for trans-led and key-population Organisations, including through philanthropic channels such as the Robert Carr Foundation. 
  • To strengthen global healthcare resilience, the EU must redirect resources from the Global Health Strategy (2022–2030) and the NDICI (Neighbourhood, Development, and International Cooperation Instrument) to sustain and support HIV programs specially in the EECA region (and with special attention to Ukraine), while expanding support to Africa, Latin America, and Asia and the Pacific. As a major donor to the Global Fund, the EU must advocate for emergency bridge funding to sustain trans-led HIV services and increase financial support for trans populations within Global Fund programs.
  • Additionally, the EU must leverage its geopolitical influence to exert pressure on private donors such as Open Society Foundations, Sigrid Rausing Trust, and Arcus Foundation, as well as pharmaceutical companies like Gilead and ViiV Healthcare, to expand investments in trans health. By advocating for increased funding and equitable access to medications, the EU can reinforce its leadership in global health governance and human rights. This includes ensuring that PrEP, PEP and ART medications – specially long-acting technologies – remain accessible in peer-led HIV-service settings, whether through voluntary or compulsory licensing. Strengthening trans health initiatives not only aligns with the EU’s commitment to equality and public health but also enhances its diplomatic standing as a global advocate for inclusive and sustainable healthcare systems.

Legal and diplomatic action by the EU

  • The Directorate-General for International Partnerships (DG INTPA) and the Directorate-General for Health and Food Safety (DG SANTE) must conduct an EU-led impact assessment to document human rights violations stemming from the funding suspension, particularly in relation to HIV prevention and treatment.
  • The EU’s Special Representative for Human Rights and the European External Action Service (EEAS) must formally raise these concerns at the UN, the G7, and in diplomatic engagements with US officials. The EU’s Fundamental Rights Agency (FRA) and EU Member States’ legal bodies must support lawsuits challenging the funding freeze in US federal courts by submitting amicus curiae briefs.
  • Through multilateral diplomatic channels, the EEAS will advance the EU’s vision for inclusive global healthcare, engaging with international partners including the US Department of State to promote sustainable funding mechanisms that align with European values and human rights standards. Direct engagement with the US Congress and Senate Committees on Foreign Affairs and Human Rights is crucial to push for a legislative override of the executive order, particularly through Congressional hearings on the humanitarian consequences.
  • The EU can directly fund US-based civil society Organisations fighting the freeze through the Global Europe Human Rights and Democracy Programme and the EU Civil Society Facility while partnering with legal networks to support strategic litigation. The EU must also escalate the issue to international human rights mechanisms, including the UN Human Rights Council, the Universal Periodic Review, and the Inter-American Commission on Human Rights (IACHR).
  • The EU must use trade agreements and the EU-US Trade and Technology Council (TTC) to tie human rights compliance to economic relations, potentially challenging the funding freeze through the World Trade Organization (WTO).

European Parliament Actions

  • The European Parliament must pass a resolution condemning the US funding freeze and calling for urgent EU financial support to sustain life-saving HIV services for marginalised and at-risk communities. The funding cut has created a humanitarian crisis, jeopardizing essential healthcare services and reversing progress in the global fight against HIV/AIDS. To address this, the Parliament must also conduct hearings and investigations with UNAIDS, civil society Organisations, and affected stakeholders to assess the full impact and develop sustainable solutions. As part of its broader commitment to human rights and public health, the Parliament must ensure that all communities—especially those facing systemic barriers to healthcare—receive the necessary support, including trans-led initiatives that play a critical role in service provision.The EU must expand targeted funding under the European Social Fund+ (ESF+) and the EU Civil Society Facility, ensuring that trans-led HIV programs receive sustained financial support, particularly in EECA, Africa, and Latin America.
  • Additionally, the EU must strengthen its diplomatic leverage by integrating human rights conditions into EU-US trade agreements and ensuring that the withdrawal of life-saving health aid is met with direct policy consequences.

Long-Term Structural Changes for HIV Funding and Global Health Governance

  • The EU’s leadership in global health governance represents a natural extension of its core values and proven track record in advancing human rights. Develop and implement new frameworks for sustainable healthcare funding that align with the EU’s leadership in global health governance and commitment to human rights, ensuring a more equitable and resilient global health system..
  • Establish alternative HIV funding mechanisms within the EU to ensure sustainable financing for key-population-led programmes across the WHO European Region, mitigating the impact of the U.S. withdrawal from WHO and the foreign aid freeze. Collaborate with UNAIDS, the Global Fund, and WHO to create funding structures that protect essential HIV services from political instability.
  • Secure EU-led financing for HIV programmes affected by the U.S. exit from WHO and foreign aid cuts by advocating for a binding international agreement within the UN General Assembly or WHO to safeguard global health funding from political interference. 
  • Expand the EU’s role in international funding structures to guarantee long-term, sustainable support for key-population-led HIV responses in the WHO European Region.

Trans-led research and data collection

  • Trans, queer, and other key-population-led research must be central in assessing the full impact of the funding freeze and shaping EU health policy responses. A trans-specific impact assessment must be launched to quantify the damage caused by these cuts. This assessment must be co-led by TGEU and the EU agencies such as the ECDC.
  • EU agencies such as the European Centre for Disease Prevention and Control (ECDC) and the EU Fundamental Rights Agency (FRA) must improve HIV surveillance by ensuring trans populations are included in epidemiological data collection, addressing significant gaps in current research.
  • Findings from this assessment must be used to influence UNAIDS (through thematic segments and NGO reports at PCB meetings), WHO, and the Global Fund’s strategic planning, ensuring that trans populations remain a priority in global HIV responses.

The EU’s strengthened leadership in global health governance is essential to maintaining and advancing decades of progress in HIV prevention and treatment. By championing inclusive healthcare policies and sustainable funding mechanisms, the EU will ensure that trans communities worldwide have access to life-saving care while promoting European values of equality, dignity, and human rights. Without it, trans communities will remain exposed to higher rates of infection, the risk of mutant HIV strains that are ART-resistant, exacerbated violence, and premature death (Nature, 2025). 

Trans health is not negotiable. It is central to ending the HIV pandemic and preventing the rise of a new one.

References

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