Canada must act to prevent the unravelling of progress toward curbing HIV/AIDS

Julio S.G. Montaner, Robert S. Hogg and Stephen H. Lewis CMAJ December 15, 2025 197 (43) E1488-E1490; DOI: https://doi.org/10.1503/cmaj.251245

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Key points

• Evidence-based strategies such as treatment, prevention and pre-exposure prophylaxis have dramatically reduced new HIV infections and AIDS-related deaths, and must be scaled up nationally and globally.

• However, at a time when the world is close to ending HIV/AIDS as a global public health threat, major global funding cuts have stalled international progress.

• Canada and other high-income countries would be wise to reinvigorate their efforts to end the HIV/AIDS epidemic, as G8 leaders committed to in 2002.

In 2002, the G8 summit in Kananaskis, Alberta, launched the G8 Africa Action Plan,1 which identified HIV/AIDS as a central threat to human development and global security. The plan has played a pivotal role in addressing the global threat posed by HIV/AIDS and, since then, global progress has been remarkable. Today, although the urgent need to end the HIV/AIDS epidemic remains, the political will has faded.

In 2023, the United States continued to be the largest donor to global efforts to control HIV, with their US$5.7 billion contribution accounting for 73% of total donor government funding, followed by the United Kingdom (US$714 million, 9%), France (US$320 million, 4%), Germany (US$228 million, 3%), and the Netherlands (US$187 million, 2%).2 Yet recent decisions to cut funding across international health programs, including a 55% (US$3.6 billion) proposed cut to the President’s Emergency Plan for AIDS Relief (PEPFAR) in 2026, and reduced pledges to the Global Fund to Fight AIDS, Tuberculosis and Malaria’s eighth replenishment for 2026–28 in November 2025, threaten to undo decades of progress.3,4 Full elimination of PEPFAR would result in a full resurgence of the global HIV epidemic by 2029, with an estimated 6.3 million AIDS-related deaths and 3.4 million AIDS orphans.5 Without urgent course correction, a full-scale collapse of global HIV/AIDS control efforts is imminent.

Evidence clearly and consistently affirms the cost-effectiveness of HIV prevention strategies. For example, the “treatment as prevention” strategy, first proposed in 2006 by the British Columbia Centre for Excellence in HIV/AIDS,6 is built on the principle that early and sustained antiretroviral therapy (ART) saves lives by preventing disease progression and HIV transmission.6 The landmark 2011 HIV Prevention Trials 052 study showed a 96% reduction in transmission among sero-discordant couples when the HIV-positive partner received immediate treatment.7 Follow-up genetic studies found no transmission when viral loads were suppressed, leading to the U = U (undetectable = untransmittable) campaign.7 A modelling study assessing the cost-effectiveness of highly active ART in BC from 1997 to 2010 showed that population-level expansion of treatment access led to substantial gains in quality-adjusted life years (QALYs), with incremental cost-effectiveness ratios of Can$23 679 per QALY with a 75% expansion, and Can$24 250 per QALY with a 50% expansion, compared with the current treatment practice.8 Treatment as prevention combined with pre-exposure prophylaxis (PrEP) to protect HIV-negative individuals at high risk has proven synergistic in reducing new infections, helping BC achieve more than a 90% reduction in both AIDS-related deaths and new infections from 1996 to 2022.9

In 2013, UNAIDS developed ambitious but achievable targets for ending the epidemic: diagnosing 90% of people living with HIV, treating 90% of those diagnosed, and achieving viral suppression in 90% of those treated (90–90–90) by 2020,10 increasing to 95–95–95 by 2025. In 2015, the United Nations formally adopted the 90–90–90 targets to drive the global strategy to reduce HIV/AIDS deaths and new HIV infections by 90% by 2030, and thus end HIV/AIDS as a public health threat by 2030.10

Canada’s performance remains uneven. Although BC has surpassed the targets, most other provinces lag. Concerningly, in 2023, new HIV infections across Canada increased by 35%, with preliminary 2024 data showing further increases.11 The epidemic is driven by intersecting social determinants of health, as experiences of stigma, discrimination, colonialism, and marginalization based on race, ethnicity, trauma, disability, immigration status, social class, sexual orientation, gender identity, drug use, incarceration, and sex work combine to increase vulnerability to HIV.12 These issues require a multi-sectoral, equity-focused response, including monitoring and surveillance, legal and policy reform, and augmented social services, tailored to the needs of affected communities and regional differences.12 The rising tide of new infections demands a coordinated, federally led response.

By 2022, globally, 86% of people living with HIV were diagnosed, of whom 76% were on ART, and in turn, of whom 71% were virally suppressed. Twenty-one countries are now within reach of the 95–95–95 target by 2025.13 However, the global HIV response now faces an annual shortfall of 9.5 billion.14 The Economist recently estimated the official development assistance by G7 countries will drop substantially between 2023 and 2026, including reductions of 56% by the US, 38% by the UK, 27% by Germany, 25% by Canada, 16% by France, and 1% by Japan.15 Global investment in infectious disease public health has stalled in the post-COVID-19 era,3 but investing in the global HIV/AIDS response is in Canada’s direct interest. A world with fewer epidemics and a reduced global burden of disease benefits everyone; the burden of HIV is not just “out there” but present here in Canada.

Prime Minister Mark Carney has called for cost-effective, nation-building initiatives that improve the lives of Canadians.16 Ending HIV/AIDS as a public health threat in Canada represents such an initiative as it saves lives, reduces long-term health system costs, and strengthens public health and social cohesion. To meet this goal, Canada must urgently scale up its HIV response through evidence-based interventions.6 The federal government must work with provinces to fully fund access to ART and PrEP for all who need them through the national pharmacare plan.9 The provincial and federal governments should enhance support for viral phylogenetic monitoring programs to detect and interrupt transmission clusters in real time, and mandate national quarterly reporting of key HIV indicators through the Public Health Agency of Canada. Canada must harmonize risk reduction policies across provinces to eliminate harmful disparities in service delivery. Legal reform is needed to modernize outdated criminal laws that target people living with HIV by perpetuating HIV stigma, impeding prevention efforts and damaging patients’ lives. Governments at all levels must expand tailored medical, legal, and social supports for high-risk and marginalized populations, including Indigenous Peoples, racialized communities, men who have sex with men, people who use drugs, and migrants.

Lastly, Canada, with the G7 and other wealthy nations should really be doubling their developmental assistance to offset the reduction in funding from the US, rather than following suit. Maintaining global funding is essential for prevention, treatment, and health system support in the countries most affected by HIV.

Together, these measures provide a pragmatic, compassionate, and fiscally responsible approach to ending HIV/AIDS. Without them, Canada will fail to meet its domestic commitment to end HIV/AIDS, and the fragile global progress made over the past 2 decades will collapse, with devastating human and economic consequences. Canada should not miss its opportunity to lead the global effort to sustain progress toward 2030 HIV targets. As Prime Minister Carney said in respond to US tariffs threats: “If the United States does not want to lead, Canada will.”17 These words resonate beyond economic policy as they reflect the values and global leadership Canadians expect from their politicians. Now is the time to deliver on the promise of a made-in-Canada strategy to end HIV/AIDS. With the right vision, political will, and partnerships with other high-income countries, Canada could show the world what it means to lead with integrity, equity, and impact.

Source: CMAJ Canadian Medical Association Journal
https://www.cmaj.ca/content/197/43/E1488

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