HIV gradually weakens the body’s immune system and makes it vulnerable to disease, including ones rarely seen in otherwise healthy people.
A generation has passed since the world saw the peak in AIDS-related deaths that prompted people to demand that governments act.
The United States eventually did, creating the President’s Emergency Plan for AIDS Relief (PEPFAR) in 2003, arguably the most successful foreign aid programme in history.
Now US President Donald Trump’s administration has put the brakes on foreign aid while alleging it’s wasteful, causing chaos in the system that for over 20 years has kept millions of people alive.
Confusion over a temporary waiver for PEPFAR means the clock is ticking for many who are suddenly unable to obtain medications to keep AIDS at bay.
“In the next five years, we could have 6.3 million AIDS-related deaths,” the United Nations AIDS agency told The Associated Press.
That’s a shock at a time of rising complacency around HIV, declining condom use among some young people, and the rise of a medication that some believe could end AIDS for good.
The agency has begun publicly tracking new HIV infections in PEPFAR-supported countries, comparing the number of new infections to the amount it would have expected if US support had continued.
Here’s a look at what happens to the body when HIV drugs are stopped.
An immune system collapse
HIV is spread by bodily fluids such as blood, breast milk, or semen.
The virus gradually weakens the body’s immune system and makes it vulnerable to disease, including ones rarely seen in otherwise healthy people.
The surprising emergence of such cases in the 1980s is what tipped off health experts to what became known as the AIDS epidemic.
Now millions of people take drugs known as antiretrovirals that keep HIV from spreading in the body.
Stopping those drugs lets the virus start multiplying in the body again, and it could become drug-resistant. HIV can rebound to detectable levels in people’s blood in just a few weeks, putting sexual partners at risk.
Babies born to mothers with HIV can escape infection only if the woman was properly treated during pregnancy or the infant is treated immediately after birth.
If the drugs are not taken, people develop AIDS, the final stage of infection.
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“Without HIV treatment, people with AIDS typically survive about three years,” the US Centers for Disease Control and Prevention (CDC) says.
For a long time, there may be no noticeable symptoms. But a person can easily spread HIV to others, and the immune system becomes vulnerable to what are called opportunistic diseases.
The US National Institutes of Health (NIH) says opportunistic diseases include fungal infections, pneumonia, salmonella and tuberculosis. For a country like South Africa, with the world’s highest number of HIV cases and one of the largest numbers of tuberculosis (TB) cases, the toll could be immense.
Unchecked by HIV treatment, the damage continues. The immune system is increasingly unable to fight off diseases. Every action, from eating to travel, must consider the potential exposure to germs.
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For years, the importance of taking the drugs every day, even at the same time of day, has been emphasised to people with HIV. Now the ability to follow that essential rule has been shaken.
Already, hundreds or thousands of US-funded health partners in countries such as Kenya and Ethiopia have been laid off, causing widespread gaps in HIV testing, messaging, care, and support on the continent most helped by PEPFAR.
At some African clinics, people with HIV have been turned away.
Restoring the effects caused by the Trump administration’s foreign aid freeze during a 90-day review period, and understanding what’s allowed under the waiver for PEPFAR, will take time that health experts say many people don’t have.
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