What to expect at CROI—A top HIV researcher speaking at CROI talks about the chaos facing the conference in San Francisco

The annual Conference on Retroviruses and Opportunistic Infections (CROI, or simply “Retrovirus”), opened March 9, one of the biggest annual HIV science conferences, where researchers from all over the world discuss the latest findings related to prevention, treatment and cure of HIV and related diseases. But this year’s CROI has been thrown into upheaval by the Trump administration’s hacking away at virtually every corner of HIV research and care access—decimating the U.S. global relief programs USAID and PEPFAR (the HIV program that is closely interwoven into USAID), censoring federal research related to highly HIV-impacted LGBTQ+ people (especially transgender people) and pressuring a right-wing Congress to slash funding for programs in the ongoing budget process, which will likely include key healthcare platforms like Medicaid and the Affordable Care Act. 

It appears that many federal researchers and officials who would normally be at CROI won’t be attending. There is also fear and confusion about what content federally funded researchers can even present, especially if it relates to Trump targets like trans people or racial equity in healthcare.

POSITIVELY AWARE spoke on February 27 with Chris Beyrer, MD, MPH, director of Duke University’s Global Health Institute and a longtime global HIV researcher, who is scheduled to give a plenary address at CROI on Monday, March 10, on the state of efforts to end the global HIV pandemic. He spoke about how the Trump attacks have thrown the conference into disarray, what those who work in his field are doing to address the attacks—and what they might have to do if the situation continues and grows.

Dr. Beyrer, thank you for talking today. Can you start by saying in your own words what you do and how you got here?

I’m an infectious disease epidemiologist by training who’s been working on HIV prevention clinical trials policy now for 33 years, since I finished my training at Johns Hopkins. I spent my first five years on the Hopkins faculty in Thailand working on HIV in Southeast Asia and setting up the infrastructure for HIV vaccine trials in Thailand. I was recruited to Duke in 2022 to be director of their Global Health Institute. I’m also continuing my own HIV work and have been continuously funded by NIAID [the National Institute of Allergy and Infectious Diseases], a great institution within the NIH [the National Institutes of Health] led by Dr. Tony Fauci from 1984 to 2022.

Alright, let’s cut to the chase: this is a really sad and scary moment to be going into CROI. Last night, Supreme Court Chief Justice Roberts said it was OK for the Trump administration not to release money for global aid disbursed through USAID and the administration said it was ending nearly 10,000 USAID and State Department contracts. Will federal employees even be allowed to go to CROI?

Given that, how are you feeling going into this CROI?

This is the toughest time I’ve experienced since before we had effective treatment. I’ve been feeling the old trauma of those terrible 15 years between when the disease was identified and when effective regimens emerged in 1996. I just co-published a paper in JIAS [Journal of the International AIDS Society] showing that, just based on this 90-day pause in PEPFAR funds, we can expect 100,000 excess deaths and 135,000 mother-to-child transmission in the next year. That made me think of all the babies and kids I took care of in Brooklyn in the ’90s. None of them survived. It’s anguishing for me.

We’re waiting to see what shakes out in the federal budget, but huge cuts are being talked about—especially to Medicaid, which serves so many Americans with or who are vulnerable to HIV. Do you fear we could see a domestic HIV setback as we’re seeing a global one now?

Of course. The budget blueprint that just passed the House points to a massive reduction in Medicaid.

Yes. Maybe 20 million of about 72 million people could lose coverage.

Right. Young gay, bi and trans people of color are where the HIV epidemic is most concentrated in the U.S. Many of them are in their early working years in low-wage jobs and they get their HIV prevention [PrEP] or treatment meds through Medicaid. Also, if Medicaid is slashed, it will also have a huge impact on low-income rural communities in deeply red states where the hospitals are dependent on Medicaid payments. We’ll have healthcare deserts.

What will your plenary be about?

I’ll open as I planned to before all this, talking about what we know about the state of the global pandemic. Even before all these political changes, we were not on track to meet UNAIDS’ 2025 target numbers, such as getting as low as half a million infections annually worldwide. The best estimates say we’re at about 1.3 million. And the main reason there is because we’ve been focusing heavily on treatment but not on primary prevention—and that is true not just for the generalized epidemic, like in eastern and southern Africa where women drive it, but for the sub-epidemics among young gay men and trans women globally—including here in the U.S. We haven’t gotten PrEP through at the levels we should.

Are you going to address the new landscape since Trump?

Absolutely. After those initial numbers, it’s going to be all about the impact of what is happening now and projections of how it will affect the numbers.

We have several faculty members getting death threats because of their work on vaccines and immunization and trans issues.

 

Will there be a fight from the research community to preserve what’s left of PEPFAR?

We’re looking at men who have sex with men [MSM] and the abrupt stoppage of all PrEP, treatment and testing services. And we’re looking globally at what the impact of the cuts is going to be on people who inject drugs. And we’re looking at what’s already happened to sex workers in Eswatini [formerly Swaziland], a small country in southern Africa where PEPFAR was providing services to that population. It looks like an abrupt increase in HIV incidence. 

So— [interrupted] sorry, I’m getting an amber alert from the university. We have several faculty members getting death threats because of their work on vaccines and immunization and trans issues. Duke had a gender-affirming care center for adolescents that had to be closed and moved to another state.

So what’s going to happen to all the people once served by PEPFAR?

To pick up the slack, countries are going to have to step up where they can. And some of the important donors who’ve left the HIV space need to come back. That’s already starting to happen. The Dutch AIDS Fund has already committed to coming back. We need other Europeans and the Australians to do the same, because many of the recipient countries will pick up the burden for preventing mother-to-child transmission but they have no interest in providing PrEP to gay men, trans women and sex workers—who are all criminalized in many of these countries. Philanthropies are going to have to step back into the HIV space, because if the nonprofits on the ground who provide services to those groups can’t make payroll, they’ll have to close their doors. Many of them already have.

It was heartening to see a small group of fired USAID workers and longtime global HIV activists getting arrested yesterday in the Cannon House Office Building in D.C. protesting the decimation of PEPFAR—will we ever see researchers like yourself in white lab coats in protests like that?

Universities have been mobilizing, getting involved in many of the lawsuits to block [the administration’s] attacks. The most important thing is that we need to get just two to three Republican senators to not go along with this. Take North Carolina, where Duke is. It has a big knowledge economy, the third-biggest biotech hub in the country. Such folks are working hard on our congressional delegation, helping lawmakers understand what’s really happening.

But will you ever become activists, fighting back publicly?

Well, there’s a lot of activism going on in people’s private lives. You have to understand that universities right now have been under intense assault and realize that they are stronger together. For example, the lawsuits which Duke has been a part of have been brought by the Association of American Medical Colleges and the Association of American Universities. There are med schools in every red state, and most of them are state schools.

But are folks from such schools speaking out?

Yes, many, I’m sure you know. I’m speaking to you right now and I fully intend to do press conferences in San Francisco and take whatever I think is the right approach.

Are you ever going to protest?

I can only speak for myself, not on behalf of my colleagues or my university. But depending on how long this goes and how severe the assaults on universities are, I can imagine that many people will feel that their personal threshold has been crossed and that they have to do that.

‘...this administration is very focused on personal retribution, which changes the calculus.’

 

Would you ever commit civil disobedience like the activists did yesterday in the Cannon Building?

Oh, I have in the past. I was a founding member of ACT UP Baltimore.

So, this is in your DNA.

Yes, but also now, I have a different kind of role leading 200 faculty, almost 350 students and 100 staff. I have to be able to lead for them. The other thing, and I’m sure you’re aware of this, is that this administration is very focused on personal retribution, which changes the calculus.

The Trump administration has been ignoring the orders of the lower courts—they did not entirely heed the court orders to unpause the freeze on both domestic and global funding that Congress had already enacted. And again, last night, Chief Justice Roberts ruled for the administration, allowing the funding freeze to continue. At what point do people realize they need to look beyond the recourse of the courts?

I can’t speak to that. I’m not a constitutional lawyer, but I will say that we’re already in a constitutional crisis. If the Trump administration flouts the courts all the way up to the Supreme Court, every American citizen is going to have to look in their heart…

And the Supreme Court is no reliable bulwark against all the things the administration is trying to do.

That’s true.

Okay, so, imagining that this is a normal CROI ahead of us, what are people excited about?

The promise of long-acting injectables, both for treatment and prevention. This is the first CROI since the trials last year [showing that Gilead’s lenacapavir provides 100% protection against HIV with only two shots a year]. That’s what I was going to talk about in my plenary, this revolutionary new tool to finally end the epidemic. But instead we’ll be talking about how to get that tool out in the field if the U.S. government is withdrawing from the effort. It could be a revolution that doesn’t happen. •