US President Donald Trump’s cost-cutting army sent the world’s foreign aid infrastructure reeling last month with its stop-work order for all programmes funded by the US Agency for International Development.
Despite a dizzying series of further announcements and reversals, including a “humanitarian waiver” for certain “life-saving” services, the ensuing chaos has been widespread and devastating.
One major effect is on HIV/AIDS, programmes which made up 14.7% of all US foreign aid spending in 2023. The US government has allowed agencies to apply for waivers for specific types of HIV programmes, but confusion and uncertainty has meant a lethal suspension of services. UNAIDS estimates that a permanent halt to PEPFAR would result in an additional 6.3 million AIDS-related deaths by 2029.
Yet, Indian HIV programmes have been affected in a more moderated way. “It did not send shock waves among recipient organisations or engaged organisations significantly,” said AIDS expert Dr Sundar Sundararaman. “It has been shocking, but it is not posing a difficulty.” Why is India’s HIV programming more resilient in the face of Trump’s bluster?
One reason is India’s relative financial independence. Since George W Bush inaugurated PEPFAR – the President’s Emergency Plan for AIDS Relief – in 2003, it has provided some $120 billion globally. In its main partner countries, it accounts for 46% of national HIV budgets (and that’s not including US contributions to the Global Fund and other funding mechanisms).
In contrast, India now finances over 90% of its HIV programmes domestically, and provided 73% of the national AIDS budget starting in 2012. PEPFAR provided just 5.6% of India’s HIV budget in 2017-’18.
The US foreign funding freeze does have some immediate effects in India. For instance, 500 field-level workers have been removed from their positions, projects like the SafeZindagi digital platform have been shut down, programmes on adolescent health in the North East are in jeopardy, and the Mitr Clinic, a clinic devoted to the transgender community in Hyderabad, has become a political target in the US.
But outside these programs, the US role in Indian HIV programmes has been largely strategic, focused on targeted projects and technical assistance.
“For India, PEPFAR carved out a very different approach to many countries in Africa or elsewhere,” Sundararaman noted. PEPFAR’s role, he said, shifted from an affluent presence in the early years of the Indian AIDS response to an influential role with the arrival of a larger set of donors. After 2010, it has played a more strategic role.
The World Bank was a major donor to India’s AIDS programmes in its early years. By 2003, funding sources had diversified considerably, with funds from the Gates Foundation and a variety of other donors.
But beyond the growing financial autonomy of India’s HIV programmes, India’s relationship to donors has been a political negotiation. Globally, PEPFAR funded procurement and supply of antiretroviral drugs in many countries, but refused to buy low-cost generic drugs. The Indian government, pushed by activists, negotiated its own drug prices with Indian drug manufacturers to provide generic drugs.
It wasn’t the Indian government alone that negotiated and challenged the influence of the US government on AIDS programming. It was also civil society. Sex worker groups, sexual minority and transgender groups, nonprofits and researcher and activist allies largely worked outside of US government funds.
Long before Trump manufactured outrage at “gender ideology”, PEPFAR had a different brand of moral regulation. PEPFAR originally restricted a third of HIV prevention funding to promoting sexual abstinence before marriage, in sub-Saharan Africa – a 2016 study found that this $1.4 billion investment was largely ineffective.
Organisations that got US government funding also had to sign the “anti-prostitution pledge”, a clause requiring that they not “promote or advocate the legalisation or practice of prostitution”. The clause created a chilling effect on organisations involved with sex workers, who were often central to the HIV response. This is because it was not clear what exactly counted as promoting prostitution.
In 2005, the Brazilian government turned down $40 million in HIV/AIDS funding in protest.
In India, the Veshya Anyay Mukti Parishad faced a similar tradeoff in 2006. Being involved with organising sex workers in Western Maharashtra for a decade already, the parishad refused to undermine its acclaimed sex-worker-led approach to HIV prevention and returned $20,000 to USAID.
Meena Seshu, the founder of Sangram, which supports the Veshya Anyay Mukti Parishad, said the decision was mutually respectful, but the outfit was immediately targeted as a trafficking organisation in the US and globally.
Despite this, standing up to funders also had its benefits. “I credit my enemies for making me famous every day,” said Seshu. “The minute we went public with the fact that we had refused to sign the pledge…people I’d never met in my life before were chasing me to find out…what this group is all about, and how come it said no to the mighty AID.”
Veshya Anyay Mukti Parishad and Sangram made connections with sex worker allies around the world who had long been fighting PEPFAR’s restrictions. Alliance for Open Society International later took the issue to the US Supreme Court.
After that, Veshya Anyay Mukti Parishad worked without outside funds for almost a year, distributing condoms they received from the Indian government. Seshu said it gave the Parishad a kind of resilience.
“The women managed…those 11 months were a dream, because we just did the programme,” she said. “There was no need to write reports for anyone…that was great because it gave us time to bond.” It also meant a refusal to be controlled by funder directives or ideologies.
“We have constantly been a kind of organisation that questions the funder,” Seshu said. Having to return funding taught the parishad that “this can happen anytime with any funder, and we have to work with that”.
It wasn’t only the US government that organisations like Veshya Anyay Mukti Parishad had to challenge. India’s HIV response was full of debate and protest. In 2010, for example, the Karnataka Sex Workers Union protested the treatment of sex workers and sexual minority communities in the state government’s HIV prevention programs at World AIDS Day.
Organisations have also built various strategies of funding their work. Durbar Mahila Samanwaya Committee in Kolkata, which began as an HIV prevention project, supports many of its programmes through its own financial cooperative, and advocates globally for sex workers’ labour rights.
The gutting of US foreign aid will have devastating effects. But the story of India’s sex worker activists may offer a different way of thinking about the future of the HIV funding infrastructure, driven by activism.
Sex worker activists know that US foreign aid is unpredictable, prone to the ups and downs of US imperial interests and regional geopolitics – and that it ultimately serves the economic and political interests of the US alone. If this aid infrastructure has to be dismantled, these groups show that sometimes it is the saviours they need to be saved from.
Gowri Vijayakumar is the author of At Risk: Indian Sexual Politics and the Global AIDS Crisis and an Associate Professor of Sociology and Women’s, Gender and Sexuality Studies at Brandeis University.
