The New “Don’t Ask, Don’t Tell” in Global Health

Something subtle is happening in the global HIV response.

There has been no announcement, no official directive from donors or international agencies. No memo declaring that certain communities should disappear from the conversation. And yet, if you spend enough time in global health meetings or reading the language of new policy documents, you begin to notice a shift. Certain words are becoming harder to say.

Not HIV. Not prevention. Not treatment.

The words that now seem to make people most uncomfortable are simpler than that: gay men.

Particularly when the conversation turns to Africa.

The programs themselves have not necessarily vanished. Clinics remain open. HIV testing and treatment continue. Prevention work still happens in many countries. But increasingly there is an unspoken understanding that the work can proceed as long as we avoid speaking too directly about who it is actually meant to serve.

No one calls it a policy. Still, the atmosphere feels familiar. It resembles something global health once believed it had moved beyond: a quiet version of “Don’t Ask, Don’t Tell.”

The irony is that the modern HIV response was built precisely because communities refused silence. In the early years of the AIDS crisis, governments were slow to confront the epidemic because doing so required acknowledging uncomfortable realities about sexuality, stigma and marginalization. Gay men and their allies forced the issue into the open. Activists organized protests, challenged regulators and pharmaceutical companies, and demanded that governments recognize the scale of the crisis. Groups like ACT UP changed the trajectory of HIV research and treatment not by softening the conversation, but by insisting on clarity.

That legacy shaped global health policy for decades. When the United States launched the President’s Emergency Plan for AIDS Relief, or PEPFAR, in 2003, it did so with an understanding that fighting HIV required reaching the populations most vulnerable to infection, even when doing so meant navigating difficult politics. The program mobilized billions of dollars to expand treatment and prevention across the world and saved millions of lives.

Two decades later, the science still points to the same reality.

Across sub-Saharan Africa, the overall trajectory of the epidemic has improved significantly. New infections have declined over the past decade, reflecting enormous progress in treatment access and prevention programs. Yet the epidemic has never affected everyone equally. According to UNAIDS-linked estimates, key populations and their sexual partners account for roughly 24 percent of new adult HIV infections in sub-Saharan Africa, even though these populations represent less than 8 percent of the adult population. For men who have sex with men and other marginalized groups, the risk of acquiring HIV can be up to eleven times higher than in the general population.

Even more troubling, the progress seen across the broader population has not been shared evenly. While overall infections have declined since 2010, infections among men who have sex with men and transgender women have not fallen at the same pace and in some places are increasing.

In other words, the epidemic remains concentrated among the very communities global health institutions now seem increasingly uncomfortable naming.

Within scientific circles, this reality is not disputed. The World Health Organization continues to identify men who have sex with men as a key population requiring targeted HIV prevention and treatment services. Epidemiologists continue to publish data showing disproportionate risk. Community organizations across Africa continue to build prevention programs designed to reach people who often fall outside traditional health systems.

The evidence has not disappeared.

What appears to be shrinking instead is the political space in which that evidence can be discussed openly.

Part of the explanation lies in the shifting politics of global health funding. The United States has long been the largest contributor to the global HIV response. Recent changes in American foreign assistance policy have introduced uncertainty into programs that have supported HIV services for decades. Organizations receiving U.S. funding increasingly face pressure to demonstrate that their work does not promote what policymakers describe as LGBTQ agendas.

For governments and organizations that rely heavily on international funding, the signal is difficult to ignore. Programs may continue, but political sensitivities shape how they are described and implemented. Language shifts. Reports speak more broadly of “vulnerable populations.” Services remain available, but individuals are encouraged not to publicly disclose their identities.

The result is a quiet compromise. Clinics remain open, but the communities most affected by the epidemic become less visible in the policies that govern those services.

Supporters of this approach argue that such caution is necessary. In countries where homosexuality is criminalized or stigmatized, openly labeling programs as services for gay men can provoke backlash that shuts those programs down entirely. In this view, softer language is a pragmatic way to protect access.

There is some truth in that argument. Public health has always required navigating political realities. But there is a difference between pragmatic discretion in difficult environments and a broader drift toward silence.

The history of HIV demonstrates why that distinction matters. Epidemics thrive in environments where stigma pushes people out of view. The early AIDS crisis spread rapidly in part because governments and health systems were unwilling to confront uncomfortable truths about sexuality and marginalization. Progress only came once those realities were acknowledged.

When public health systems begin avoiding those realities again, even indirectly, the consequences can be serious. Prevention programs become less precise. Data becomes harder to collect. Communities lose trust in institutions that claim to serve them while avoiding acknowledging their existence.

There is no official policy today called “Don’t Ask, Don’t Tell” in global health. But the effect can begin to look familiar when politics makes certain communities harder to name. The HIV response was built by people who refused to allow stigma and silence to define public health. That history carries a lesson worth remembering now: epidemics are not defeated by speaking more carefully about who they affect. They are defeated by having the courage to see them clearly — and to say so out loud