Whereas advocacy was once the driving force for U.S. public support for HIV drug development and access, the nation’s response to the global epidemic is now shaped by austerity. Extending past scholarship about the role of advocates and governments in support of drug development and access around the world, in this article I identify key shifts in U.S. public sector support over the past 40 years. During the early years of the AIDS epidemic, the U.S. government and civil society expedited drug development for antiretroviral therapy (ART). After the turn of the century, a new wave of advocacy expanded access for ART, including to low- and middle-income countries through the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR). On the heels of these accomplishments, advocates and governments set an ambitious agenda to ‘End AIDS’ by 2030. However, progress toward this goal has been limited by a new era of austerity, as demonstrated by U.S. government spending on HIV.