The Trump administration’s halted fundingopens in a new tab or window to the President’s Emergency Plan for AIDS Relief (PEPFAR) and dissolution of the U.S. Agency for International Development (USAID) have had devastating effects on HIV prevention, screening, testing, and treatment programs across the globe, experts said.
Some of the hardest-hit regions have been sub-Saharan and South Africa, as shown in recent research presented at the International AIDS Society (IAS) Conference on HIV Scienceopens in a new tab or window in Kigali, Rwanda.
“The impacts are already clear and devastating: declines in testing, diagnoses, treatment initiation, and viral suppression, especially among vulnerable groups like children and key populations,” Eric Cioè-Peña, MD, MPH, of the Center for Global Health at Northwell Health and Zucker School of Medicine at Hofstra/Northwell in Hempstead, New York, told MedPage Today.
“These aren’t just numbers; they’re people losing access to the most effective public health intervention of our time,” he added. “PEPFAR has saved millions of lives since its creation under President George W. Bush and remains one of the most impactful investments in global health ever made.”
Eric A. Meyerowitz, MD, of Montefiore Health System and Albert Einstein College of Medicine in the Bronx, New York, told MedPage Today that PEPFAR “is probably the most successful global health program and foreign policy success of my lifetime,” having saved an estimated 26 million lives in Africa so far.
In a last-minute moveopens in a new tab or window to spare PEPFAR, the Senate removed the program from the list of funding cuts included in the Rescissions billopens in a new tab or window sent to President Trump’s desk in July. While that decision will not necessarily undo all the damage that has occurred since the funding interruption began in January, it does ensure that funding will resumeopens in a new tab or window going forward, for nowopens in a new tab or window.
The IAS issued a statementopens in a new tab or window welcoming the “bipartisan move to protect PEPFAR.”
“PEPFAR has been one of the greatest success stories in global health, transforming the HIV response,” IAS President Beatriz Grinsztejn, MD, PhD, said in the statement. “Global advocacy played a crucial role in persuading U.S. lawmakers to protect this vital program, reminding them that decisions about PEPFAR shape the health and futures of people around the world. Yet uncertainty remains, with ongoing threats to global health funding.”
Indeed, it remains unclear whether any of the lost funding from USAID programs will be replaced.
Cioè-Peña acknowledged a need to rethink how U.S. foreign aid is structured, “but reform cannot come at the cost of people’s lives,” he said. “These decisions have been executed in a callous and chaotic way, with no regard for the downstream human cost.”
While there is time to correct course — and the resumption of PEPFAR funding has been one large piece of that — the clock is ticking, he added.
“From a humanitarian perspective, the U.S. has a moral obligation to follow through on the commitments it made,” Cioè-Peña said. “But even from a purely pragmatic standpoint, this affects us: collapsing HIV programs abroad leads to viral rebound, drug resistance, and increased transmission. Disease does not respect borders. We will pay for this short-sightedness in the long term, both in health and in geopolitical influence.”
Impact on PrEP in sub-Saharan Africa
The pause to all foreign aid programs began with a directive in January that paused PEPFAR funding for 90 days. Among the programs affected was the provision of pre-exposure prophylaxis (PrEP) in sub-Saharan Africa for all people except those pregnant or breastfeeding.
In a study presented at the IAS meeting, Jack Stone, PhD, of the University of Bristol in England, and colleagues modeled these effects for various subpopulations using data on oral PrEP from July to September 2024 in countries receiving PEPFAR funding.
A total of 742,136 people across 28 sub-Saharan countries were receiving PrEP funded by PEPFAR by late 2024; 27.7% were people in key populations: 1.7% who inject drugs, 18.4% were female sex workers, 7.1% were men who have sex with men, and 0.5% were transgender women.
Stone’s team found that halting PrEP funding for 1 year could result in an estimated 6,671 additional new primary HIV infections, 85% of which would occur among key populations and 68% of which would occur in just five countries: Tanzania, Nigeria, South Africa, Zambia, and Uganda.
The new infections would translate to an increase of 0.8% for people who inject drugs, 2.9% for female sex workers, 2.2% for men who have sex with men, and 1.4% for transgender women. There was substantial variation within each country, however, with impacts in the countries with the highest coverages ranging from a 7.8% increase in people who inject drugs to an 18.1% increase among men who have sex with men.
“This really highlights the need to find funding, not only to continue PrEP services, but also to expand them, particularly among key populations,” Stone said in his presentation.
Subsequent secondary transmissions from a 1-year pause were estimated at 10,313 additional infections over 5 years, but accounting for secondary infections along with under-reporting from men who have sex with men, the true number of total primary and secondary infections is likely closer to 15,739, Stone reported.
“This evidence suggests that there’s a real need to identify alternative sources of funding in the short and long term,” he noted. “We need to do this in such a way that we ensure that interventions are not vulnerable to political shifts in the changing priorities of international donors.”
Interrupted Services in Mozambique
With the third highest HIV prevalence and second highest global incidence in the world, Mozambique has antiretroviral therapy (ART) available in 97% of its health facilities, serving approximately 2 million of the 2.4 million people living with HIV in the country. Yet, 93% of the expenses for those services comes from the U.S., mostly from PEPFAR.
Dorlim Moiana Uetela, PhD, of the Instituto Nacional de Saúde in Marracuene, Mozambique, and colleagues assessed the impact of the funding cessation using data from the national district health information system to compare health services indicators.
They identified a 25% decrease in ART initiation in people ages 15 and older from February 2024 to February 2025. There was also a 15% decrease in ART initiation from February to May of this year, as well as a 39% increase in interruption of treatment from April to May.
“HIV treatment interruptions put people with HIV at risk for opportunistic infections and death,” Meyerowitz said. “Having so many simultaneous interruptions to HIV treatment will change the net state of immunosuppression of entire communities.”
Among those receiving treatment, 38% fewer viral load tests were performed and 37% fewer test results were received in February 2025 versus February 2024. Furthermore, the rate of viral suppression was 33% lower this February. Greater reductions were seen among children under age 15, with 44% fewer viral load tests, 71% fewer test results received, and a 43% reduction in viral suppression.
Though the resumption of PEPFAR funding should alleviate the impacts, the researchers had estimated that a continued absence of funds would add 83,000 new HIV infections, a 15% increase, and 14,000 HIV deaths, a 10% increase, by the year 2030.
“These are conservative estimates of the impact on the HIV epidemic,” Uetela said, since they only focused on a handful of metrics, excluding, for example, community activities. “Securing sustainable funding sources is essential to sustaining progress toward eliminating HIV as a public health threat in Mozambique.”
Cioè-Peña said these data “paint a disturbing picture” in Mozambique. “Within weeks of the funding pause, we saw immediate and measurable declines across the care continuum,” a predictable result of removing so much of the country’s HIV budget overnight, he said.
“What’s important for people to understand is that these systems are not fragile because they’re mismanaged; they’re fragile because they were built in partnership with and are deeply reliant on sustained U.S. support,” he added. “Reform of global health aid is necessary, yes, but reform through abandonment is malpractice.”
USAID Termination Hits Johannesburg Programs
In Johannesburg, South Africa, where approximately 623,000 adults live with HIV, one of the programs funded by PEPFAR was Accelerating Program Achievements to Control the Epidemic (APACE), aimed at supporting the city’s health department in reaching the United Nations’ 95-95-95 goalsopens in a new tab or window of 95% of people living with HIV knowing their status, receiving treatment, and being virally suppressed.
After the funding halt, APACE was terminated in February, and it’s unclear whether the reinstitution of PEPFAR will fund it again. Khensani Chauke, MPH, of the Anova Health Institute in Johannesburg, compared HIV tests, positive diagnoses, and ART initiations in the first quarters of 2023, 2024, and 2025, accounting for seasonal variations. They found an 8.5% reduction in HIV testing, a 31% drop in HIV diagnoses, and a 30% reduction in ART initiation between the first quarter of 2024 and the first quarter of 2025.
“One lesson learned from COVID is that infectious diseases do not stay in one area and can quickly spread to every corner of the globe,” Meyerowitz said. “Public health is a public good, meaning it is in the interest of all of us on the global scale to have strong public health systems. We are all healthier and safer when life-saving medications are available where they are needed.”
“The world is watching,” Cioè-Peña said. “We have the ability to eliminate HIV over the course of my lifetime, or we could watch the pandemic rebound to the horrific levels we saw in the 1990s and early 2000s.”
