THE SUDDEN REVERSAL of United States (‘US’) funding for the global fight against HIV shocked the world in January 2025. The immediate rise in deaths and new HIV infections in Africa has been devastating, and modeling studies predict a durable impact. These cuts abandoned evidence-based practices, further stigmatized key populations, and endangered decades of progress built on a human rights approach to HIV care and prevention.
In this analysis, we will review the human toll of cuts to the President’s Emergency Plan for AIDS Relief (‘PEPFAR’) and United States Agency for International Development (‘USAID’) through the lens of HIV in Africa and consider the implications for the future of the pandemic globally and in the US.
HIV in 2026
The HIV pandemic evolved from a global catastrophe to an inspirational triumph of the power of activism, collective action, public health, and science. Among the remarkable global achievements to date are 31 million people with HIV (PWH) receiving treatment, a 57 percent decline in new infections, a decline in annual deaths from 2.5 million to 600,000, and serious planning to end the epidemic in some regions. An integral part of this evolution was a human rights-based approach that offered the best framework for understanding the disease and for effective, evidence-based prevention, treatment, and public policy.
Despite substantial progress, the HIV pandemic remains volatile and uncontrolled in 2026. Momentum towards 95 percent coverage of People living with HIV (‘PLWH’) with antiretroviral therapy (‘ART’) has stalled, with 25 percent still untreated, and HIV incidence remains high. Every day, 1500 girls and young women in Africa, 1500 members of key populations, and 330 children acquire HIV worldwide, resulting in 1.3 million new infections in 2024. HIV incidence rates continue to rise in Eastern Europe, Central Asia, South America, and in conflict regions, and outbreaks continue in key populations in all countries.
Before and after PEPFAR
In the 1990s, there were 2 million deaths due to HIV per year in Africa, life expectancy was falling substantially, fewer than 50,000 people were on ART, and HIV prevalence was around 8 percent. The US Congress passed PEPFAR in 2003 with a pledge of 15 billion dollars to support selected countries in Africa, Vietnam, and the Caribbean for HIV prevention and treatment. Roughly 60 percent of PEPFAR funding has been implemented through USAID, and because of PEPFAR and USAID, the US provided ART for 50 percent of all PLWH in sub-Saharan Africa and most of the PrEP (used to prevent acquisition of the virus) for HIV prevention among key populations at risk in sub-Saharan Africa. One analysis found that PEPFAR saved 26 million lives and prevented 2.9 million HIV infections in adults and in 7.8 million babies from 2004-2013 in 16 African countries. As importantly, PEPFAR supported HIV research centers, training activities, and the associated laboratory support and infrastructure necessary for ongoing HIV research, care, and prevention.
Also, before PEPFAR, the magnificent Global Fund for AIDS, TB, and Malaria (GFATM) was inaugurated in 2002. It has provided 69 billion dollars in 155 countries through an open bidding process to date, and it is estimated to have saved 70 million lives and provided testing, prevention, and care to hundreds of millions of people worldwide. The US has been the largest donor to GFATM, contributing roughly one third of donations for a total of 27 billion dollars from inception to 2026.
By 2024, 55 countries worldwide received PEPFAR support. In Africa, the HIV prevalence declined from 8 to 5 percent, 21 million people were on ART due to PEPFAR, and a total of 31 million received ART with GFATM and other support. Death rates in sub-Saharan Africa decreased by 57 percent, life expectancy was returning to pre-pandemic levels, 2.5 million people were newly enrolled on PrEP, 83.8 million people were provided with HIV testing, and 342,000 health workers were directly supported by PEPFAR. In 2014, PEPFAR led the DREAMS public-private partnership in 15 countries in Africa with an investment of 2 billion dollars for comprehensive HIV prevention in girls and young women. To date, that program has reached 2.3 adolescent girls and young women and reduced new HIV infections by 25-40 percent. The Key Populations Investment Fund similarly prioritized equity-focused prevention and care for key populations.
The impact of PEPFAR was not limited to HIV. During the COVID pandemic in Africa, 42 percent of national SARS testing occurred in PEPFAR supported laboratories. Over its first 20 years, 13.4 million people at high risk of TB started TB preventive therapy, and 7.1 million orphans and vulnerable children were provided with critical care and support. PEPFAR and USAID also supported malaria prevention and treatment services, humanitarian assistance for migrant and displaced persons from conflict regions and natural disasters, food and clean water programs, and others too numerous to list.
From 2001-2022, USAID programs were estimated to have reduced mortality in adults in Africa by 15 percent or 91.8 million persons and in young children by 32 percent or 30.4 million children. In the same era, USAID funding prevented 8 million deaths from malaria, 8.9 million deaths from tropical illness, and 25.5 million deaths from HIV. USAID humanitarian assistance also led to substantial reductions in deaths from TB, malnutrition, diarrheal illness, and maternity. Greater health and longer survival have been associated with rising household incomes and a greater likelihood of children staying in school and receiving improved nutrition.
Best practices in HIV care and prevention increasingly employed human-rights based foundations. Diversity, equity and inclusion were essential elements, including the respectful engagement of community in care systems and health policy and person-centered care that respected the rights and dignity of each individual. A recent study found that key population empowerment and active engagement yielded the biggest improvements in HIV care and viral suppression. Key populations include men who have sex with men, transgender individuals, sex workers, people who inject drugs, and the sexual partners of these individuals. Sensitivity to the special needs for women, children, and families with HIV was proven to decisively improve care and prevention. Service integration of HIV into mainstream primary care and maternal-child health systems has offered desirable cost efficiencies, but local law and custom make it unsafe for PWH to seek care in many countries. The unique aspects of combined HIV and gender-affirming care for transgender and non-binary individuals, both adult and children, was extremely challenging in 2024, and it has been further strained by the heinous legal and cultural attacks on their very existence.
‘Annus Horribilis’ 2025
On January 20, 2025, President Trump issued a series of executive orders affecting USAID and PEPFAR that resulted in a 90 day budget freeze, an immediate stop work order, and limited waivers for some services, as well as the cancellation of most PEPFAR sub-awards and the abrupt dissolution of USAID by Elon Musk and Department of Government Efficiency (‘DOGE’).
The limited waiver exceptions were supposed to include critical medical care and treatment, but their implementation and enforcement were chaotic. Explicitly prohibited activities included key population actions, orphan support, social and behavioral change, circumcision, all other PrEP, and community led monitoring. These stipulations recalled the early days of PEPFAR when some requirements ran counter to established science, as with the demand for abstinence-based HIV prevention, a widely discredited strategy for HIV prevention. With no clear preparation or enforcement of these nuances, HIV care and support services were immediately disrupted or suspended altogether, budgets were frozen, and services for health care, lab support, community health, and prevention were frozen, and ultimately abandoned as workers were laid off and sought work elsewhere.
At the same time, President Trump also defunded collaboration with UN organization, withdrew the US from WHO, defunded NGOs not aligned with administrative priorities, ended support for South Africa, and he issued expansive orders to eliminate global activities promoting best public health practices for key populations and programs that address health diversity, equity and inclusion, and gender equity.
The PEPFAR alternative – the ‘America First Global Health Strategy’ – was made public in September 2025. While maintaining support for commodities and front line health workers, it called for bilateral country agreements and required a rapid reduction in non-front line support and program consolidation by December 2026. PEPFAR had already achieved 50 percent reductions in per capita spending and 30 to 50 percent increases in country contributions from 2010-2024 under the leadership of Eric Goosby, Deborah Birx, and John Nkengasong. As of February 2026, 16 country Memoranda of Understanding were completed for a total pledge of 11.2 billion dollars. Notably, South Africa, the country with the highest HIV burden globally, has not been included. Overall, the current pledges will result in a 4.5 billion dollar decrease in US funding for PEPFAR countries over a 5 year period.
Impact of PEPFAR and USAID cuts on HIV in Africa
Reliable national data has been a critical casualty of the chaos at PEPFAR and USAID. Local data may offer more reliable information. In a representative population-based study of 36 clinics in Kwazulu Natal, South Africa, 40 percent of clinics reported disrupted services in 2025. This included 30 percent reductions in medical and nursing staff, 30 percent reductions in clerical and data entry support, and 25 percent declines in community health workers. The disruptions were widespread and involved health facilities beyond those directly funded by PEPFAR, undermining the whole health system and disrupting services for 830,000 PLWH which is 50 percent of PLWH in the province.
Another recent study of 68 clinics in 32 countries in Africa found that 47 percent had experienced serious service disruptions in 2025. These included loss of HIV medications in 28 percent, lab service interruptions in 34 percent, and 47 percent disruptions of data and specimen tracking and patient outreach. Taken together, these local studies suggest a profound disruption of health care services for large portions of the population.
A 90 day delay in ART was found to lead to 100,000 excess deaths in a credible modeling study, and longer term disruptions could cause 7.5-13.4 million deaths by 2030. Another analysis in 26 PEPFAR countries found 4.4-10.7 million new infections and 77-2.9 million deaths over 5 years in the absence of PEPFAR. Another modeling study predicted 25 million excess deaths by 2040. Also, without PEPFAR by 2030, one half million children with HIV will die, 1 million children will be infected with HIV, and 2.3 million children will be orphaned. An analysis of USAID cuts predicted an excess of 14 million deaths by 2030. The variability of these terrible numbers is of less consequence that their consistency in pointing towards overwhelming increases in deaths and transmissions of HIV.
Before 2025, 80 percent of global PrEP use was in Sub-Saharan Africa, and following these cuts, 11 countries reported reductions in PrEP access, including declines of 81 percent in Nigeria and 13 percent in South Africa. In total, 2.5 million PrEP users in Africa lost access to PrEP in 2025.
Credible estimates of 4 to 15 percent reductions in health care services at the national level reinforce this evidence. From 75 to 100 percent of key population services were lost in seven African countries. The UK, Germany and other countries have announced funding cuts for HIV services in Africa of 25-40 percent, further undermining HIV care and prevention in Africa in 2026. The global health diplomacy shown by the US in 2025 has opened the door for policies based on regression and isolation.
Implications for the future of HIV
US funding cuts in Africa have cost lives and abandoned proven, rights-based public health practices. Simultaneous attacks in the US and abroad on transgender individuals, reproductive justice, LGBTQ+ individuals, people who inject drugs, and sex workers have exacerbated stigma and discrimination and pose an additional lasting threat to progress with HIV.
In the US, the Trump administration ended programs that address health diversity, equity, inclusion, and gender equity and attempted to undermine programs promoting best public health practices in HIV care and prevention for key populations and women at risk. A vivid example is the attempt to reduce funding by 535 million dollars for the Ryan White CARE Act (‘Ryan White’) in the 2026 budget. The Ryan White CARE Act in the US supports HIV medications, health care, and support services for low income people with HIV infection. A credible modeling study found that defunding Ryan White would lead to the loss of effective HIV treatment for 65 percent of enrollees in the AIDS Drug Assistance Program and 49 percent of primary care recipients in Ryan White supported clinics, and a 73 percent increase in the incidence of HIV in 30 states over 5 years.
All evidence suggests that activism, advocacy, and inclusion of key populations and the expansion of community-based service has been a critical component of the progress in HIV prevention and care to date in Africa and in the US. This is why the lesser known ‘WHO 10/10/10 goals’ are valued equally to the treatment goals. PEPFAR explicitly endorsed these goals in 2024. Inclusion and community engagement ensure that people at risk of HIV can safely receive prevention services, and PLWH can safely receive lifesaving medications for HIV and TB. Diversity in programming ensures that all voices are heard, including those most vulnerable to HIV. Community engagement led the National Institutes of Health (‘NIH’) to faster new drug development and approval at the NIH and US Food and Drug Administration in the 1980s and 1990s in the US. It is a serious mistake for the Trump administration to ignore the merit of these evidence-based practices and enshrine discriminatory policies that will worsen stigma and undermine decades of progress in HIV care and prevention.
The resounding theme of the 2025 World AIDS Conference in Rwanda was, “We will not go back,” and yet the cuts to PEPFAR and USAID have set the world directly in that direction. The Kigali Declaration (2025) called for meaningful partnerships that are respectful of the rights and dignity of PLWH and collaborative global research with meaningful access to scientific advances such as long-acting therapy, telehealth and artificial intelligence. It also explicitly prioritized HIV prevention and the protection of scientific integrity and human rights.
Jonathan Mann, the father of HIV and Human Rights, said that “AIDS shows us once again that silence, exclusion, and isolation—of individuals, groups, or nations—creates a danger for us all.” He also said that each country would be judged by its management of the HIV pandemic. By withdrawing funding and reversing decades of progress towards diversity, equity and inclusion in effective HIV care and prevention and by promoting discrimination towards PLWH and vulnerable populations at risk of HIV, the Trump Administration has taken us in a dangerous direction and ensured that their actions will be judged harshly.