PEPFAR Maintains HIV Treatment for 20 Million, But Faces Funding Delays and Service Disruptions
The U.S. President's Emergency Plan for AIDS Relief (PEPFAR) has maintained global HIV treatment levels for over 20 million people, though recent data reveals declines in certain metrics, significant funding delays, and concerns about the sustainability of services as the U.S. government transitions to a new global health strategy. Multiple reports indicate that while core treatment numbers have not collapsed, the program is experiencing operational challenges, including reduced testing, workforce cuts, and disruptions to prevention and support services.
Program Data and Trends
Treatment Numbers
The U.S. State Department released data on September 2025 showing PEPFAR supported over 20 million people on HIV treatment across 50 countries. This represents a slight decrease from the same period a year earlier. Preliminary data indicates the global treatment count dipped by approximately 100,000 people between reporting periods.
Some observers expressed concern about the decline, noting it is the first time in PEPFAR's history that fewer people received therapy compared to the previous year. Other experts, including Jeff Imai-Eaton of the Harvard T.H. Chan School of Public Health, stated that the most severe anticipated outcomes did not materialize.
"The most severe anticipated outcomes did not materialize." – Jeff Imai-Eaton, Harvard T.H. Chan School of Public Health
Testing and Prevention
The number of people receiving U.S.-supported HIV testing decreased from over 80 million to under 70 million in one year. New HIV diagnoses dropped by 13% in clinics without service disruptions and by nearly 30% in clinics with disruptions. Programs for high-risk populations and condom distribution have been reduced. However, the number of pregnant and breastfeeding women starting pre-exposure prophylaxis (PrEP) increased from 43,000 in late 2024 to 103,000 in late 2025.
Workforce and Services
PEPFAR supported a 24% reduction in frontline health care workers. Reports indicate some patients received expired drugs due to supply chain issues and experienced prolonged wait times. Support groups for teenagers with HIV and patient appointment reminder services have been terminated or suspended in some locations.
Policy Transition and Funding Delays
New Global Health Strategy
The Trump administration has been implementing an "America First Global Health Strategy" that aims to transition financial responsibility for HIV programs to recipient national governments. The State Department set a March 31 deadline to negotiate new contracts directly with governments. "Bridge funding" was intended to maintain "existing life-saving activities" during this transition.
The second installment of bridge funding, due in December, was often delayed. For example, funding for programs in Cote d'Ivoire arrived in March, after activities had already been scaled back. Many organizations reported a three-month extension of the bridge plan (April-June), but the arrival of these funds remained uncertain.
Congressional Appropriations
Congress appropriated nearly $6 billion for global HIV/AIDS work for the previous fiscal year, matching prior funding levels. Congress has provided more funds than the administration requested for fiscal year 2026 and pushed back against proposed cuts in 2025.
Allegations of Fund Withholding
Multiple sources, including officials who requested anonymity, alleged the State Department is deliberately withholding some congressionally appropriated funds. Analysis of government spending data by Dr. K.J. Seung of Brigham and Women's Hospital concluded that "much of the money is stuck at the State Department."
Following the dismantling of USAID, the CDC became a primary implementer of HIV/AIDS programs. A CDC official, speaking anonymously, stated that the State Department is "simply not transferring enough of [funds] to CDC to keep these programs running" and described the situation as a "controlled demolition."
The State Department rejected these assessments, stating that funds are being "directed more strategically [and] with greater accountability" and are flowing "as they have always been." The CDC stated it is using "available resources" and directed further questions to the State Department.
"Much of the money is stuck at the State Department." – Dr. K.J. Seung, Brigham and Women's Hospital
Impact on Programs and Personnel
Country-Level Operations
Dr. Caspian Chouraya, who oversees HIV/AIDS programs in 12 African countries for the Elizabeth Glaser Pediatric AIDS Foundation, reported funding delays have necessitated discussions regarding potential layoffs. His organization experienced project shutdowns, including support groups for teenagers with HIV and patient contact services. Funding for Cote d'Ivoire's 53 health facilities was delayed until March, forcing teams to scale back activities.
Community Health Workers
Harerimana Ismail, a community health worker in Uganda whose U.S.-funded salary of approximately $50 per month was terminated in January 2025, continued his work voluntarily by growing vegetables and selling potatoes to sustain himself.
Research Findings on Program Effectiveness
A study published in The Lancet Global Health by Aleya Khalifa and Dr. David Serwadda examined data from over 90,000 children in Uganda's Rakai District from 1995 to 2022. The study found that the number of children who lost a parent declined from nearly 25% in the early 2000s to 6% in 2022. Children with HIV-positive mothers are now approximately twice as likely to be orphaned, compared to 20 times more likely in the mid-1990s. The study attributed this decline to access to antiretroviral drugs (ART) made available through PEPFAR.
"The most effective way to prevent HIV-related orphanhood is to keep parents alive." – U.S. State Department
Official Responses and Concerns
U.S. Government Positions
The State Department stated that "PEPFAR continues to provide HIV testing, care, and treatment services" and that "the most effective way to prevent HIV-related orphanhood is to keep parents alive." The department noted that new global health agreements prioritize life-saving HIV medicines and frontline workers.
Senator Patty Murray (D-Wash.) expressed "serious concern" regarding the delays and uncertainty, stating it is the administration's "legal responsibility to ensure PEPFAR continues to serve people and save lives — without interruption."
Program Sustainability
Dr. David Serwadda reported that significant reductions in foreign aid disrupted HIV treatment programs in Africa, including Uganda, leading to instances where healthcare workers could not deliver drugs due to unpaid wages. While many programs eventually resumed with reduced budgets, some were terminated.
An agreement with Uganda was signed in December to invest up to $1.7 billion over five years to combat infectious diseases, representing a 25-30% reduction compared to previous PEPFAR funding levels. Dr. Serwadda views country-level ownership as potentially more sustainable but expressed apprehension about the transition phase.
The CDC has confirmed it is using "available resources" for HIV/AIDS work. The State Department asserted it is taking "decisive steps to ensure continuity of lifesaving" services.