In the initial months of the second Trump administration, US foreign aid infrastructure was rapidly dismantled, including the United States Agency for International Development (USAID), a principal implementing agency of the President’s Emergency Plan for AIDS Relief (PEPFAR). This abrupt policy shift placed the lives of millions of people living with HIV at risk and significantly weakened global HIV prevention efforts. Numerous health services and local organizations were forced to close, staff were dismissed, and essential HIV services became inaccessible. Concurrently, financial support was withdrawn from the Joint United Nations Programme on HIV/AIDS (UNAIDS). These changes were enacted without prior notice, consultation or international coordination, and unfolded in the context of a global HIV response unprepared for such a disruption. While the consequences are severe, this unprecedented circumstance offers a critical moment for reflection and reimagining the future of the HIV response.
Introduction
The consequences of the election of Donald Trump as the 47th president of the United States of America are seismic, sweeping and global. They include remaking the US federal government by deepening executive power, restructuring the administration by slashing staff and budgets, reversing progressive social policies, initiating trade wars, and dismantling foreign aid. This latter process, which has been advanced through the newly formed Department of Government Efficiency (DOGE), led by billionaire Elon Musk, significantly harms aid recipient countries and people, and erodes decades of trust and goodwill.
In this paper, we explore the consequences of these shifts related to support for PEPFAR, which was mainly implemented by USAID.1
PEPFAR was established by President George W. Bush in 2003 as a primarily humanitarian five-year effort to “prevent 7 million new AIDS infections, treat at least 2 million people with life-extending drugs, and provide humane care for millions of people suffering from AIDS and for children orphaned by AIDS.”2 PEPFAR initially focused on 14 countries in Sub-Saharan Africa and the Caribbean, and was continued by the US Congress through iterative reauthorizations every five years. The most recent reauthorization was in March 2024, for one year.3
PEPFAR’s mandate grew to support more than 50 countries, as well as contributing to the Global Fund — a multilateral partnership to defeat HIV, tuberculosis (TB), and malaria in low- and middle-income countries — and supporting UNAIDS. The US government disbursed more than US$120 billion in aid through PEPFAR over two decades. In 2024, $4.8 billion was committed to bilateral efforts, $1.65 billion to the Global Fund to Fight AIDS, TB and Malaria, and $50 million to UNAIDS.
USAID was one of the first US agencies dismantled by DOGE. It was denounced as “a criminal organization” by Musk, and as “being run by radical left lunatics” by Trump.4 In February and March 2025, mass layoffs resulted in the dismissal of thousands of US-based and international staff, and the closure of the agency’s headquarters in Washington, DC. Although PEPFAR was not explicitly named in the restructuring, and assurances were made that waivers would safeguard essential health programs, it soon became evident that USAID’s core administrative and financial infrastructure had become inoperative — effectively halting global implementation of aid programs.5
PEPFAR kept 26 million people alive and prevented 7.8 million HIV infections among infants.6 In 2023 alone, PEPFAR provided HIV testing for 71.1 million people, antiretroviral therapy (ART) for 20.4 million people, and critical care and support for 7 million orphans and vulnerable children. Prevention programs reached millions of people, reduced mother-to-child (vertical) transmission;7 increased access to pre-exposure prophylaxis (PrEP);8 expanded medical male circumcisions;9 distributed condoms; provided harm reduction kits for injecting drug users;10 undertook community-based programs for adolescent girls;11 strengthened human rights responses; addressed gender inequalities;12 and directly supported 327,000 healthcare workers.13
The dismantling of USAID and the immobilization of PEPFAR occurred without warning, congressional oversight or consultation with implementing partners. There was no engagement with affected countries through diplomatic channels, nor with representatives of HIV networks and civil society organizations. There was no opportunity for a phased, coordinated transition or contingency planning.
Countries and implementers were rightly dismayed — especially given that PEPFAR’s work was framed as a partnership guided by core principles and values, including “respect and humility…in every interaction we have with our partners and beneficiaries,” “accountability and transparency… committing to being open and public with all critical information on our intentions and programmatic results,” and assurance of “sustained engagement.”14 DOGE did not consider these ethical obligations and rode roughshod over decades of work, undermining trust and violating the US Constitution in the process.15 , 16
With USAID and many of its staff removed, Trump aides outlined a new vision for US foreign aid. This includes establishing a new “Agency for International Humanitarian Assistance” with new priorities, including pursuing economic and geopolitical advantages through aid.17 A list of USAID contracts was presented to the US Congress to support this transition. At the time of writing, early March 2025, more than 5,300 contracts had been cancelled, with 898 remaining, including around 75 involving HIV.18
It was confirmed that funding for UNAIDS was withdrawn — approximately 40 percent of its operational budget. This weakens the organization’s capacity to collate and disseminate country and global data on HIV, support policies and guidance on HIV programming, and assist countries with resource mobilization, program implementation and sustainability.19
A letter of intent to withdraw United States membership and funding from the World Health Organization (WHO) by January 2026 was issued in January 2025. An executive order by President Trump also limited any official engagement with the WHO in the interim.20 These steps have negative implications for the WHO’s complementary support for the HIV response.
Funding obligated to the Global Fund — a multilateral funding agency addressing HIV, TB and malaria, mainly in low- and middle-income countries — was kept in place. The Global Fund pools funds from country donors, foundations and the private sector. The United States contributed $6 billion to the 2023–2025 funding cycle. The 2026–2028 cycle appears to be obligated at a similar level.21 Whether or not this funding is sustained for the new cycle, the economic impacts of tariffs and other consequential actions taken by the Trump administration may reduce funding commitments from other donors.
An Emerging Crisis
Over the past two decades, PEPFAR has established itself as a significant and impactful global health initiative. However, its approach to HIV response included implementing projects at high cost and uneven coherence across countries. Each authorization of PEPFAR by the US Congress included realignment based on fiscal, ideological, geopolitical and legislative concerns,22 and the diverse needs and contexts of recipient countries did not always align seamlessly with PEPFAR’s programmatic framework. Critiques included a propensity for vertical programming, lack of integration with other health concerns,23 limited emphasis on local ownership and sustainability,24, 25 conditionality and restrictions in funding,26 imbalanced resource allocation and limited effectiveness.27
Despite these shortcomings of the program, the immediate withdrawal of funding places lives at risk, especially in Sub-Saharan Africa, where more than 26 million people live with HIV, representing 66 percent of the global total of nearly 40 million people.
The list of contracts submitted by Trump aides mainly includes HIV projects in southern and East Africa, with a few in Latin America and Ukraine. Numerous contracts in countries including Malawi, Namibia, South Africa, Tanzania and Uganda were cancelled, as were dozens of contracts in other Sub-Saharan African countries, Latin America and the Caribbean, and Asia. Large-scale HIV research studies were also terminated.
For countries with reprieved HIV contracts, the main challenges are ensuring continuity of activities in a context where payments are not forthcoming, staff have already been let go, and HIV commodities and service points are not immediately available. For many projects, there will be no continuity due to termination, and responding to critical gaps without resources is immediately necessary. Lives will inevitably be lost, and health and well-being for many will be compromised. For example, ART must be taken continuously by people living with HIV to avoid health complications. Interruptions weaken immunity and increase the risk of advanced HIV disease. Adherence to ART also significantly reduces HIV viral load, thereby preventing onward transmission of HIV.
Prevention of mother-to-child transmission requires sustained access to drugs and supportive services,28 and HIV prevention depends on access to commodities, including condoms, PrEP29 and voluntary medical male circumcision services. Gaps are inevitable, and new infections will increase as PEPFAR is cut.
Reliance on PEPFAR for financing a large proportion of country HIV responses has been widespread. In Côte d’Ivoire, Haiti and the United Republic of Tanzania, PEPFAR accounted for more than 90 percent of HIV program funding. In Ethiopia, Jamaica, Lesotho, Liberia, Malawi, Mozambique, Nigeria, Rwanda, Senegal, Uganda, Zambia and Zimbabwe, this proportion ranged from 50 to 89 percent. In 12 other countries, mostly in Sub-Saharan Africa, PEPFAR support accounted for 30 to 49 percent of funding.30
UNAIDS has documented immediate concerns. By mid-March 2025, for example, HIV prevention programming in Tanzania was halted, and there were imminent stock-outs of ART. Technical support for health facilities also ended. In Botswana, HIV support services carried out by civil society organizations were curtailed. In Mozambique, two million people living with HIV relied on services primarily provided by PEPFAR that were shut down, with employment of nearly 20,000 community health workers and thousands of other healthcare providers terminated. In Malawi, many non-governmental organizations halted their HIV services, and more than 3,000 healthcare workers and treatment supporters lost their jobs. In South Africa, 40 health projects were cancelled.31
Most PEPFAR projects supporting key populations — those at higher risk of HIV infection and more likely to be marginalized when seeking treatment — have been cancelled. Support has also been withdrawn for country health data systems and surveys, which are crucial for health planning.
Although the full impacts of the funding cuts have yet to be determined, a modelling study of 26 lower- to middle-income countries explored the potential impacts of a 24 percent reduction in international aid in combination with a PEPFAR funding withdrawal.32 It was estimated that there would be an additional 4.4 million to 10.7 million new HIV infections and 770,000 to 2.9 million AIDS deaths over the 2025–2030 period (with key populations more likely to be impacted), in comparison to a scenario where there was sustained funding.i
The Role of PEPFAR in the Global HIV Response
Although US investments in PEPFAR, the Global Fund and UNAIDS have undeniably contributed to saving millions of lives, they also promoted siloed, disease-specific systems for HIV response. These vertical approaches stand in contrast to more integrated, cost-effective strategies that are also more sustainable.
Donor funding requires effective systems and accountabilities for managing large budgets, and these follow centralized, top-down modalities that necessitate metrics allowing for matching funding inputs with measurable outputs and results. Procuring, dispensing and managing ART is readily measurable, as are HIV prevention commodities and services. This has contributed to the biomedicalization of the HIV response, which continues to be pursued. For example, investing in Lenacapavir, a newly developed PrEP medication that is effective for six months, has been widely advocated but will be disproportionally costly to implement and challenging to scale up in the context of PEPFAR cuts. 33, 34
In contrast to biomedically focused HIV prevention, people-centred, activist-driven and multisectoral mobilizations have been demonstrably impactful in reversing HIV epidemics in the past. Examples include early responses to HIV such as the activism and peer support led by gay men in the United States,35 political and multisectoral leadership and community engagement in Uganda,36 empowerment and education among sex workers in Kolkata, India,37 and Thailand’s 100 percent condom campaign, led by government and other stakeholders.38
High-budget, centralized HIV programs also negatively impact community-led organizations that have responded to HIV at the grassroots level. When PEPFAR and the Global Fund were established in the early 2000s, external donor support to community-based and non-governmental organizations declined in favour of countries contributing their HIV funding to the Global Fund.39 These funds were then delivered through government-approved, centralized mechanisms, with some financing managed by larger non-governmental agencies to support selected smaller entities. PEPFAR followed a similar approach, although funds were channelled through US implementing partners, or directly to selected local non-governmental organizations.
The global goal of ending AIDS by 2030, set by the United Nations General Assembly in 2016, and linked to the SDGs, led to UNAIDS modelling that determined HIV targets for 2020 and 2025. Prominent among these were the 90-90-90 and 95-95-95 targets40 for ART uptake and viral load suppression, which include ensuring people living with HIV remain healthy, and preventing HIV transmission through sustained viral load suppression. Achieving the 2025 targets has proven elusive, with only nine countries achieving them in 2024, and 10 more considered to be on track.41 Achieving the goal of ending AIDS is likely now more elusive, considering the challenges in sustaining high levels of ART uptake and viral load suppression in the context of the US funding withdrawal.
Targets have been set for the uptake of HIV prevention commodities and services, and UNAIDS has also formulated targets for the social aspects of response. These include the 10-10-10 targets42 that focus on removing the social and legal barriers to an effective HIV response and the 30-80-60 targets43 that focus on ensuring that people and communities affected by HIV, including key populations, are meaningfully involved in leading HIV responses.
Although these targets are nearly impossible to measure (as they require complex research to assess), they have helped orient programs towards addressing inequalities — including through PEPFAR funding.44 However, projects addressing these aspects have not been recommended for ongoing funding by the current Trump administration.
The goal of ending AIDS by 2030 requires nearly all people living with HIV to be on treatment, and new infections to have declined to very low levels. Achieving this goal has supported strong arguments for increased donor funding and intensive programming for the coming period, which is now unlikely, given shortfalls in PEPFAR commitments, in combination with the impacts and crises emerging due to the withdrawal of US foreign aid across multiple sectors.
Most wealthy countries have already folded their foreign aid agencies into other arms of government and reduced foreign aid commitments. For example, the UK Department for International Development was subsumed into the Foreign, Commonwealth and Development Office, and is now shifting development funds into defence spending and support for asylum seekers in the United Kingdom. Numerous other European countries have also followed this approach. Canada merged the Canadian International Development Agency into Global Affairs Canada, and countries such as China may provide support, but do not have the immediate expertise and systems needed to pivot to health programming. Philanthropic foundations do not have sufficient resources to fill the gap.45
Low- and middle-income countries have no choice but to overcome their dependency on foreign aid for funding their HIV responses, and innovative financing and lower-cost programming must be prioritized. This includes moving away from siloed and vertical programming for HIV towards integrated and holistic approaches to healthcare, for which models already exist. Examples include primary health care,46 task shifting and community health,47 digital health,48 and health systems strengthening.
While resources must be found for HIV commodities and health services, opportunities for strengthening multisectoral and civic responses must be explored in addition to incorporating socio-cultural and behavioural approaches.
Innovative approaches can be adopted or strengthened to fund HIV responses. In 2016, for example, these were explored for the African Development Bank;49 they included health trusts or endowment funds, social health insurance, airline levies, consumption taxes (such as Botswana’s proposed alcohol levy), debt swap agreements and concessional borrowing. Community groups could also be funded locally through the private sector or philanthropic initiatives.
The sustainability of HIV responses must also be addressed. This includes ensuring that sustainability is integrated into all HIV programming, with both medium- and long-term considerations considered. For example, people living with HIV need lifelong treatment that will extend well beyond 2030. The Global Fund and UNAIDS developed guidelines for sustainability roadmaps with support from PEPFAR, and several countries have undertaken sustainability planning.50 Any existing plans will now need to be revised to consider new circumstances, and the Global Fund would do well to prioritize integration and sustainability planning in any forthcoming grants.
Conclusions
The rapidity and scale of current shifts in the foreign aid landscape constitute what polymath and influential academic Nassim Taleb describes as a Black Swan event.51 Such events involve a combination of seemingly unpredictable “unknown unknowns” with highly significant consequences worldwide. Previous occurrences include the 9/11 attacks of 2001, the financial crisis of 2007–2009, and the COVID-19 pandemic. They illustrate a lack of global resilience and have immediate and far-reaching consequences.
Black Swan events give rise to retrospective analyses that suggest “we should have seen that coming.” However, in real terms, whatever breadcrumbs there may have been on the trail, the present catastrophe at the hands of President Trump, and the seismic shifts set to follow, are beyond all reasonable expectations.
Should we have seen it coming? The AIDS pandemic and response were exceptional, and focused attention has been sustained for decades.52 Princeton Lyman, a former US ambassador to South Africa, suggested wealthy countries were not keen on writing cheques forever.53 The most recent US congressional authorization of PEPFAR for only one year was a warning sign. Project 2025, the Heritage Foundation’s blueprint for “an effective conservative administration,” also suggested ideological realignment and reduced funding for USAID.54 Nevertheless, until 2025, the United States largely upheld its commitment to foreign aid, recognizing the strategic value of soft power and often compensating for funding gaps left by other donors. Against this backdrop, the scale and abruptness of the withdrawal from global health commitments — particularly in the manner executed — was both unprecedented and difficult to anticipate.
It was easy for many countries to deepen their dependency on foreign aid, despite efforts among all donors to encourage localization. PEPFAR, the Global Fund and UNAIDS have all considered transition planning an inevitable necessity, and there was some progress before 2020.55 The impetus was lost with the advent of the COVID-19 pandemic, but countries are now bound to sharpen their focus on opportunities to re-envision their HIV responses, including building resilience.
A recent analysis of external assistance in Eastern and Southern African countries with high HIV prevalence highlighted the complex challenges associated with transitioning from donor-supported to domestically led HIV responses. The study found that treatment programs have been prioritized at the expense of primary prevention efforts, and HIV services remain insufficiently integrated into broader primary healthcare systems. Structural barriers — such as stigma, discrimination and punitive legal frameworks — continue to limit access to services for key populations. Moreover, the capacity of local organizations and communities to support the HIV response remains constrained. The analysis emphasized the importance of investing in local capacity development, strengthening primary prevention and fostering greater political commitment as critical strategies for reorienting national responses in a more sustainable and equitable direction.56
In the final analysis, complex and unanticipated factors underpin the Black Swan event introduced by the Trump administration, and remarkable changes are underway across a broad spectrum of US domestic and international politics, including health. Unfortunately, it appears that ideological zeal and antipathy will magnify adverse outcomes, and countries will do well to remain wary of any new vision of US foreign aid — especially as they are heavily weighted towards securing economic and geopolitical advantages for the United States. Instead, they should seek new and respectful partnerships that recognize mutuality, avoid dependency, address immediate health emergencies, and support sustainable health responses.
