Over the past two decades, a U.S. program that helps prevent and treat HIV/AIDS has saved more than 26 million lives around the world. The U.S. President's Emergency Plan for AIDS Relief, better known as PEPFAR, has been credited with changing the course of the global HIV epidemic for the better. But that progress is now in jeopardy, thanks to Trump administration actions.

PEPFAR took a massive hit from Trump’s Jan. 20 executive order that froze funding for the U.S. Agency for International Development, which is the home to the program. PEPFAR relies on USAID for nearly two thirds of its budget to deliver HIV prevention and treatment services in 55 countries.

“There’s pauses and delays in funding that are causing disruptions at the clinic level and patients are being turned away from care,” Jirair Ratevosian, DrPH, MPH, a former chief of staff to PEPFAR at the U.S. State Department, told The Nation's Health. “There's a lot of still confusion and logistical challenges that have been created due to the funding freeze that are still being sorted out and that is causing more delays to programs.”

A Feb. 1 U.S. State Department waiver for PEPFAR to continue services came with limits, such as focusing on those that help prevent transmission between mothers and their children, according to the Foundation for AIDS Research, also known as amFAR. As news of the waivers failed to trickle down to global providers, delivery of services had already been halted at some sites, with people with HIV turned away from treatment.

A January amFAR survey of over 153 providers in 27 countries found 36% had to completely shut down their services. About 80% of respondents said PEPFAR accounts for at least half of their budgets. As many as 220,000 people receive PEPFAR-funded HIV treatments daily, including 7,000 children, according to the survey.

Recent staff purges at the Centers for Disease Control and Prevention added fuel to the fire. Since Feb. 13, the Trump administration has fired as many as 1,300 CDC workers who were in their one- to two-year probationary periods as of 2024. A third of PEPFAR’s budget comes from CDC and the staffing loss is expected to impact global programs.

While the global health community deals with the fallout from the funding pause, experts say the long term impacts of a potential permanent funding loss are sobering. In South Africa alone, shuttering PEPFAR would result in 601,000 HIV-related deaths, 565,000 new HIV infections and lower life expectancy by 3.71 years in the next decade, according to a Feb. 11 Annals of Internal Medicine study.

“I think the global health architecture in what we’ve seen over the last four weeks, it’s very interconnected across different agencies,” said Ratevosian, who is a Hock Fellow at Duke Global Health Institute and a Governing Council member for APHA’s International Health Section. “It’s driven by competent, educated, smart, driven, innovative staff that need to be part of its operations. What we do here matters to the rest of the world. It matters to people’s lives. It matters to people’s day to day, and our actions have consequences. Sometimes those actions can be deadly if we’re not taking full consideration of the actions that are being proposed.”

The funding uncertainty comes at a time when PEPFAR was reaching milestones in HIV prevention. Prior to the funding freeze, PEPFAR had entered a partnership in December to provide 2 million people with lenacapavir, a long-acting injectable HIV pre-exposure prophylaxis medication that awaits U.S. Food and Drug Administration approval. PEPFAR is responsible for more than 90% of PrEP initiations worldwide, according to the U.S. State Department.
The pause on USAID funding ground foreign aid and the global health infrastructure to a halt. As of Monday, the Trump administration had plans to put almost all of USAID's 4,700 employees on leave and end 1,600 positions, according to the Associated Press.

“Global health is less than 1% of the total budget,” Ratevosian said. “But programs like PEPFAR — and overall our foreign aid portfolio — they promote economic development around the world. They advance humanitarian goals. They create trade. They create global health security. All those things ultimately make America more prosperous. They make America more safe. They make America more secure.”

Health advocates and activist groups such as the Treatment Action Group protested the freeze on PEPFAR at the State Department in Washington, D.C., on Feb. 6, decrying the assault on HIV treatment as well as the temporary blackout of health agency website data for vulnerable populations that are more susceptible to infectious diseases. Nearly 40 million people worldwide were infected with HIV at the end of 2023, according to the World Health Organization.

“What we’ve seen from the incoming administration is just sickening,” Treatment Action Group Executive Director Mark Harrington said in a Feb. 6 statement. “Activists have spent four decades fighting for expanded government investment to prevent, treat, and ultimately end HIV. Science and policy advances, including PEPFAR, have saved and are saving tens of millions of lives in communities around the world. We’re unwilling to stand by and let the new administration destroy decades of progress against one of the world’s deadliest pandemics.”

Dozens of members of Housing Works, an advocacy group for people living with HIV/AIDS, marched in Washington, D.C., Feb. 6 to protest the freeze of PEPFAR funds by the Trump administration. (Photo courtesy Housing Works)