2 weeks ago

Background on PEPFAR

• The President’s Emergency Plan for AIDS Relief (PEPFAR), first authorized in 2003, is the largest commitment by any nation to address a single disease, working in more than 50 countries.
• PEPFAR is credited with having saved 26 million lives and enabling 7.8 million babies to be born without HIV infection. Studies have also found that PEPFAR funding is associated with several “spillover” effects including significant reductions in all-cause mortality, increases in childhood immunizations and in GDP growth, and retention of children in school.
• PEPFAR has been reauthorized by Congress four times, most recently in March 2024 for one year. Although that authorization expired on March 25, 2025, PEPFAR is a permanent part of U.S. law and, other than a set of eight time-bound provisions, continues as long as Congress appropriates funding.
• The FY 2025 Continuing Resolution that passed in March included level funding for PEPFAR’s bilateral programming at USAID, State, and CDC, and DoD of $4.85 billion (as well as level funding for the Global Fund to Fight AIDS, Tuberculosis and Malaria and UNAIDS). The U.S. is the top donor government to HIV efforts, through PEPFAR and its contributions to the Global Fund.
• PEPFAR is overseen by a U.S. Global AIDS Coordinator, a Senate-confirmed position appointed by the President and holding the rank of ambassador, at the State Department’s Bureau of Global Health Security and Diplomacy (GHSD). GHSD coordinates its implementation through other government agencies (primarily USAID and CDC) and with implementing partners, civil society, and recipient countries.

Current Status of PEPFAR

The following administration actions have had a significant impact on PEPFAR operations:

• Funding freeze/stop-work order: The stop-work order initially froze all PEPFAR programming and services, halting existing work in the field, including provision of antiretroviral therapy. Because it halted payments, many implementers had to let go of thousands of staff and end some services.
• Limited Waiver: PEPFAR received a limited waiver on February 1 (with additional information on February 6), allowing it to continue “life-saving HIV services”. However, the waiver only permits certain activities: HIV treatment and care, prevention of mother-to-child transmission (PMTCT), pre-exposure prophylaxis (PrEP) for pregnant and breastfeeding women, and HIV testing. Other services, including PrEP for anyone else (including those already on PrEP) and HIV prevention more generally, as well as programming for orphans and vulnerable children, are not permitted. Even with the waiver, implementers have faced challenges in getting permission to resume HIV programming and difficulties in getting paid.
• Dissolution of USAID: USAID was the main government implementing agency for PEPFAR, obligating 60% of its bilateral assistance in FY 2023. Without USAID and most of its staff, PEPFAR’s implementation capacity has been affected. In addition, recent announcements of reductions at CDC, PEPFAR’s second largest implementing agency (obligating 37% in FY 2023), could further affect PEPFAR.
• Canceled awards: It was recently reported that the administration has canceled 86% of all USAID awards. KFF analysis finds that of the 770 global health awards identified, 379 included HIV activities, 71% of which were terminated, including several HIV treatment awards as well as most HIV prevention.
• Legal actions: In response to two lawsuits filed against the administration’s actions, a federal judge issued a preliminary injunction ordering the government to pay for work completed by February 13, 2025, although not all payments have been made and the court has not stopped the government from canceling awards.
• Reorganization. The administration notified Congress on March 28, 2025 of its intent to permanently dissolve USAID and that any remaining USAID operations would be absorbed by the State Department with remaining global health activities to be integrated into GHSD.

Impact on PEPFAR Services and Outcomes

Numerous reports have documented the impacts of these actions on services and outcomes:

• A survey of PEPFAR recipients conducted in the first week of the stop-work order (January 24-28) found that more than 60% had laid off staff, 36% had completely closed down, and 86% reported that clients would lose access to HIV treatment within one month if the freeze was not lifted.
• A market assessment in PEPFAR countries found that, as of March 2025: HIV testing had been disrupted in 10 countries and there was a risk of ARV stocks outs in 8 countries, viral load testing stockouts in 13 countries, and oral PrEP medication stock-outs in in 4 countries. Even where HIV commodities were in country warehouses, the pause in PEPFAR support made it difficult, and in many cases impossible, to transport commodities to clinics.
• UNAIDS country offices have identified: the loss of thousands of HIV health workers in Kenya, Malawi, South Africa and Mozambique; disruptions to diagnostic and treatment services for pregnant women and children in Zimbabwe; partial or complete cessation of community outreach services in Angola and Eswatini; and the expected loss of a quarter of the workforce of the largest network of people living with HIV in Ukraine.
• A recent rapid assessment survey of 108 WHO country offices found that almost half reported moderate or severe disruptions to HIV services, including for medicines and health products, due to the U.S. foreign aid freeze and other shortages.
• The roll-out of long-acting injectable PrEP, which PEPFAR had been slated to support, is now at risk.
• In addition to these impacts, modeling studies have estimated that:
  • A 90-day PEPFAR funding pause and associated service disruptions could result in over 100,000 excess HIV-related deaths over a year in sub-Saharan Africa.
  • Ending PEPFAR could result in up to 11 million additional new HIV infections and nearly 3 million additional AIDS-related deaths by 2030 across 26 countries. Another study found that ending funding in all 55 PEPFAR-funded countries could result in an additional 16 million deaths and 26 million new HIV infections by 2040.
  • An additional 2-4 million deaths could occur each year in sub-Saharan Africa.
  • In sub-Saharan Africa, ending PEPFAR funding could result in 565,000 new HIV infections over 10 years and reduced life expectancy of people living with HIV by 3.71 life-years.

What to Watch

• Foreign aid review results: The administration could soon release results of its 90-day foreign aid review (which has already been extended by 30 days), including for PEPFAR. It is unknown whether it will recommend limiting PEPFAR’s activities largely to care and treatment and/or whether other changes will be proposed, and how or if Congress will respond to these recommendations.
• Leadership. The President has not yet nominated a Global AIDS Coordinator and it is unclear when or whether someone will be nominated.
• Reauthorization: It is unknown if Congress will seek to reauthorize PEPFAR, which could afford it an opportunity to propose changes to the program and extend certain time-bound provisions.
• Reorganization. The proposed permanent dissolution of USAID and integration of any remaining USAID global health activities into GHSD, raises several questions, including whether additional capacities will be provided to allow for the management and implementation of PEPFAR as well as other health programs.
• Funding/Budget Request: The administration’s initial FY 2026 budget request includes significant reductions in funding for global health, as well as rescissions to prior year funding amounts. While details are not provided, it notes that funding is preserved for any current PEPFAR beneficiaries. A more detailed budget request is expected in the next few weeks.