The Trump Administration’s Foreign Aid Review: Status of PEPFAR

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, 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. has been the top donor government to HIV efforts, through PEPFAR and contributions to the Global Fund. The administration’s FY 2026 budget request includes $2.9 billion for bilateral PEPFAR activities, a decrease of $1.9 billion (final appropriation levels are determined by Congress).
• 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 – before its dissolution – 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 faced challenges in getting permission to resume HIV programming and difficulties 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, announcements of reductions at CDC, PEPFAR’s second largest implementing agency (obligating 37% in FY 2023), could further affect PEPFAR.
• Canceled awards: In early 2025 it was reported that the administration canceled 86% of all USAID awards. KFF analysis found 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. On August 13, the U.S. Court of Appeals for the D.C. Circuit overturned the district judge’s preliminary injunction, ruling that plaintiffs lacked legal standing to challenge the administration’s termination of funding. While a District Court subsequently found that the plaintiffs could seek relief through another legal avenue and granted a preliminary injunction ordering the government to obligate expiring funds, the Supreme Court ultimately ruled that the government could withhold these funds.
• 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. On May 29, 2025, the State Department further notified Congress of its proposed reorganization plan and programs moved in July.
• Long-Acting Injectable PrEP: On September 4, 2025, the administration announced that PEPFAR would partner with the Global Fund to support provision of long-acting injectable PrEP to up to 2 million people in high-burden countries by 2028 (the announcement had initially been made by the Biden administration, and it was uncertain if it would continue).
• New Global Health Strategy: In September 2025, the administration released the America First Global Health Strategy. Per the new strategy, the U.S. will:
  • Negotiate bilateral, multi-year agreements with countries receiving PEPFAR assistance. Agreements will include co-investment by countries and aim to transition the majority of countries to full self-reliance by the end of the agreement period;
  • Provide 100% of current levels of PEPFAR funding for commodities (including antiretrovirals, diagnostics, and preventive medications) and for frontline healthcare workers through FY 2026 and reduced funding thereafter;
  • Rapidly reduce funding for PEPFAR activities other than health commodities and frontline health personnel.

Impact on PEPFAR Services and Outcomes

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

• An analysis conducted shortly after the stop-work order was issued found that 71% of PEPFAR implementing partners reported the cancellation of at least one category of activities; 50% reported staff reductions; and only 14% said they could maintain operations for one month or longer without PEPFAR funding. 
• A recent analysis found that the disruption in PEPFAR funding was associated with reduced access to HIV services and commodities, including antiretroviral treatment, PrEP, and HIV, CD4, and viral load tests.
• UNAIDS offices have identified several impacts including: 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 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.
• In addition to these impacts, several modeling studies have estimated potential effects of funding reductions. For example, one estimated that 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

• Leadership: The President has not yet nominated a Global AIDS Coordinator, and it is unclear when this might occur
• 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 dissolution of USAID, integration of remaining USAID global health activities into GHSD, and other proposed changes at the State Department raise questions about the potential impact on PEPFAR’s operations.
• Funding/Budget Request: The administration’s FY 2026 budget request includes significant reductions in funding for global health, including a $1.9 billion reduction for PEPFAR (final appropriation amounts will be determined by Congress). The administration also submitted its first rescission package to Congress in June, including proposed rescissions of $400 million in FY 2025 funding for PEPFAR. Congress voted to amend the package, exempting PEPFAR from the rescission.
• New Global Health Strategy: Over the next few months, it is expected that the administration will develop bilateral agreements with countries regarding PEPFAR programming and plans to scale down funding, the details of which will significantly shape the future of the global HIV response.