How US Funding Cuts Created a Double Threat to HIV Progress in Africa

THE SUDDEN REVERSAL of United States (‘US’) funding for the global fight against HIV shocked the world in January 2025. The immediate rise in deaths and new HIV infections in Africa has been devastating, and modeling studies predict a durable impact. These cuts abandoned evidence-based practices, further stigmatized key populations, and endangered decades of progress built on a human rights approach to HIV care and prevention. 

In this analysis, we will review the human toll of cuts to the President’s Emergency Plan for AIDS Relief (‘PEPFAR’) and United States Agency for International Development (‘USAID’) through the lens of HIV in Africa and consider the implications for the future of the pandemic globally and in the US. 

HIV in 2026

The HIV pandemic evolved from a global catastrophe to an inspirational triumph of the power of activism, collective action, public health, and science. Among the remarkable global achievements to date are 31 million people with HIV (PWH) receiving treatment, a 57 percent decline in new infections, a decline in annual deaths from 2.5 million to 600,000, and serious planning to end the epidemic in some regions. An integral part of this evolution was a human rights-based approach that offered the best framework for understanding the disease and for effective, evidence-based prevention, treatment, and public policy.

Despite substantial progress, the HIV pandemic remains volatile and uncontrolled in 2026. Momentum towards 95 percent coverage of People living with HIV (‘PLWH’) with antiretroviral therapy (‘ART’) has stalled, with 25 percent still untreated, and HIV incidence remains high. Every day, 1500 girls and young women in Africa, 1500 members of key populations, and 330 children acquire HIV worldwide, resulting in 1.3 million new infections in 2024. HIV incidence rates continue to rise in Eastern Europe, Central Asia, South America, and in conflict regions, and outbreaks continue in key populations in all countries.  

Before and after PEPFAR

In the 1990s, there were 2 million deaths due to HIV per year in Africa, life expectancy was falling substantially, fewer than 50,000 people were on ART, and HIV prevalence was around 8 percent. The US Congress passed PEPFAR in 2003 with a pledge of 15 billion dollars to support selected countries in Africa, Vietnam, and the Caribbean for HIV prevention and treatment. Roughly 60 percent of PEPFAR funding has been implemented through USAID, and because of PEPFAR and USAID, the US provided ART for 50 percent of all PLWH in sub-Saharan Africa and most of the PrEP (used to prevent acquisition of the virus) for HIV prevention among key populations at risk in sub-Saharan Africa. One analysis found that PEPFAR saved 26 million lives and prevented 2.9 million HIV infections in adults and in 7.8 million babies from 2004-2013 in 16 African countries. As importantly, PEPFAR supported HIV research centers, training activities, and the associated laboratory support and infrastructure necessary for ongoing HIV research, care, and prevention.

Also, before PEPFAR, the magnificent Global Fund for AIDS, TB, and Malaria (GFATM) was inaugurated in 2002.  It has provided 69 billion dollars in 155 countries through an open bidding process to date, and it is estimated to have saved 70 million lives and provided testing, prevention, and care to hundreds of millions of people worldwide. The US has been the largest donor to GFATM, contributing roughly one third of donations for a total of 27 billion dollars from inception to 2026.

By 2024, 55 countries worldwide received PEPFAR support. In Africa, the HIV prevalence declined from 8 to 5 percent, 21 million people were on ART due to PEPFAR, and a total of 31 million received ART with GFATM and other support. Death rates in sub-Saharan Africa decreased by 57 percent, life expectancy was returning to pre-pandemic levels, 2.5 million people were newly enrolled on PrEP, 83.8 million people were provided with HIV testing, and 342,000 health workers were directly supported by PEPFAR. In 2014, PEPFAR led the DREAMS public-private partnership in 15 countries in Africa with an investment of 2 billion dollars for comprehensive HIV prevention in girls and young women. To date, that program has reached 2.3 adolescent girls and young women and reduced new HIV infections by 25-40 percent. The Key Populations Investment Fund similarly prioritized equity-focused prevention and care for key populations.

The impact of PEPFAR was not limited to HIV. During the COVID pandemic in Africa, 42 percent of national SARS testing occurred in PEPFAR supported laboratories. Over its first 20 years, 13.4 million people at high risk of TB started TB preventive therapy, and 7.1 million orphans and vulnerable children were provided with critical care and support. PEPFAR and USAID also supported malaria prevention and treatment services, humanitarian assistance for migrant and displaced persons from conflict regions and natural disasters, food and clean water programs, and others too numerous to list.

From 2001-2022, USAID programs were estimated to have reduced mortality in adults in Africa by 15 percent or 91.8 million persons and in young children by 32 percent or 30.4 million children. In the same era, USAID funding prevented 8 million deaths from malaria, 8.9 million deaths from tropical illness, and 25.5 million deaths from HIV. USAID humanitarian assistance also led to substantial reductions in deaths from TB, malnutrition, diarrheal illness, and maternity. Greater health and longer survival have been associated with rising household incomes and a greater likelihood of children staying in school and receiving improved nutrition.