How Trump’s PEPFAR restrictions threaten the HIV global response

.AIDS 2026 | Rio de Janeiro.

Despite promises from the Trump administration to protect HIV care worldwide, the administration’s restrictions and funding cuts to the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) has decimated the global HIV response in a short time, according to findings released at a press conference ahead of AIDS 2026, the 26th International AIDS Conference, being held in Rio de Janeiro, Brazil, July 26–31.

PEPFAR, launched by President George W. Bush in 2003, has saved an estimated 26 million lives worldwide. But according to the new data presented prior to AIDS 2026, PEPFAR cuts and policy restrictions put in place by the Trump administration have undermined HIV prevention efforts in places that most need them. 

Closed clinics, fired health workers, restricted services

Summarizing the PEPFAR Pulse report, conducted between November 2025 and April 2026and compiled from 166 partner organizations across 46 countries, Elise Lankiewicz, policy associate at the Foundation for AIDS Research (amfAR) and the survey’s co-author, said programming partners were affected by PEPFAR restrictions in two ways: termination of awards and a demand to change programming to align with the priorities of this U.S. administration. Lankiewicz said that while core HIV treatment services were less impacted, prevention and wraparound services for treatment have taken a significant hit, with morethan 16,000 full-time staff working in prevention and related services losing their jobs.

“Disruption was widespread,” she said. “No part of [PEPFAR] escaped unscathed, and that includes areas of the program that this administration intended to protect.”

Researchers concluded that in less than one year, PEPFAR cuts resulted in the closing of more than 1,700 HIV treatment sites worldwide, including more than 1,000 public health facilities, 325 access points and 126 drop-in centers, researchers concluded. Just over 20% of treatment providers reported discontinuing at least one HIV clinical care service. Providers also reported reduction or loss of condoms (23%), laboratory commodities (23%), pre-exposure prophylaxis (PrEP) (22%) and antiretroviral medicines (20%).

More than half (52%) of the survey’s respondents said they lost at least one funding award. Locally-based organizations were hardest hit. Those that retained funding were forced to comply with new conditions to keep the money: more than three quarters (77%) said they scaled back activities to comply with new U.S. policy requirements, which include executive orders against diversity, equity and inclusion (DEI), reproductive rights and gender-affirming care, as well as an expanded “global gag rule.” The majority of respondents said they censored their program language (61%) and the same percentage said they discontinued at least one service. Nearly half (44%) ended services for specific populations.

“The PEPFAR that survived is not necessarily the PEPFAR that existed before,” Lankiewicz said.

PEPFAR funding to South Africa, the country with the heaviest burden of HIV in the world, has been terminated; however, the country already funds the majority of its HIV response.

PEPFAR grants are distributed through partner organizations that offer HIV testing; prevention, including condoms and PrEP; and treatment if needed. But last year many of these grants were slashed by the Trump administration, including more than half that had been managed via the U.S. Agency for International Development (USAID), the agency dismantled by Trump a year ago. 

Partners describe the same set of conditions: programming limited to designated life-saving activities, restrictions on DEI and gender and requirements to stop or scale back services for populations most vulnerable to HIV, Lankiewicz said. Among partners providing prevention services, 43% permanently stopped at least one prevention activity, with condom programming and practical pre-exposure prophylaxis sustaining the deepest cuts. Community-based services and peer networks that connect people to treatment and keep them in care were disrupted everywhere: more than 80% of partners reported disruptions in every single community service category. 

“Within PEPFAR, treatment was largely protected, while prevention and the services that reach people at highest risk were cut most deeply,” she added. “PEPFAR is one part of the broader HIV response, and governments and other donors will absorb some of what was lost, but absorption will be uneven, and it is least likely for the services we found to be cut most deeply—community-based and key population services—which many governments have historically been unwilling or unable to fund.” 

Most commonly, clinics using PEPFAR funds remained open but worked at lower capacity, she said. “That’s because PEPFAR implementing partners often serve as support systems within places like government clinics. In those situations we anticipate that services would continue, but with fewer staff. Staff data systems may be compromised, [and] supply chains may be compromised.” The facilities most likely to close were drop-in centers and mobile clinics, as well as any services that reached most vulnerable populations, including gay or transgender people, people who inject drugs, sex workers and victims of gender-based violence.

Lankiewicz added that the service disruptions in the survey may be a significant under-count, because closed organizations no longer had active email accounts and therefore couldn’t respond to the survey.

“Our findings document not a collapse, but a narrowing of PEPFAR services concentrated among the populations and programming that, in the long term, decide whether epidemic control is won or lost,” she concluded. “It’s incredibly hard to cut one award without there being ripple effects throughout the system.”

Children with HIV fared worse with PEPFAR cuts 

In a separate analysis of PEPFAR data, Ramona Godboal of Heidelberg Institute of Global Health and Clinton Health Access Initiative shared data on how PEPFAR disruptions impacted children living with HIV worldwide. 

Following a year of disruption to U.S. global health programs, researchers isolated the change in PEPFAR’s direct site-level support for pediatric treatment, comparing 2025 with the previous year, and calculated the change in the reported number of children living with HIV who receive treatment services at sites where PEPFAR is funding at least some component of healthcare worker salaries, commodities or technical assistance. They then compared that change with each country’s year-to-year history. 

The data showed 77,000 fewer children living with HIV benefited from PEPFAR’s support for treatment services in 2025 as compared to 2024, a 14.2% decline. Researchers note that the data reflect only children receiving U.S.-supported care, and some children—though it’s unclear how many—may have received treatment through other national governments or sources. 

In 21 countries with substantial pediatric caseloads, 20 of the 21 showed declines, and in every case the decline in support for children on treatment was steeper than the decline observed among adults, researchers concluded. The greatest absolute declines were in South Africa, where nearly 31,000 fewer children received PEPFAR-supported treatment, followed by Zimbabwe and Kenya, which reported declines of over 6,000 each. South Africa and India also had steep percentage declines, both exceeding 40%.

Godbole said that a decline in PEPFAR-supported pediatric treatment isn’t inherently bad news: it usually means fewer babies are born with HIV due to the effectiveness of vertical (mother-to-child) transmission prevention efforts. And the number of infants and children on PEPFAR-supported treatment has been naturally declining over the past few years. To test whether the 2025 declines were within that typical pattern or if they represented a more disturbing pattern, researchers established each country’s mean year-to-year change from 2019 to 2024. Five countries reported declines that deviated from historical trends: Haiti, Kenya, South Africa, Uganda and Zambia. 

“While this analysis can’t tell us what happened to individual-level treatment status nor population-level coverage, our country-level results do challenge broad assertions of program stability,” Godbole said. 

“These results and their limitations are exactly why we need urgent on-the-ground follow-up to make sure that children aren’t falling out of care. And finally, we need PEPFAR to resume regular public age-disaggregated data releases so we can tell whether declines have continued or stabilized,” Godbole added.