The United States government released what is likely the final report from the President's Emergency Plan for Aids Relief (Pepfar) earlier this month, and the chief science officer announced his resignation days later as the US transitions to a patchwork of individual partnerships with each country, potentially driven by resource extraction.
While fostering greater leadership from other nations has long been a goal of global HIV efforts, experts fear the US is moving too hastily without the robust monitoring that Pepfar has provided for over two decades. They worry about losing ground to the virus even as the end of the HIV epidemic appears within reach.
“I worry that this administration probably doesn’t have the same level of ambition for global health that previous [leaders] have,” said Mike Reid, who recently stepped down as chief scientific officer at Pepfar. “That’s really too bad, because we have extraordinary scientific tools right now, like long-acting prevention tools such as lenacapavir, and we should be raising our ambition, not narrowing it.”
According to Pepfar data, the number of people remaining on HIV treatment globally has stayed relatively stable at 20.3 million. However, independent analyses reveal significant decreases in other areas, such as testing and workforce capacity.
“The number of people on treatment, while it looks stable, obscures a lot of changes that have been happening underneath,” said Brian Honermann, deputy director of policy at amfAR, the Foundation for Aids Research. “Where we see the really large disruptions is in all of the wraparound services that get people diagnosed, get them initiated on treatment, and retain people in care.”
A preprint analysis coauthored by Honermann found that the total number of people on HIV treatment declined slightly by 0.3%, but HIV testing dropped by 17%. People initiating PrEP (pre-exposure prophylaxis) to prevent HIV infection fell by 33%, and the number of healthcare workers providing HIV services decreased by 24%.
The amfAR report examined two categories of facilities: those that reported data in all four quarters of 2025, likely because they maintained at least some Pepfar funding throughout the year, and those that reported only in certain quarters, possibly due to disrupted funding. Infant testing fell by 6% at continuously reporting facilities and by 60% at intermittently reporting facilities, while infant diagnoses also dropped by 12% and 31%, respectively.
The decline in infant testing, diagnosis, and treatment is “particularly concerning” because infants with HIV face incredibly high mortality rates, the report stated.
A statement from the State Department (which erroneously says 20.6 million people are receiving HIV treatment, rather than 20.3 million) highlighted dramatic decreases in pediatric HIV treatment and testing. HIV treatments for children fell from 643,627 in 2022 to 508,703 in 2025, and testing dropped from 1.7 million to 1.1 million over the same period. The statement attributed the decline to the program’s success, but it remains unclear whether this represents a true reduction or undetected infections.
“We anticipate that the numbers of people that are going to be diagnosed will go down over time, but it’s important to put that in the context of whether the testing is happening in the first place,” Honermann said.
Another analysis by the health policy nonprofit KFF found that people newly enrolled in HIV treatment had dropped by 16%, one of the steepest declines in recent years. The number of people testing positive for HIV and receiving treatment during pregnancy fell by 14%.
Accessing data on US government global HIV initiatives will likely become more difficult as the State Department moves away from Pepfar’s rigorous data collection toward Memorandums of Understanding (MOUs) with each country.
In March, the New York Times reported that the State Department had considered using HIV support as a tool to pressure Zambia into signing resource extraction agreements. While those conversations remain classified, such a move would jeopardise progress on global health, Reid said.
“I didn’t want to work for an administration that potentially was predicating life-saving services on a minerals agreement, because I think we were slowing progress at exactly the moment when we need to accelerate it,” said Reid, who is also an associate professor at UCSF School of Medicine and an HIV physician in San Francisco. “I don’t think these frameworks should serve the goal of economic or commercial prosperity.”
Many countries in Africa, for example, have been squeezed by high fuel prices and other major expenses due to the Iran war. “Assuming that countries will be able to maintain care and treatment programs and sustain them at the levels that we have been able to is optimistic,” Reid said.
The new bilateral agreements have not included other key nongovernmental organisations, such as the Global Fund, Reid noted. Moreover, many US experts who could support the transition to country leadership have been laid off or fired. The US Agency for International Development (USAID) was dismantled last year, and layoffs at the US Centers for Disease Control and Prevention (CDC) hit global health work particularly hard.
The accountability structures that made Pepfar effective are now being dismantled, Honermann said. “That puts us, as US taxpayers, in the position of, in order to do oversight of this programming, having to go ask permission to access data from a foreign government to do oversight of these tens of billions of US taxpayer dollars.”
No longer reporting detailed data will also make it harder to understand which programs are working well and which are not, experts said. “For our programs to be as effective and efficient as possible, we need more data than we’re going to collect,” Reid added.
Honermann concluded: “We’re really concerned that we’ve actually lost track of a large number of people.”
Pepfar, created by George W Bush in 2003, has been credited with saving 26 million lives and changing the course of the HIV epidemic. Within days of Trump taking office in January 2025, the entire program was temporarily halted, and it was only resumed with limitations, such as offering PrEP only for pregnant and breastfeeding women.
“Not everything that has happened over the last 12 months, 18 months, has been bad,” Reid cautioned, noting that it is “remarkable” how quickly the Trump administration has made progress on country transition, a long-standing goal. Countries have also worked swiftly to fill gaps and create new leadership structures. However, Reid added, the administration has “exposed the global HIV program to a massive shock”.
“It’s not clear that we need to have moved this fast … the pace of the proposed transition, I think, has a real risk that will outstrip the systems needed to manage it safely,” he said.
