The global public health community was optimistic about meeting the United Nation’s goal of eradicating HIV by 2030. Then came Trump’s cuts. Within hours of his second inauguration, Trump ordered a 90-day freeze on all foreign aid programs, including the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR), pending a review by the State Department. When that review was completed, funding was not restored.
Called “one of the greatest public health interventions of all time,” PEPFAR was established by President George W. Bush in 2003. Since then, the program has become the major funder of HIV services throughout the world, spending more than $110 billion on testing, counseling, prevention, and treatment. The UN credits PEPFAR with saving more than 26 million lives. Although the State Department has granted waivers for “lifesaving humanitarian assistance,” most of PEPFAR’s work was terminated, including the provision of antiretroviral therapy (ART).
The first antiretroviral treatment approved by the Food and Drug Administration was AZT (zidovudine) in 1987. Its discovery transformed the diagnosis of HIV from a death sentence into a chronic disease. If taken correctly, ART prevents disease transmission and allows people with HIV to have a normal lifespan. Discontinuing the therapy, even for a short period, leads to virus reemergence, often with irreversible consequences. People who have ended treatment, like those who remain untreated, are infectious to others and vulnerable to opportunistic infections such as tuberculosis, pneumocystis pneumonia and certain rare cancers such as Kaposi sarcoma. Stopping ART also can contribute to the emergence of a drug-resistant virus, endangering the entire population.
The PEPFAR Program Impact Tracker, created by a mathematical modeler and a product management leader in the wake of Trump’s PEPFAR freeze, found 56,329 adult and 5,995 child HIV-related deaths between January 24 and June 1, 2025. The effect of the freeze has been especially devastating in sub-Saharan Africa, the home of more than half of all people living with HIV and the focus of the program’s work. The number of those receiving ART in that region rose from nearly zero in the early 2000s to approximately 21 million by 2023. As a result, HIV deaths dropped from approximately 2.2 million in 2003 to approximately 390,000 in 2023. In Kenya alone, the PEPFAR freeze affected 40,000 doctors, nurses, and other health workers.
The tiny country of Eswatini offers another example of a consequence of the loss of PEPFAR funds. The Elizabeth Glaser Pediatric Aids Foundation has reported that it has had to stop HIV therapy for 85,000 people in that country of 1.2 million, as well as end HIV testing for pregnant women and babies. A New York Times article described the personal ramifications: the desperation of Sibusiso, a 39-year-old, unemployed man, who had traveled every three months to a clinic in Eswatini’s capital to refill his medication. When he arrived in late January, he found the clinic door locked. “I’m now thinking of dying,” he said. “What am I going to do without this treatment?”
Then, in June, HIV advocates around the globe cheered when Congress removed PEPFAR from the rescissions bill and restored $400 million of its funding. Their joy was short-lived. On July 23, the New York Times reported that State Department officials were “quietly” drafting plans to end the original purpose of PEPFAR—the distribution of HIV services and programs in low-income countries. Despite the meaning of the last three letters of PEPFAR’s name (for AIDS Relief), the program would now focus on “the detection of outbreaks that continue to threaten the United States and the creation of new markets for American drugs.”
News of these plans arrives at a critical moment. At the July 2024 International AIDS Conference, researchers announced that lenacapavir, a new drug given as an injection every six months, is virtually 100 percent effective in preventing HIV in adolescent girls and young women in Uganda and South Africa. “It felt to many like a generational moment,” wrote Mark Siedner, an infectious disease physician, and Rochelle Walensky, former director of the Centers for Disease Control and Prevention. “After years of failed vaccine trials, this was something nearly as valuable.” Dr. Linda-Gail Bekker, the deputy director of the Desmond Tutu HIV Centre in Cape Town and an investigator in the drug trial, remembered getting “cold shivers,” when she saw the results. “After all our years of sadness, particularly over vaccines,” she said, “this truly is surreal.” Lillian Mworeko, the head of the International Community of Women Living with HIV Eastern Africa, explained, “For a young woman who can’t get an appointment at a clinic in a town, a young woman who can’t keep pills without facing stigma or violence—an injection just twice a year is the option that could keep her free of HIV.” The prestigious journal Science named lenacapavir the “breakthrough of the year.” In June, the Food and Drug Administration approved the drug for use in the United States.
For many Africans, however, initially this may have seemed a hollow victory. In the United States, Gilead Sciences, the manufacturer of lenacapavir, charged $42,250 for a year’s supply, a price that clearly was prohibitive for the vast majority of people in low-income and middle-income countries. History is littered with examples of US pharmaceutical companies conducting clinical trials in Africa for HIV drugs that end up being used primarily in the United States. Africa has been an attractive site for drug tests because the cost of conducting research is lower there than in the United States, fewer regulatory constraints exist, and the historically high prevalence of HIV means that the job of finding study participants is relatively easy. Before the establishment of PEPFAR, however, the high cost of many of the drugs tested in Africa limited their use in Africa.
At the 2000 International AIDS Conference, Edwin Cameron, a justice of the Constitutional Court of South Africa, berated pharmaceutical companies for charging exorbitant prices for HIV medications in Africa and using licensing laws to prevent other companies from manufacturing cheaper versions. As a gay, African man with AIDS, he was “a living embodiment of the inequity of drug availability and access in Africa.” Although 290 million Africans lived on less than one U.S dollar each day, his salary as a judge enabled him to pay $400 a month for AZT and another drug he took twice a day. Three years later, PEPFAR began to fund the distribution of HIV drugs throughout Africa.
Soon after the results of the lenacapavir trial, Gilead announced that it had made arrangements with six manufacturers to produce generic versions of the drug which would cost approximately $40 per person per year. Those manufacturers, however, expected PEPFAR to be a major buyer. Without its funding, the economic viability of the generic drug is uncertain. “Now is not the time to pull back,” warned Anthony Fauci, the former director of the National Institute of Allergy and Infectious Diseases, “for history will judge us harshly if we squander the opportunity that is before us.”
Emily K. Abel is professor emerita at the UCLA-Fielding School of Public Health. Her most recent book is Gluten Free for Life: Celiac Disease, Medical Recognition, and the Food Industry (NYU Press, 2025).
Sources
Edwin Cameron, “The Deafening Silence of AIDS,” Health and Human Rights, 1, no. 1 (2000): 19.
Mark Siedner and Rochelle Walensky, “Tested in Africa, Used in America,” Statnews, September 18, 2024.
Wycliffe Muia, “Nigeria and Kenya among Nations Running out of HIV Drugs,” BBC, March 18, 2025.
“Lenacapavir: A Giant Step Forward in HIV Prevention—But a Missed Opportunity for Achieving Equity and Access,” British Medical Journal, October 14, 2024.
John Eligon, “Trump’s Foreign Aid Freeze Causes Fear of HIV Resurgence in Africa,” New York Times, January 30, 2025.
David Cox, “This New Drug Could Help End the HIV Epidemic—But US Funding Cuts Are Killing Its Rollout,” Science, February 21, 2025.
Stephanie Nolan, “New Drug Provides Total Protection from HIV in Trial of Young African Women,” New York Times, June 24, 2024.
Sonia Shah, The Body Hunters: Testing New Drugs on the World’s Poorest Patients (New Press, 2006).
PEPFAR Program Impact Tracker, https://pepfar.impactcounter.com/
Stephanie Nolan, “U.S. Quietly Drafts Plans to End Program that Saved Millions from AIDS,” New York Times, July 23, 2025.