PEPFAR at a Crossroads: Year Two of US Policy Impact on Global HIV Response

A year after policy shifts began to reshape the US President’s Emergency Plan for AIDS Relief (PEPFAR), the global response to HIV has entered a second year of significant structural change. The program faced a period of considerable uncertainty in early 2025, stemming from the absence of reauthorization by the US Congress, temporary suspensions in foreign assistance spending, and substantial alterations to how PEPFAR operates. These conditions haven’t fully resolved, and the ongoing lack of long-term reauthorization continues to drive programmatic and structural changes, fundamentally redesigning the HIV response on a global scale.

The Uncertain Landscape of PEPFAR Reauthorization

PEPFAR, established in 2003 by President George W. Bush, is the largest commitment by any nation to address a single disease. To date, the program has invested over $100 billion in the global HIV/AIDS response, and reports having saved over 25 million lives. The Office of the U.S. Global AIDS Coordinator and Global Health Diplomacy leads and manages the program, working through seven U.S. Government departments and agencies. However, the program’s latest reauthorization expired on March 25, 2025, leading to the lapse of certain time-bound requirements, even as the core program continued to function due to existing permanent authorities.

This lapse occurred against a backdrop of broader shifts in US foreign aid policy. As noted by the Kaiser Family Foundation (KFF), the Trump administration’s review and rollback of foreign aid initiatives added to the uncertainty surrounding PEPFAR’s future. While PEPFAR can continue as long as Congress appropriates funds, the changes implemented by the administration pose significant challenges to the program’s long-term effectiveness.

Who is Affected by These Changes?

The structural changes within PEPFAR have far-reaching implications, primarily affecting the 50+ partner countries that rely on the program for HIV prevention, care, and treatment. These countries, largely located in sub-Saharan Africa, but too including nations in Asia, Latin America, and the Caribbean, have made substantial progress in combating the HIV epidemic with PEPFAR’s support. Disruptions to PEPFAR funding or program implementation could reverse these gains, leading to increased HIV infections and mortality rates. Beyond the direct impact on individuals living with or at risk of HIV, these changes also affect the broader health systems in partner countries, which have been strengthened through PEPFAR investments.

The impact extends to the millions of healthcare workers, community health volunteers, and researchers who contribute to the HIV response in these countries. The global health security landscape is affected, as a weakened HIV response could have broader implications for pandemic preparedness and response.

The Nature of the Structural Transformation

The changes unfolding within PEPFAR are not simply about funding levels; they involve a fundamental redesign of how the program operates. The lack of reauthorization has allowed for the implementation of programmatic and structural changes that are altering the coordination of the global HIV response. While specific details of these changes are still emerging, they appear to focus on streamlining operations, increasing country ownership, and prioritizing certain program areas over others.

The KFF report highlights that, despite the expiration of reauthorization, PEPFAR continues to operate due to its foundation in permanent authorities of U.S. Law. In fiscal year 2024, $7.1 billion was appropriated for PEPFAR, including $5.4 billion for bilateral HIV efforts, $1.65 billion for contributions to the Global Fund to Fight AIDS, Tuberculosis and Malaria, and $50 million for UNAIDS. The FY 2025 Continuing Resolution maintained this level of funding. However, the absence of a renewed mandate raises questions about the program’s long-term sustainability and its ability to adapt to evolving challenges.

What Does This Imply in Plain English?

Essentially, PEPFAR is continuing to function, but without the clear direction and oversight that reauthorization would provide. This creates a period of uncertainty and potential vulnerability. While funding has been maintained for now, the lack of a long-term commitment could discourage partner countries from making long-term investments in their HIV responses. The shifts in program implementation could also lead to disruptions in service delivery, particularly for vulnerable populations.

The changes being instituted by the US administration, coupled with the lack of reauthorization, are creating a more complex and challenging environment for PEPFAR. This could hinder the program’s ability to achieve its goals of controlling the HIV epidemic and saving lives. HIV.gov emphasizes that PEPFAR saves lives, prevents millions of HIV infections, and supports countries to achieve HIV epidemic control, while strengthening global security. The current situation threatens to undermine these achievements.

Risk Context and the Importance of Continued Investment

The HIV epidemic remains a significant global health challenge. According to UNAIDS, there were 39.0 million people living with HIV globally in 2022. While significant progress has been made in reducing new infections and increasing access to treatment, the epidemic is not over. The COVID-19 pandemic disrupted HIV services in many countries, reversing some of the gains made in recent years.

PEPFAR plays a critical role in mitigating these risks. The program’s investments in prevention, care, and treatment have saved millions of lives and prevented countless new infections. A sustained commitment to PEPFAR is essential to ensure that these gains are not lost. Any reduction in funding or disruption to program implementation could have devastating consequences, particularly for the most vulnerable populations.

What Comes Next: A Procedural Outlook

The future of PEPFAR hinges on several key developments. Congress must reauthorize the program to provide a clear and long-term mandate. This reauthorization should include provisions to strengthen program oversight, enhance country ownership, and ensure accountability.

Secondly, the US administration must reaffirm its commitment to PEPFAR and perform with partner countries to address the challenges facing the program. This includes providing adequate funding, supporting program implementation, and promoting innovation. Finally, ongoing monitoring and evaluation are crucial to assess the impact of the structural changes and identify areas for improvement. Regular reviews of PEPFAR’s performance, coupled with transparent reporting, will be essential to ensure that the program remains effective and accountable.