The Trump administration's approach to foreign aid has led to significant disruptions in the global fight against HIV, with substantial funding cuts affecting more than 77 percent of organizations that previously received support through the President's Emergency Plan for AIDS Relief (PEPFAR). These cuts have led to the closure of at least 1,700 HIV-related sites and the loss of over 16,000 health worker jobs, according to a survey by the HIV research group amfAR.
The consequences of these reductions have been disproportionately borne by vulnerable populations, including LGBTQ individuals, young women, and sex workers. Nearly two-thirds of affected grantees reported disruptions to their ability to provide HIV treatments and other essential services. Organizations noted that their grants were terminated, with some citing violations of President Donald Trump's executive order against "unlawful diversity, equity, and inclusion" as justification. In many cases, groups were flagged due to phrases like "gender" or "LGBTQ" in their names or mission descriptions, even when their work focused on critical issues like "gender-based violence."
PEPFAR, established in 2003 by President George W. Bush, was the largest commitment by any nation to combat a single disease. Over two decades, it is credited with saving approximately 25 million lives and preventing millions of HIV infections in newborns. The program's success was built on a bipartisan foundation, with past administrations prioritizing public health outcomes over ideology. This approach often included funding for contraceptives and targeted outreach to populations most at risk.
However, the current administration's priorities appear to have shifted. While the Trump administration released some data indicating a reduction in HIV prevention services, the amfAR survey provides a clearer picture of the on-the-ground impact. Access to preventative services, including testing and contraception, has been severely curtailed. Notably, 90 percent of organizations serving gay and bisexual men were forced to reduce or eliminate access to PrEP, a key HIV prevention method. Over half of organizations serving pregnant women also saw disruptions, increasing the risk of HIV transmission to infants.
"You can't cut pieces of the architecture of how PEPFAR functions and expect to maintain a really robust treatment program in the long term," said Jennifer Sherwood, director of research and public policy at amfAR. "If you cut the testing program, the prevention programs, the kind of services that allow people to stay in care and return to care, you're going to see that you can't maintain a treatment program."
The administration has also attempted to reshape foreign aid by directing funds more directly through national governments. While theoretically prioritizing local expertise, amfAR's survey indicates that local organizations have experienced greater funding losses and site closures compared to international groups. This trend runs counter to global health objectives, according to Sherwood.
Concerns are mounting that public health outcomes are no longer the primary measure of success for PEPFAR. Jirair Ratevosian, a senior fellow at the Duke Global Health Institute, expressed alarm over the decision to end PEPFAR support for South Africa, which has the world's largest HIV epidemic. He noted that cutting funding to countries like South Africa could lead to millions of new infections and threaten global progress against HIV.
"HIV control is not their chief concern," Ratevosian stated, citing projections that cutting PEPFAR in Zimbabwe could result in 75,000 new HIV infections in a single year. The long-term impact in South Africa could be over 2 million additional infections over two decades. "You can't have a global HIV strategy if you're not engaging these countries."
Even organizations that did not lose funding have reported altering their work, including the populations they serve and the language they use, to comply with new policies. This network of changes, stemming from U.S. directives, is prompting significant shifts in HIV prevention and treatment efforts worldwide.