The President’s Emergency Plan for AIDS Relief, or PEPFAR, was launched in 2003 under President George W. Bush. The program was codified under the United States Leadership Against HIV/AIDS, Tuberculosis, and Malaria Act of 2003, and it is one of the largest U.S. global health initiatives, directing billions toward HIV/AIDS prevention and treatment to over 50 nations [1]. It provides particularly crucial support in sub-Saharan Africa, and over two decades, PEPFAR has been credited with saving over 25 million lives [2]. However, concerns over sustainability, dependency, and shifting U.S. political support have raised questions about its future. President Donald Trump’s 2025 decision to freeze foreign aid for 90 days has put PEPFAR at risk, potentially reversing years of progress [3]. Even though PEPFAR was codified by statute, the funding is subject to the discretion of the executive branch. As U.S. foreign policy shifts under the Trump administration, funding cuts could severely impact HIV/AIDS programs in high-prevalence regions. Analyzing PEPFAR’s successes, challenges, and the broader political landscape is crucial for understanding its trajectory.
PEPFAR emerged in response to the early 2000s global HIV/AIDS crisis, when access to life-saving antiretroviral treatment was scarce in low-income nations. Through this, $15 billion over five years [4] was authorized to expand antiretroviral access, prevent new infections, and support vulnerable populations. Subsequent administrations have continued funding, accumulating a total of $120 billion of U.S. funding while adapting to evolving challenges such as drug resistance, tuberculosis co-infections, and the need for sustainable health systems [5].
Trump’s 2025 foreign aid freeze has created significant disruptions to PEPFAR. Clinics relying on PEPFAR have reported antiretroviral shortages, staff cuts, and decreased HIV testing. The freeze has hit sub-Saharan Africa particularly hard, forcing the region to ration medication and delay vital care. These disruptions could lead to increased transmission rates and higher mortality. In South Africa, for example, United States funding accounts for nearly a quarter of the nation’s spending for HIV treatment, research, and prevention [6]. South Africa has one of the highest prevalences of HIV. As of 2017, an estimated 7.9 million people in South Africa live with HIV, representing over 20% of the overall population [7]. The halt in PEPFAR funding dismantled several programs that were made for HIV testing and support. According to the International Treatment Preparedness Coalition (ITPC) and the Networking HIV and AIDS Community of Southern Africa (NACOSA), $800 million in HIV grants were terminated, which is creating ripple effects of staffing cuts on health systems functionality [8].
Outside of health repercussions, the aid freeze could shift alliances between PEPFAR-supported countries. As the U.S reduces its commitment to global health, international communities may begin to exclude the U.S. from their global health initiatives and shift diplomatic relations between other nations. In an interview with Newzroom Afrika, the Health Minister of South Africa, Dr. Aaron Motosoaledi, pointed out that South Africa is also supported by the Global Fund, which provides $7 billion every three years to fight HIV, AIDS, TB, and malaria. Dr. Motosoaledi also suggested investing more in South Africa’s National Health Insurance system. He says in the interview, "If we have used our money impeccably, we won’t need outside funders." He also emphasizes that South Africa already allocates 8.5% of its GDP to healthcare, which is higher than several BRICS nations such as Russia (7.2%) and China (6.5%) [10].
The fragility of PEPFAR has prompted recipient countries to continue increasing domestic health investments and reduce reliance on foreign assistance. Countries like Rwanda have made strides in increasing domestic health investments. According to the Rwanda Budget Policy Statement 2025/2026, released by the Ministry of Finance and Economic Planning in March 2025, Rwanda allocates 15.1% of its national budget to health [9]. Additionally, this report states that, “In 2009, Rwanda and its PEPFAR-funded partners aligned to support a second 'sustainability and country ownership' phase of the AIDS response, which promoted the transition of HIV clinical service program leadership from partnering nongovernmental organizations (NGOs) to the host country” [10]. This transition proved successful: "Within 5 years, Rwanda’s national HIV program achieved near-universal access to HIV prevention, care, and treatment” [11]. As shown in Rwanda's case, institutionalizing aid through international treaties or global health trusts can provide more reliable support and limit the ability of a single country to disrupt global health initiatives.
Legal scholars and global health advocates have increasingly called for more durable international frameworks and agreements to protect public health funding from political shifts. These frameworks can take the form of multilateral treaties, legally binding commitments through our international organizations like the World Health Organization, or even the creation of global health trusts that are insulated from domestic budget cycles. Such actions would decrease the capacity of individual states to undermine crucial health services abroad, restoring stability and continuity to programs like PEPFAR. Embedding health aid within a stronger legal framework could transform global health from a charitable endeavor into an enforceable obligation. For instance, the WHO’s recent legally binding pandemic agreement aims to bolster global preparedness and coordination [12]. Incorporating mechanisms similar to those of foreign aid programs like PEPFAR would protect them from abrupt suspensions and interference.
PEPFAR’s success highlights the power of investing in global health, as health well-being cannot be isolated based on borders. However, PEPFAR’s vulnerability to U.S. policy changes shows that there needs to be a more resilient funding model. As the world grapples with the consequences of the Trump Administration’s 2025 aid freeze, policymakers, global health organizations, and advocates must collaborate to preserve the gains made in the fight against HIV/AIDS. Without renewed commitment, the United States risks millions of lives, reversing decades of progress in public health, and losing potential partners in a rapidly evolving international landscape.
[1] “Name of the article” Tram, Ratevosian, and Beyrer (2025)
[2] “PEPFAR Misses Reauthorization Deadline: What's Next for Global HIV Fight?” Ratevosian 2025
[3] The White House 2025
[4]“THE BUSH RECORD - FACT SHEET: President Bush’s Global Health Initiatives Are Saving Lives around the World” (n.d.)
[5] “The U.S. President Emergency Plan for AIDS Relief (PEPFAR)” KFF 2024
[7] “Moving towards the UNAIDS 90-90-90 Targets” 2022.
[8] “Service-Level Effects of HIV Funding Cuts - Networking HIV and AIDS Community of Southern Africa (NACOSA)” 2025.
[9] Public Services International, "Health in the Balance: How the USAID Pullout Exposed East Africa's Over-Reliance on Donor-Driven Systems," accessed April 22, 2025.
[10] Transitioning to Country Ownership of HIV Programs in Rwanda” Binagwaho et al. 2016.
[11] id at 10.
[12] “How the World Health Organization could fight future pandemics” Farge and Rigby 2025.
