The US government released likely the last report from the President's Emergency Plan for AIDS Relief (Pepfar) earlier this month, and its chief science officer resigned days later. The US is moving to a patchwork of individual partnerships with each country, potentially driven by resource extraction.
While transitioning leadership to other countries has long been a goal, experts fear the US is moving too quickly without adequate monitoring. They worry about losing ground to HIV even as the end of the epidemic is in sight.
"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 Pepfar's chief scientific officer. "That's really too bad, because we have extraordinary scientific tools right now, like long-acting prevention tools like lenacapavir, and we should be raising our ambition, not narrowing it."
The number of people on HIV treatment globally has remained relatively stable at 20.3 million, according to Pepfar data. However, independent analyses reveal significant decreases in 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 HIV testing declined by 17%, people starting PrEP dropped by 33%, and healthcare workers providing HIV services fell by 24%. Infant testing fell by 6% at continuously reporting facilities and by 60% at intermittently reporting facilities. Infant diagnoses also fell by 12% and 31%, respectively.
"The decline in infant testing, diagnosis, and treatment is particularly concerning because infants with HIV have incredibly high mortality rates," the report stated.
A State Department statement highlighted dramatic decreases in pediatric HIV treatment and testing, attributing them to the program's success. However, it is unclear if infections are going undetected.
"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 KFF found that people newly enrolled in HIV treatment dropped by 16%, one of the steepest declines in recent years. The number of people testing positive and receiving treatment during pregnancy dropped by 14%.
Accessing data on US global HIV initiatives will likely become harder as the State Department moves away from Pepfar's rigorous data collection toward Memorandums of Understanding with each country. The New York Times reported in March that the State Department has considered using HIV support to pressure Zambia into signing resource extraction agreements.
"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. "I don't think these frameworks should serve the goal of economic or commercial prosperity."
Many African countries have been squeezed by high fuel prices 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 brought in other key NGOs, including the Global Fund. Many US experts who could support the transition have been laid off. USAID was dismantled last year, and CDC layoffs hit global health work hard.
"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," Honermann said.
No longer reporting detailed data will also make it harder to understand which programs are working. "For our programs to be as effective and efficient as possible, we need more data than we're going to collect," Reid said.
Honermann added: "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 saved 26 million lives. Within days of Trump taking office in January 2025, the program was temporarily halted and resumed with limitations. Reid noted that not everything has been bad, and countries have worked quickly to fill gaps. However, 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," Reid concluded.
