Call for urgent support as US funding cuts threaten HIV/AIDS programs

In the face of ongoing funding disruptions to US foreign assistance programmes, a group of international experts calls for urgent action to ensure the continuation of life-saving interventions and support for children and families affected by HIV/AIDS in sub-Saharan Africa.

The new Health Policy analysis, published in The Lancet, estimates that 1 million children could become infected with HIV, nearly half a million could die from AIDS by 2030, and 2.8 million children could experience orphanhood in the region without consistent, stable funding for US President's Emergency Plan for AIDS Relief (PEPFAR) programmes.

The authors say their analysis presents strong evidence that funding PEPFAR programmes for at least five more years is critically important to prevent unnecessary paediatric illness, death, and orphanhood, maintain current progress in efforts to prevent new HIV infections worldwide, and uphold the USA's position as a leader in global health diplomacy.

PEPFAR, established by the United States Government in 2003, has been a cornerstone in addressing the global HIV/AIDS epidemic, providing over $120 billion in funding to treat and prevent HIV/AIDS. The programme is estimated to have saved more than 26 million lives and ensured 7.8 million babies were born HIV-free. It currently supports over 20 million people with HIV prevention and treatment services, primarily in sub-Saharan Africa.

However, continued funding of PEPFAR programmes remains uncertain, raising concerns about the future of HIV/AIDS prevention and treatment efforts, particularly in light of US President Trump's executive order pausing all foreign aid for 90 days pending a review. Despite PEPFAR receiving a limited waiver to continue some programmes, many of PEPFAR's services have been disrupted or suspended since 20 January 2025.

The future of PEPFAR programmes hangs in the balance. Losing stable, long-term support for PEPFAR programmes sets global progress to end HIV/AIDS back to the dark ages of the epidemic, especially for children and adolescents. A sudden withdrawal of PEPFAR programmes, especially in the absence of a long term strategy to replace them, could lead to a resurgence of HIV infections and preventable deaths, and a dramatic rise in the number of children orphaned by AIDS in the coming years – a setback that could erode two decades of progress."

Lucie Cluver, Study Co-Lead Author and Professor, University of Oxford

Cluver adds, "Continued investments in PEPFAR programmes combined with progressive growth in African co-financing can create a sustainable transition for country-led ownership of HIV programmes and preserve the legacy of PEPFAR's lifesaving work." 

The authors conducted an original modelled analysis using existing data to predict the risks children in sub-Saharan Africa would face in the absence of PEPFAR programmes, including increased HIV infections, AIDS-related deaths, and orphanhood. The estimates suggest that by 2030, there could be 1 million new cases of paediatric HIV and 460,000 additional AIDS-related deaths in children. Furthermore, if there is a complete cessation of PEPFAR, it could substantially reduce adult life expectancies, and leaving 2.8 million additional children orphaned. 

"We are already seeing the devastating impacts of the USA's recent foreign aid freezes," said co-author Susan Hillis, Imperial College, London (UK). "By eliminating many programmes PEPFAR supports for children beyond HIV treatment and prevention, such as programmes that prevent sexual violence and support general child health and wellbeing, many of the children and adolescents who currently benefit from PEPFAR programmes will slip through the cracks -- increasing their chances of acquiring HIV or leading to further transmission, ultimately resulting in many preventable HIV infections and deaths." 

The authors also highlight how PEPFAR programmes have demonstrated long-term sustainability by reducing children's lifetime risk of acquiring HIV. Prior to the widespread availability of antiretrovirals in Africa, more than 20 million people died from AIDS-related causes in the region, leaving behind millions of orphaned children. PEPFAR's efforts have significantly contributed to decreasing the number of AIDS orphans from its peak of over 14 million children in 2010 to 10.5 million by 2023. 

In addition to modelling the immediate effects of PEPFAR funding disruptions, the authors assessed PEPFAR's impact beyond HIV/AIDS, highlighting the international diplomacy, economic benefits – including a four-fold increase in two-way trade between the USA and countries in Africa, educational improvements, and healthcare advancements, as well as various initiatives to combat violence against girls and protect vulnerable children.

"Renewing PEPFAR investments safeguards the health and well-being of millions of people and reinforces the USA's position as a global leader in foreign assistance and health diplomacy. Programmes like PEPFAR have successfully elevated public opinion of the USA and enabled bilateral cooperation not only with countries receiving PEPFAR support, but also globally, which in turn contributes to protecting national security, strengthening trade, and advancing strategic diplomacy. Ending PEPFAR would create a void likely filled by other countries, with reports indicating China and Iran are poised to assume global health leadership roles, enabling them to increase their influence in the region," said co-lead author Gibstar Makangila, Executive Director of Circle of Hope (Zambia).

The authors also offer insights into how to build more sustainable PEPFAR programmes into 2030 and beyond, citing ongoing efforts to unite both international and local partners to close funding gaps, increase country- and community-led initiatives, and support improvements to domestic healthcare systems. PEPFAR-supported countries in Africa have already demonstrated commitments to ownership of HIV responses by 2030 with progressive increases in co-financing health systems from $13·1 billion per year in 2004 to $40·7 billion per year in 2021.

"Our analysis not only highlights the immediate health implications of inadequate funding but also emphasises the broader socio-economic benefits of PEPFAR investments and offers a glimpse into the future of PEPFAR programmes, where long-term strategies that build local capacity to improve health and wellbeing for all is vital for global health security, especially as it's projected that in the next 25 years, half of all children and adolescents worldwide will live in Africa", said co-author Joel-Pascal Ntwali--N'Konzi of the University of Oxford (UK).

Co-author Prof Chris Desmond, of the University of Kwazulu-Natal (South Africa) added, "What is urgently needed now is a well-planned transition to expanded country-ownership of PEPFAR programmes that will take this lifesaving work forward and offer stability and sustainability for countries that currently rely on PEPFAR support now and into the future, which in turn also benefits the USA and solidifies its position as a global leader in the effort to end HIV."

The authors note some important limitations of this analysis, including that the international funding landscape is rapidly changing and the future of PEPFAR programmes are unknown. Additionally, this analysis used the best available data on HIV infections and death rates to develop future estimates.

In a related Correspondence, also published in The Lancet, 11 senior health officials from African countries wrote "Together, we are confident that we can achieve the goal of ending the HIV and AIDS pandemic as a global threat for our children and families, as our African nations collaborate with the USA and other international donors to continue transitioning towards strengthening and increasing domestic investments for health, and for HIV as a key priority within such investments. Together, we can end this fight and finish well, making not just the USA and Africa, but indeed the world, safer, stronger, and more prosperous."