Counting the costs of global HIV funding disruptions

In a session on US government funding cuts at the Conference on Retroviruses and Opportunistic Infections (CROI 2026) held in Denver, US this week, Dr Jennifer Kates, from the Kaiser Family Foundation, started by asking a crucial question: “What’s the impact on people?”

But the question is challenging to answer. “The data systems that were available to look at the impact had been taken down,” Kates said. “Or even if they weren’t, staff who would be able to access the information were no longer there. It’s very hard to find people out of care, when they’re out of care.” She emphasised the importance of modelling studies to capture an accurate current snapshot and a preview of what’s to come.

The undoing of PEPFAR’s success?

Before the US President’s Emergency Plan for AIDS Relief (PEPFAR) began in 2003, there were fewer than 50,000 people on antiretroviral therapy (ART) in sub-Saharan Africa, with more than two million HIV-related deaths globally every year. After nearly 23 years of PEPFAR, 21 million people are on treatment in sub-Saharan Africa, with 600,000 annual HIV-related deaths globally. While PEPFAR can’t be credited with all the success of the past two decades, it’s certainly been responsible for a sizeable part of it. PEPFAR has also been unique politically – in the US, it traditionally had healthy bipartisan support.

While PEPFAR has been essentially flat funded for the past few years, the $5 billion contribution still comprised a massive 80% of all international donor funding to global HIV efforts. The bulk of this funding – 91% – went directly to sub-Saharan Africa. But in terms of the overall US federal budget, PEPFAR accounted for only 1%.

While most think specifically of HIV testing, prevention, treatment and care, PEPFAR funds also went to health systems strengthening, such as creating and maintaining laboratory infrastructure and data systems to ensure resources reach the people who need them. Care was also not limited to HIV: areas such as TB, cervical cancer and gender-based violence screening also fell under PEPFAR’s remit, and there were socio-economic programmes including cash transfers and nutrition support. Part of its immense success was a holistic, multi-pronged approach that worked on numerous levels, from the individual to the broader health system.

It’s estimated that PEPFAR has saved a staggering 26 million lives because of this approach.

But in 2025, PEPFAR’s exceptional momentum was slowed down by a new administration with radically different ideas about global health funding – particularly for HIV. Scientists and communities are still gauging the damage caused by the PEPFAR stop-work order and limited waivers imposed by the Trump administration.

Non-clinical aspects of HIV care have been hardest hit

Dr Ellen Brazier, from the City University of New York, presented data from a rapid survey of clinics and programmes in 32 countries, conducted by the International epidemiology Databases to Evaluate AIDS (IeDEA) research consortium.

This survey encompassed seven regions and was sent out to 30 PEPFAR-funded and 11 non-PEPFAR countries in mid-2025. Survey questions asked about disruptions to areas such as HIV-related services, medication availability, laboratory services and clinic operations, resolution of these disruptions at the time of the survey, and any mitigation strategies employed.

Overall, responses came in from most of the countries surveyed, 32 (78%), representing 68 individual clinics and eight programmes (a programme could have multiple associated clinics).

Most of the responding sites were in countries supported by PEPFAR at the start of 2025 (88%). Nearly half (47%) reported some disruption in HIV services:

• 28% reported medication availability challenges,
• 34% reported disruptions to laboratory services, such as for viral load testing,
• 47% reported clinic operation disruptions: adherence support, patient tracing, record management staffing and other operational requirements.

Limited mitigation measures were put in place. In terms of resolving these disruptions by mid-2025, there was a great deal of variation by region. For instance, while southern Africa had not fully resolved disruptions (for instance, a quarter of clinics and programmes had not resolved PrEP disruptions) clinics in Latin America reported that they had by mid-2025. However, when asked about this, Brazier explained that there were very few PEPFAR-supported countries in Latin America and many clinics were tertiary level hospitals – they would often have other buffers in place.

Overall, Brazier emphasised the high variability seen in the resolution of disruptions: while some were fully resolved, the effects of losing personnel such as data managers and other non-clinical staff would still be felt for some time. These non-clinical functions, such as maintaining laboratory equipment and identifying clients who don’t return for follow-up visits, are not simply complementary – they are essential to the clinical aspects of providing HIV care. In terms of clinical aspects, the loss of HIV PrEP for populations such as young women and female sex workers was highlighted.

Dr Lindsey Filiatreau, from Washington University in St. Louis, Missouri, presented research from South Africa. In addition to the PEPFAR-specific roadblocks, South Africa was singled out in one of Trump’s executive orders from February 2025 – one that essentially ended US support for South Africa due to tensions between the countries fuelled by the spread of misinformation regarding the supposed ‘genocide’ of White farmers in South Africa.

Filiatreau’s research team aimed to quantify the real-world impacts of PEPFAR funding disruptions to HIV service delivery, clinic operations and staffing in one of the provinces with the highest HIV prevalence, Kwa-Zulu Natal.

To do this, they drew on data from the broader Uhambo Lwami study and sampled 36 out of 519 clinics across six regions of Kwa-Zulu Natal. This represented a sample of 179,586 people with HIV from a population of 1,622,247 across all the clinics.

The researchers explored interruptions to areas such as HIV testing, PrEP provision, HIV treatment, TB and HIV care, condom supply and many non-clinical areas such as data entry, patient tracing and systems management.

At the clinic level, 39% of clinics reported any service, operations or staffing interruption. However, when considering the number of clients these clinics serve, over half of all clients living with HIV in the province were impacted by these disruptions (51%). While disruption to areas such as providing HIV testing and treatment services affected approximately 10% of clinics and 27% of clients, loss of staff such as data capturers impacted 27% of clinics and 36% of clients.

As with Brazier’s findings, Filiatreau emphasised the ‘silent’ clinic functions, such as data entry and patient tracing, that were commonly impacted. The disintegration of patient monitoring systems ultimately impacts clinical care, even when medications are available. Thus, access to data capturing, routine monitoring and support systems is essential.

“Our findings demonstrate that funding disruptions have effects beyond interruptions to ART supply, new infections and increasing deaths,” Filiatreau stated. She also spoke about the erosion of trust in the health system – not just by health system users, but by the many employees whose contracts were suddenly terminated. These staff were hesitant to go back when clinics reopened and they were needed. “We’ll have substantial rebuilding to do. These things [HIV services]… can be taken away overnight, but they can’t be rebuilt overnight.”

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