WORLD - On January 20, 2025, U.S. President Donald Trump issued an executive order calling for a 90-day pause and review of U.S. foreign development assistance.
The decision placed significant uncertainty around major global health programs, including those supported through the U.S. Agency for International Development (USAID) and the U.S. President’s Emergency Plan for AIDS Relief, widely known as PEPFAR.
Since its launch in 2003, PEPFAR has been considered one of the most successful public health initiatives in modern history. The program has helped save more than 25 million lives by employing preventive methods, expanding access to testing and treatment, and strengthening local health systems in countries heavily affected by HIV.
More than a year later, the effects of reduced and disrupted funding are becoming increasingly visible.
A new Market Impact Memo released by the Clinton Health Access Initiative in June 2026 shows that HIV services across selected countries in Africa and Asia have declined across several critical areas, from prevention and testing to pediatric treatment and monitoring.
The findings point to a shrinking resource base, rising pressure on national health systems, and growing concerns over access to lifesaving services.
Prevention is Losing Ground
One of the clearest signs of disruption is the decline in HIV prevention services. According to CHAI, oral Pre-Exposure Prophylaxis (PrEP) initiations fell by 42% in 2025 compared to 2024 across 10 reporting countries.
This represents around 677,000 fewer people starting oral PrEP, a major setback at a time when prevention remains central to controlling new HIV infections.
There is some progress in long-acting prevention. The joint Global Fund and PEPFAR procurement commitment for long-acting lenacapavir increased from 2 million to 3 million person-years for 2026–2028. However, this remains far below the estimated annual need of nearly 20 million people requiring PrEP.
Testing and Diagnosis are Also Declining
The decline is not limited to prevention. HIV testing dropped by 12% in 2025 compared to 2024 across eight reporting countries, equal to around 5.8 million fewer tests.
This decline has direct consequences. Confirmed HIV-positive identifications fell by 28%, meaning around 200,000 fewer people were identified as HIV-positive.
Fewer tests mean fewer diagnoses, and fewer diagnoses mean fewer people entering treatment early enough to protect their health and prevent onward transmission.
For HIV programs, testing is not a standalone service. It is the entry point to prevention, treatment, monitoring, and long-term care. When testing weakens, the entire continuum of care is affected.
Children are Being Left Behind
Unsurprisingly, children are bearing the brunt of these budget cuts. CHAI reports that new pediatric antiretroviral therapy initiations declined by 15%, equivalent to around 2,500 fewer children starting treatment across eight countries.
The total number of children on antiretroviral therapy also fell by 11%, representing around 26,000 fewer children on treatment across nine countries.
Pediatric HIV services often depend on specialized care, community follow-up, and active linkage to treatment. When budgets are reduced, community workers are cut, and testing supplies become less reliable, children are more likely to be missed.
Countries are Trying to Fill the Gap
In response to the funding shock, several countries have begun looking for ways to protect essential HIV services.
Kenya and Rwanda are among the countries that have reported efforts to mobilize domestic resources to maintain priority HIV programs previously supported by U.S. funding. Both countries have emphasized the importance of treatment continuity for people living with HIV and are discussing future budget allocations for antiretroviral treatment to avoid disruptions in access to medication.
Ethiopia has introduced a new payroll tax as part of efforts to address the financial gap left by the USAID funding pause. The proposed funds would contribute to a new Ethiopian Disaster Risk Response Fund, which is expected to support projects previously financed by USAID, including HIV medication.
Botswana and South Africa have also been working with organizations that lost U.S. funding to refer clients to government facilities for essential services. In Malawi, the government is coordinating with partners, including UNAIDS, to sustain HIV services and strengthen national leadership over service delivery planning and management.
These responses show that governments are trying to protect critical services. However, they also reveal the scale of the challenge. Domestic financing may help reduce immediate disruption, but many countries are being asked to absorb major costs at a time when health budgets are already under pressure.
A Critical Moment for the Global HIV Response
The CHAI memo presents a clear warning: the global HIV response is entering a fragile period. Prevention is declining, testing is falling, fewer people are being diagnosed, and children are increasingly at risk of being left behind.
The coming months will be critical. Without coordinated action, stronger domestic and international financing, and careful protection of essential services, recent funding disruptions could reverse years of progress in the fight against HIV.
