Editorial Note: Originally published in May 2025, this resource has been updated as new information became available.
Starting on the first day of his second term, President Trump issued several executive actions that have fundamentally changed foreign assistance. These included: an executive order which called for a 90-day review of foreign aid; a subsequent “stop-work order” that froze all payments and services for work already underway; the dissolution of USAID, including the reduction of most staff and contractors; and the cancellation of most foreign assistance awards. Although a waiver to allow life-saving humanitarian assistance was issued, it was limited to certain services only and difficult for program implementers to obtain. Since then, responsibility for remaining global health programs has been transferred to the State Department. While there have been several legal challenges to these actions, there has been limited legal remedy to date. As a result, U.S. global health programs were disrupted and, in some cases, ended. Changes to the Department of Health and Human Services, including proposed cuts and reorganization, are also likely to affect these programs. This fact sheet is part of a series on the status of U.S. global health programs.
Background on PEPFAR
- The U.S. President’s Emergency Plan for AIDS Relief (PEPFAR), first authorized in 2003, is the largest commitment by any nation to address a single disease, working in more than 50 countries and the U.S. has been the top donor to HIV efforts, through PEPFAR and contributions to the Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund).
- PEPFAR is credited with having saved 26 million lives and enabling 7.8 million babies to be born without HIV infection. Studies have also found that PEPFAR funding is associated with several “spillover” effects including significant reductions in all-cause mortality, increases in childhood immunizations and in GDP growth, and retention of children in school.
- PEPFAR has been reauthorized by Congress four times, most recently in March 2024 for one year. Although that authorization expired on March 25, 2025, PEPFAR is a permanent part of U.S. law and, other than a set of eight time-bound provisions, continues as long as Congress appropriates funding.
- PEPFAR, per its authorizing statute, is to be overseen by a U.S. Global AIDS Coordinator, a Senate-confirmed position appointed by the President and holding the rank of ambassador, at the State Department’s Bureau of Global Health Security and Diplomacy (GHSD). GHSD is charged with coordinating its implementation through other government agencies (primarily USAID – before its dissolution – and CDC) and, historically, with implementing partners, civil society, and recipient countries.
- Prior to the start of the Trump administration, U.S. funding for PEPFAR in FY 2024 was $4.9 billion; funding for the Global Fund was $1.65 billion.
Current Status of PEPFAR
The following administration actions have had a significant impact on PEPFAR operations:
- Stop-work order: The stop-work order initially froze all PEPFAR programming and services, halting existing work in the field, including provision of antiretroviral therapy. Because it halted payments, many implementers had to terminate staff and end some services.
- Limited Waiver: PEPFAR received a limited waiver on February 1, 2025 (with additional information on February 6, 2025), allowing it to continue “life-saving HIV services”. However, the waiver only permitted certain activities: HIV treatment and care, prevention of mother-to-child transmission (PMTCT), pre-exposure prophylaxis (PrEP) for pregnant and breastfeeding women, and HIV testing. Other services, including PrEP for anyone else (including those already on PrEP) and HIV prevention more generally, as well as non-clinical programming for orphans and vulnerable children, were not permitted. Even with the waiver, implementers faced challenges in getting permission to resume HIV programming and difficulties getting paid.
- Dissolution of USAID: USAID was the main government implementing agency for PEPFAR, obligating 60% of its bilateral assistance in FY 2023. Without USAID and most of its staff, PEPFAR’s implementation capacity and operations have been affected. In addition, announcements of reductions at CDC, PEPFAR’s second largest implementing agency (obligating 37% in FY 2023), and questions about the stability of CDC’s funding, could further affect PEPFAR.
- Canceled awards: In early 2025, it was reported that the administration canceled 86% of all USAID awards. KFF analysis found that of the 770 global health awards identified, 379 included HIV activities, 71% of which were terminated, including several HIV treatment awards as well as most HIV prevention.
- Legal actions: In response to two lawsuits filed against the administration’s actions, a federal judge issued a preliminary injunction ordering the government to pay for work completed by February 13, 2025, although not all payments have been made and the court did not stop the government from canceling awards. The government appealed the ruling, and after several subsequent rulings in the case, the Supreme Court ultimately allowed the government to rescind (cancel) a portion of expiring global health funds before the end of the fiscal year. Further proceedings have been stayed, pending the outcome of a separate case.
- Reorganization: The administration notified Congress on March 28, 2025, of its intent to permanently dissolve USAID and that any remaining USAID operations would be absorbed by the State Department with global health activities to be integrated into GHSD. On May 29, 2025, the State Department further notified Congress of its proposed reorganization plan, and with the dissolution of USAID, programs moved in July 2025.
- America First Global Health Strategy: In September 2025, the administration released the America First Global Health Strategy, its roadmap for future U.S. government global health engagement. Per the strategy, the U.S. is negotiating bilateral, multi-year agreements with countries receiving U.S. global health assistance with an aim to transition the majority of countries to full self-reliance by the end of the agreement period. HIV programs are an anchor of the strategy, and HIV has been included in most of the agreements signed to date, although there is little information available on activities and funding. A U.S. Global AIDS Coordinator has yet to be nominated.
- Long-acting injectable PrEP: On September 4, 2025, the administration announced that PEPFAR would partner with the Global Fund to support provision of long-acting injectable PrEP to up to 2 million people in high-burden countries by 2028.
- Policy restrictions: In January 2025, the Trump administration reinstated the expanded Mexico City Policy from Trump’s first term and further expanded it in January 2026 to apply to almost all non-military foreign assistance, many more entities, and additional areas of restrictions including activities related to diversity, equity and inclusion and “gender ideology” under a broader umbrella of the “Promoting Human Flourishing in Foreign Assistance” (PHFFA) Policy.
- Funding: The Trump administration has requested significantly less funding for PEPFAR in its budget requests and canceled funding for numerous HIV-related projects and awards. Despite this, Congress has continued to appropriate funding at or close to prior year levels for PEPFAR, including $4.8 billion in FY 2026. It also appropriated $1.25 billion for the Global Fund in FY 2026.
Impact on PEPFAR Services and Outcomes
Numerous reports have documented the impacts of these actions on services and outcomes:
- An analysis conducted shortly after the stop-work order was issued found that many PEPFAR implementing partners reported the cancellation of at least one category of activities; staff reductions; and risks to operations.
- A rapid assessment survey of 108 WHO country offices, conducted in 2025, found that almost half reported moderate or severe disruptions to HIV services, including for medicines and health products, due to the U.S. foreign aid freeze and other shortages.
- A recent analysis in 14 countries found that the disruption in PEPFAR funding was associated with significant drops in access from early 2025 through early 2026 and that recovery remains limited, with ongoing reduced access to HIV services and commodities, including antiretroviral treatment, PrEP, HIV tests, and clinical monitoring tests.
- A tracking survey found that PrEP initiations declined by 13% and 66% in five high-burden countries between January-September 2024 and January-September 2025.
- A summary of available data as of December 2025 found that while some recovery had been reported in service uptake for HIV testing and treatment services, funding cuts and disruptions were continuing to have negative consequences for coverage of PrEP and other HIV prevention services, programs for adolescent girls and young women, and community-led HIV responses.
- In addition, several modeling studies have estimated that cuts in or termination of U.S. HIV funding could result in significant increases in new HIV infections and HIV-related deaths over the coming years.
- A recent analysis surveyed almost 170 PEPFAR-funded organizations in 46 countries, finding that more than 1,700 HIV service sites “closed entirely after terminated or delayed PEPFAR payments” since funding cuts in 2025 and that among organizations that lost funding almost none were able to find alternative funding support. It also found a range of HIV services, including those directed at key populations, HIV prevention such as PrEP and condom distribution, and PMTCT, were stopped, interrupted, or disrupted.
- A KFF analysis of the latest PEPFAR data provides a snapshot of PEPFAR results after the Trump administration’s changes: For some indicators, progress declined in FY 2025 Q4, including support for prevention services such as PrEP and the DREAMS program for adolescent girls and young women, both of which were significantly scaled back by the administration. There was also a drop in the number of people with HIV newly enrolled on antiretroviral therapy (ART), an important measure of access. There were areas where progress has been maintained or potentially improved, including the total number of people with HIV on ART, which was stable, and an increase in the number of people living with both HIV and TB who are receiving ART.
What to Watch
- Implementation of the America First Global Health Strategy multi-year agreements with countries
- Status of U.S. funding appropriated by Congress for PEPFAR and contributions to the Global Fund
- Impact of the PHFFA Policy on U.S. funding and programs
- Impact of U.S. changes to global health programs on health outcomes
- The future of transparent PEPFAR data monitoring and reporting