Pepfar – the campaign to end HIV globally – earned a short-lived reprieve recently when US Congress voted to restore $400m in funding, but State Department officials have, for years, been mapping out a plan to shut down the project in the coming years.
Planning documents for the President’s Emergency Plan for Aids Relief, obtained by The New York Times, call for the organisation to set a new course focusing on “transitioning” countries away from US assistance, some in as little as two years.
Pepfar would then cease to exist as an initiative to provide medicines and services needed to treat and prevent the spread of HIV in low-income countries, and be replaced by “bilateral relationships” with those countries, focused on the detection of outbreaks that could threaten the United States, and the creation of new markets for American drugs and technologies, according to the documents.
“With targeted investment, Pepar’s HIV control capabilities in these countries could be transformed into a platform for rapid detection and outbreak response to protect Americans from disease threats like Ebola,” the plan says.
However, the document had not been finalised, according to a State Department source. “The referenced document is not reflective of the … Department’s policy on Pepfar and was never cleared by Department leadership,” she said.
The proposed plan has been under review for weeks, and word of it has already reached Pepfar’s partners and governments in other countries. The draft obtained by The New York Times contains comments and edits from many senior staff at the programme.
The proposal for shutting it down in coming years underscores ongoing tension between Congress, which has repeatedly indicated support for Pepfar, and Trump administration officials who wish to sharply curtail or end it.
Previously, the organisation’s guiding ambition was to end HIV as a public health threat by 2030. But the Trump administration has targeted Pepfar for sharp reductions, part of a broad move to cut foreign aid, which officials believe is wasteful and a misuse of taxpayers’ money.
The abrupt termination of congressionally approved funding for the non-profit organisations that partnered with Pepfar has already hobbled the programme and crippled the global HIV response.
Conservative critics say that Pepfar-supported countries have, for more than two decades, relied on the US to fund the bulk of their HIV programmes while spending too little themselves, and that Pepfar has fostered a culture of dependence.
Now, Congress has cut $7.9bn in foreign aid funding but rejected proposed cuts to Pepfar, restoring a planned $400m clawback for the 2025 financial year.
Asia Russell, Executive Director of HealthGap, which lobbies for funding for global health, called the proposal a death warrant, saying “countless people will die if it is allowed to go forward”.
The documents assume a 42% reduction in Pepfar’s current budget of $4.7bn.
The planning documents note that “no global health programme in history has transitioned at this scale, and HIV is a uniquely challenging disease to control without a cure or vaccine”.
“However, we believe the transition … can become the premier example of the US commitment to prioritising trade over aid, opportunity over dependency, and investment over assistance.”
Accelerated plan
Phasing out Pepfar has been under discussion as a long-term goal for about a decade. But accomplishing a handover within a few years is a drastically accelerated timeline.
“It is entirely not feasible to phase out that quickly,” said Robert Black, a Professor of International Health at Johns Hopkins Bloomberg School of Public Health, who oversaw an evaluation of Pepfar ordered by Congress.
“There will be some countries that can manage …. but some of the African countries with enormous HIV problems and national financial problems, debt and other development issues – I cannot see they are going to be able to pick up all or even a large proportion of the costs in that kind of time frame.”
The documents obtained by The New York Times propose that the new Pepfar plan goes to countries for their input in October, and be sent to Congress for approval by December.
This plan would require countries to spend significantly more of their own money on HIV programmes.
In countries that delivered on their pledges, the documents say, Pepfar would continue to fund the purchase of some medications and pay some health worker salaries at a declining rate over three to five years.
Countries that are close to controlling their epidemics, including South Africa, Botswana, Namibia and Vietnam, would see a shutdown within two years.
Nations that have high rates of HIV infection and that now receive significant support, including Kenya, Lesotho, Zambia, Zimbabwe and Angola, would be on a three-to-four-year timeline.
Countries with conflict, very low income levels or fragile states would have five to eight years. They include the Democratic Republic of Congo, Haiti, Malawi, Mozambique, South Sudan, Tanzania, Uganda and Ukraine.
“Three years… it’s really a very short period for a heavy programme like the HIV programme in Zambia – it’s impossible,” said Dr Mwanza wa Mwanza, who has worked in senior roles in the HIV programme in Zambia for nearly a decade.
“New infections and deaths from HIV disease are still too high,” he added. “If the transition is too fast, all of our gains could be reversed.” Countries need to be involved in establishing how much time they will need, he said.
The plan acknowledges that the timelines are ambitious. There would be a “potential risk to global and US health outcomes if the transitions are too rapid”, the documents say.
Some of the proposed changes would probably be welcomed by countries Pepfar supports. Assistance for HIV would no longer be run separately, but rather be folded in with programmes to counter malaria, TB and other health problems.
But Pepfar has also operated gold-standard services that Health Ministries in many low-income countries have said they won’t be able to maintain on their own. The plan eliminates those.
For example, the plan proposes walking away from an effort in which the organisation has “spent billions of dollars developing” electronic medical records that are, “in nearly every case, unlikely to be financially sustained by the country’s government”.
The plan says little about one of the few clear shifts in policy on HIV response under the Trump administration: an abrupt termination of funding for most efforts to prevent new infections.
Certain groups marginalised
Since early February, Pepfar has funded HIV prevention only for pregnant and breastfeeding women – cutting off sex workers, men who have sex with men and people in so-called discordant couples in which one person has the virus and the other doesn’t.
These key groups were receiving targeted services, like free condoms or daily HIV-blocking medication, in an effort to control the epidemic.
But there is a hint that this policy could change. The draft plan says Pepfar will “make catalytic, market-shaping investments in biomedical tools, such as the new twice-yearly HIV prevention injection that will curb new infections”.
African governments had hoped to start rolling out that new shot – lenacapavir – by the end of this year. Pepfar was expected to fund about half of an initial purchase of lenacapavir for 2m people over the next three years, doses that are already in production by Gilead Sciences.
Without US funding, the future of this potentially transformative intervention has been in doubt.
The plan says Pepfar should make commitments to generic producers that would allow them to make lenacapavir at $40 per patient per year by the end of 2028, and distribute the drug in eight to 12 priority countries in the meantime – implying Pepfar might honour its original commitment to buy the Gilead product.
However, the planning documents do not explain how the shots would be distributed. Such medicines were provided in recent years through supply chains now crippled by the upheaval of recent months. The HIV prevention programmes are mostly gone.
The plan also would end America’s role in data collection, and countries would have to immediately begin to collect and provide data on their own that meets Pepfar’s congressional reporting standards. If they failed to do so, their funding would end immediately.
The plan proposes ending the traditional character of Pepfar as a public health response, shifting more HIV care to private-sector providers who could be allowed to buy medications and diagnostics at the price Pepfar has negotiated for the public sector.
The documents stress repeatedly that the success of Pepfar withdrawal will depend on much of its current role being filled by the Global Fund to Fight Aids, TB and Malaria.
A Pepfar employee offering comments in the document noted that there was no clarity on whether the United States, which has provided a third of the fund’s budget, was going to continue to contribute and thus what level of support the Fund may be in a position to offer countries.
Opposition voices being raised
Activists say the good news is that opposition is now, at last, emerging from within Trump’s Republican Party against the non-evidence-based cuts to the programme that has, for two decades, been supported by both the Democrats and Republicans and saved more 25m lives.
The bad news for South Africa is that despite the $400m in funding now being “restored”, this doesn’t mean any of the formerly US-funded HIV projects that have closed in this country will restart. In fact, quite the opposite, writes Mia Malan for Bhekisisa.
The $400m is about 8.5% of Pepfar’s $4.725bn budget for this financial year and was part of a larger $9.4bn ”rescissions package” – reduced to $9bn and passed as the HR4 Rescissions Act of 2025.
Rescissions happen when the presidential administration wants to cancel funding that was approved by Congress and then use it for something else.
What the decision to remove the $400m from the package does mean, however, is that activism could finally be starting to pay off.
But the Rescissions Act is, in itself, bad news.
“It opens the floodgates for the Trump administration to say ‘we don’t want this or that in the budget that Congress approved’,” said Mitchell Warren, Head of international advocacy organisation Avac. “It’s trying to take the congressional power of the purse and put it in the executive branch to usurp the role of Congress in deciding how much money – and on what to spend it.”
How did we get here?
In the US, Congress – the Senate and the House of Representatives – decides how much government money goes to whom. Both the Senate and the House have to pass budgets.
But, as analysts at the Centre for Budget and Policy Priorities in Washington point out, Trump wants more control over how his administration’s money is spent.
In March, he signed the 2025 budget that Congress approved into law. Three months later, he decided he wanted to change some of that and submitted a $9.4bn rescission request, which the House of Representatives (it has five more Republican than Democrat members) passed on 12 June.
When it was the Senate’s turn to vote on this, some Republican senators weren’t happy with the $400m Pepfar cut, signalling they wouldn’t sign off on the deal unless the Pepfar part was removed.
Because there was a danger of them swinging the vote, the Republicans removed the $400m from the Rescissions Bill and got the House to pass that too. All that’s left is for Trump to now sign the Act.
But what is known is that the law governing rescissions, the Impoundment Control Act, says the President can only request that Congress takes back funding that it previously approved if the money has not yet been obligated – that means funds hadn’t yet been given to a particular recipient, for instance, an HIV project in South Africa.
We also know that the $400m was part of the financial budget for 2025, said Warren, but because the law gives Pepfar permission to spend money over five years, that money doesn’t have to be legally spent until 2029.
Unless the rules of Trump’s “limited waiver” are changed, Pepfar funds can mostly not be spent on any of the evidence-based strategies it paid for before Trump was elected in January.
What do scientists and activists want the $400m to be used for?
Jirair Ratevosian, US policy adviser specialising in global health and human rights, said this moment should be used to gain Republican support to change the waiver rules, so that Pepfar money can cover more of the populations and services needed for HIV prevention.
The twice-yearly lenacapavir jab could be used to convince Republican Congress members, said Ratevosian. “Pepfar has long wanted to get countries to transition to taking more ownership [read: pay more] for their HIV responses. So now activists are arguing: ‘Preventing more new infections with the jab will make it easier for countries to take ownership because the pandemic will be easier to manage’.”
In December, Pepfar said it would join the Global Fund to buy enough lenacapavir for 2m people over three years. But in July, the Global Fund had to go ahead with the deal by itself, because Pepfar seemed to no longer be on board.
See more from MedicalBrief archives:
Government inaction over HIV funding cuts puts millions at risk
SA HIV programme future unclear as Pepfar dodges $400m cut
No extra funding in Budget for Pepfar gaps