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U.S. is taking a ‘real risk’ with hasty shift in efforts to fight HIV, experts say
Last year, HIV advocates piled up hundred of mock coffins in front of the U.S. State Department. (Photo courtesy of Pink News / AFP / Getty)
Donald Trump’s decision last year to shut down the U.S. Agency for International Development (USAID) and abandon the country’s flagship anti-AIDS initiative PEPFAR continues to take its toll, even beyond the predicted millions of deaths those actions are expected to cause.
U.S. legislators were told that shutting down USAID will cost $19 billion and public health experts warned that the U.S. is running the risk of AIDS rebounding in nations where PEPFAR is being phased out in favor of a “patchwork of individual partnerships with each country, potentially driven by resource extraction.”
Below are more details about the situation, presented in edited excerpts from The Hill and The Guardian.
The now-shuttered U.S. Agency for International Development (USAID) has told Congress it has $19 billion in funds to cover costs associated with closing out the programs it terminated last year, according to a notification sent late last month and obtained by The Hill.
The notification acknowledges that the price of closing out the agency is likely to cost less than the multibillion-dollar number, but it’s unclear where the leftover funds will go.
Humanitarian aid experts and Democrats are urging the administration to show some urgency in disbursing it for dire humanitarian needs.
“If I was an appropriator, I’d be alarmed that the administration is withholding life-saving aid,” Sam Vigersky, international affairs fellow with the Council on Foreign Relations, said. “Between the war with Iran and global funding cuts from the U.S. and others, needs are near record highs. We’re in a moment where every dollar matters.”
USAID was fed “into the woodchipper,” as described in February by tech billionaire Elon Musk, who took on the task of shutting down USAID with his so-called Department of Government Efficiency. It locked out staff members and took over the computer systems, terminating the majority of programs in the agency’s roughly $40 billion annual budget.
Researchers estimated that more than 500,000 children and more than 260,000 adults died as a result of the aid cuts.
On April 20, a notification was sent to Congress from USAID detailing that it planned to use remaining funds to cover costs associated with the closeout of terminated foreign assistance awards. The notification was first reported by Devex.
“Unobligated and/or unliquidated funds that remain after USAID has completed all closeout actions may be used for other foreign assistance programs, such as those currently managed by the Department of State,” the notification reads.
The “resources available” for closeout funding, the notification said, includes more than $625 million of unobligated funds from 2024 and $3.2 billion in unobligated funds related to global health and economic development programs from 2025. The notification also tallied more than $15 billion in “unliquidated obligations on terminated awards for DOAGs.”
DOAGs refer to development objective agreements, typically five-year grant agreements between the U.S. and a foreign country.
Closeout costs are listed as “covering final settlements, pending invoices, adjustments to negotiated indirect cost rate agreements, costs associated with disposition of assets and/or other claims.”
The notification notes that the expected closeout costs are “anticipated to be substantially less than these total amounts.”
One former USAID official, who was granted anonymity to speak candidly, noted the remaining funds were almost half of the State Department’s entire $50 billion foreign assistance budget this year. In 2024, the last year of total data for USAID, the budget was around $35 billion.
“The trend that this speaks to and that Congress should be very concerned about, is that the Trump administration is not spending the money they are appropriating for them,” they said.
The notification does not include any names of administration officials. Office of Management and Budget Director Russell Vought — whom President Trump has dubbed the “grim reaper” — was assigned as acting USAID administrator last year and tasked with overseeing the agency’s complete shutdown. Reuters reported in February that the White House was using $15 million of USAID funds for Vought’s security.
Senate Democrats took specific exception with the notification holding back $3.2 billion in development and humanitarian assistance that was appropriated in fiscal 2025. They called it an “unnecessary and illegal impoundment of funds.”
“We write to demand that you reverse this proposal and put the funds to their intended use to save lives and advance U.S. interests as directed by Congress last year,” Sen. Brian Schatz (D-Hawaii) and 16 of his colleagues wrote in a letter sent April 24.
They note that the $3.2 billion was signed into law by Trump in March 2025 and expires at the end of this September.
The assistance is earmarked for $300 million for programs to combat HIV/AIDS, $250 million for malaria programs, $320 million for maternal and child health programs, and $650 million for global health security.
“The Administration should immediately begin using these foreign assistance funds to deliver results for the American people. There is no reason for this FY25 funding to be withheld to cover the wasteful costs this Administration has incurred because it chose to dismantle USAID,” the lawmakers wrote.
The State Department, Senate Democrats and Republicans with oversight of State Department funds did not return multiple requests for comment from The Hill.
Emily Byers, managing director of global development policy with Save the Children, pointed to a single $69 million program in Niger to illustrate how much impact the remaining funds could stretch. The program was terminated in the USAID shutdown.
The organization’s maternal and child health program delivered life-saving health and medical services to 1.4 million women and 1.1 million children in Niger, she said. This included immunizations, malnutrition screening and treatment, disease outbreak prevention and treatment, diagnosis and treatment of childhood illnesses and antenatal and obstetric care.
“Congress has shown continued leadership by appropriating critical funding for maternal and child health and humanitarian response; those investments reflect a bipartisan commitment to saving lives,” she said. “We urge the administration to ensure those resources are swiftly and effectively used to protect children and families in crisis.”
In the past, HIV testing in Nigeria was made possible by PEPFAR. Now it’s at risk or terminated.
Experts fear losing ground to virus even as the end of the HIV epidemic is in sight, and say decline in infant testing is “particularly concerning.”
The US government released likely the last report from PEPFAR (President’s Emergency Plan for Aids Relief) [in April] and the chief science officer announced his resignation days later as the US moves to a patchwork of individual partnerships with each country, potentially driven by resource extraction.
While more leadership with other countries has long been the goal with global HIV efforts, experts fear the US is moving too quickly without being able to monitor its efforts as well as it has done with PEPFAR for more than two decades. They fear losing ground to the virus even as the end of the HIV epidemic is in sight.
“I worry that this administration probably doesn’t have the same level of ambition for global health that previous [leaders] have,” said Mike Reid, who recently announced that he was stepping down as chief scientific officer at Pepfar. “That’s really too bad, because we have extraordinary scientific tools right now, like long-acting prevention tools like lenacapavir, and we should be raising our ambition, not narrowing it.”
The number of people remaining on HIV treatment globally has stayed relatively stable at 20.3 million people, according to the data from PEPFAR. But other areas, like testing and workforce capacity, have seen significant decreases, independent analyses of the data reveal.
“The number of people on treatment, while it looks stable, obscures a lot of changes that have been happening underneath,” said Brian Honermann, deputy director of policy at amfAR, the Foundation for Aids Research. “Where we see the really large disruptions is in all of the wraparound services that get people diagnosed, get them initiated on treatment, and retain people in care.”
The total number of people on HIV treatment declined slightly by 0.3%, but HIV testing declined by 17%, according to a preprint analysis coauthored by Honermann. People going on PrEP (pre-exposure prophylaxis) to prevent HIV infection dropped by 33%, and the number of healthcare workers providing HIV services dropped by 24%, the report found.
The amfAR report looked at two categories of facilities – those that reported data in all four quarters of 2025, perhaps because they maintained at least some of their PEPFAR funding throughout the year, and those that reported only in certain quarters, perhaps because their PEPFAR funding was disrupted. Infant testing fell by 6% at continuously reporting facilities and by 60% at intermittently reporting facilities, while infant diagnoses also fell by 12% and 31%, respectively.
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The decline in infant testing, diagnosis, and treatment is “particularly concerning” because infants with HIV have incredibly high mortality rates, the report said.
A statement from the state department (which erroneously states that 20.6, not 20.3, million people are receiving HIV treatment) highlighted dramatic decreases in pediatric HIV treatment and testing. HIV treatments for children dropped from 643,627 in 2022 to 508,703 in 2025, and testing fell from 1.7 million in 2022 to 1.1 million in 2025. The statement attributed the decline to the program’s success – but it’s not clear if that’s a true decline, or if infections are going undetected.
“We anticipate that the numbers of people that are going to be diagnosed will go down over time, but it’s important to put that in the context of whether the testing is happening in the first place,” Honermann said.
Another analysis by the health policy nonprofit KFF found that people newly enrolled in HIV treatment had dropped by 16%, one of the steepest drops in recent years. The number of people testing positive for HIV and receiving treatment during pregnancy dropped by 14%, the report found.
It will probably get harder to access data on the US government’s global HIV initiatives because the state department is moving away from PEPFAR’s rigorous data collection and toward Memorandums of Understanding (MOUs) with each country.
The state department has considered using HIV support as a tool to pressure Zambia into signing resource extraction agreements, the New York Times reported in March. While those conversations are classified, such a move would imperil progress on global health, Reid said.
“I didn’t want to work for an administration that potentially was predicating life-saving services on a minerals agreement, because I think we were slowing progress at exactly the moment when we need to accelerate it,” said Reid, who is also an associate professor at UCSF School of Medicine and an HIV physician in San Francisco. “I don’t think these frameworks should serve the goal of economic or commercial prosperity.”
Many countries in Africa, for example, have been squeezed by high fuel prices and other major expenses because of the Iran war.
“Assuming that countries will be able to maintain care and treatment programs and sustain them at the levels that we have been able to is optimistic,” Reid said.
The new bilateral agreements have not brought in other key nongovernmental organizations, including the Global Fund, Reid said. And many of the US experts who would be able to support the transition to country leadership have been laid off or fired. The US Agency for International Development (USAID) was dismantled last year, and layoffs at the US Centers for Disease Control and Prevention (CDC) hit global health work particularly hard.
The accountability structures that made PEPFAR effective are now being dismantled, Honermann said. “That puts us, as US taxpayers, in the position of, in order to do oversight of this programming, having to go ask permission to access data from a foreign government to do oversight of these tens of billions of US taxpayer dollars.”
No longer reporting detailed data will also make it harder to understand which programs are working well and which aren’t, experts said.
“For our programs to be as effective and efficient as possible, we need more data than we’re going to collect,” Reid said.
Honermann added: “We’re really concerned that we’ve actually lost track of a large number of people.”
PEPFAR, created by George W. Bush in 2003, has been credited with saving 26 million lives and changing the tide of the HIV epidemic. Within days of Trump taking office in January 2025, the entire program was temporarily halted, and it was only resumed with limitations, such as offering PrEP only for pregnant and breastfeeding women.
“Not everything that has happened over the last 12 months, 18 months, has been bad,” Reid cautioned, noting that it is “remarkable” how quickly the Trump administration has made progress on country transition, a longtime goal. And the countries have worked quickly to fill in gaps and create new leadership structures. But, Reid added, the administration has “exposed the global HIV program to a massive shock.”
And, he continued, “it’s not clear that we need to have moved this fast … the pace of the proposed transition, I think, has a real risk that will outstrip the systems needed to manage it safely.”
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