US funding cuts cause immediate drops in numbers testing and on HIV treatment

Cuts in US funding for HIV programmes have already led to declines in testing and treatment starts in several countries, research presented last week at the 13th International AIDS Society Conference on HIV Science (IAS 2025) in Kigali shows. Longer-term reductions in donor funding could lead to 10.8 million extra HIV infections and 2.9 million extra deaths by 2030, modelling suggests.

The US government announced a pause in all foreign assistance through USAID on 21 January 2025. USAID grant holders were told to stop work on 24 January and thousands of HIV testing counsellors and clinic staff were laid off in programmes supported by USAID funding. In some countries, vital medications were stranded in warehouses because USAID funded the supply chain that brought those drugs to pharmacies. Although a limited waiver was granted to allow funding of PEPFAR treatment and care services, studies from Mozambique and South Africa’s largest city show the swift impact of the USAID funding cut on testing, HIV diagnosis and new treatment initiations in the first quarter of 2025.

In Mozambique, one of the poorest countries in southern Africa, PEPFAR has provided around two-thirds of the funding for the country’s HIV programme for more than a decade. Approximately 2.2 million people are living with HIV in Mozambique, the third highest number globally; 88% are diagnosed and 95% of those diagnosed are on treatment.

A comparison of service activity between 2024 and 2025 shows substantial reductions in treatment initiation and viral load testing, as well as a rise in treatment interruptions.

Over 15,000 fewer people started antiretroviral treatment between February and May 2025 compared to the same period in the previous year, a 14% reduction.

The number of viral load tests carried out fell by 38% in adults and 44% in children, while the proportions who were virally suppressed in these tests fell by 33% in adults and 43% in children.

Treatment interruptions, measured by the number of missed drug pick-ups, increased by 39% between April and May 2025, but it is too early to say whether this is a real phenomenon or a result of missing data, the investigators concluded.

Using the UNAIDS Optima model of HIV transmission and disease progression, the Mozambique researchers compared the trend before January 2025 with trends observed from February 2025 and simulated the impact of the changes on new HIV acquisitions and HIV-related mortality.

The team estimated that 83,000 new HIV infections would occur by 2030 as a result of the loss of funding, a 15% increase compared to the previous epidemic trend. An additional 14,000 people would die of HIV-related causes, a 10% increase over the previous trend.

In South Africa, USAID was supporting the Anova Health Institute to improve rates of HIV testing, diagnosis and treatment initiation in the Johannesburg district, which has approximately 623,000 adults living with HIV. USAID funding was terminated in February 2025. In a poster presentation, Anova Health reported that comparison of testing and treatment initiation activity between the first quarters of 2024 and 2025 showed substantial reductions in testing (down 8.5%), HIV diagnosis (down 31%) and treatment initiation (down 30%).

The study investigators say that the declines in testing and diagnosis reflect the loss of healthcare workers, especially those providing more intensive counselling or carrying out index or community-based testing designed to reach those more vulnerable to HIV acquisition.

Long-term global impact of funding cuts

The US government is not the only major donor to reduce international aid. The United Kingdom and France anticipate cuts of 40% in foreign assistance by 2026, while the Netherlands will cut assistance by 70%. But the US is the major provider of international assistance, providing 73% of all donor funding for HIV programmes in 2023 in low- and middle-income countries.

To assess the potential impact of reductions in funding on HIV transmission and mortality, researchers at the Burnet Institute, Melbourne, used the UNAIDS Optima epidemic modelling tool for 26 countries with recently updated models. The 26 countries account for between 43 and 50% of all people living with HIV globally and receive 49% of all global aid and 54% of PEPFAR funding. Outcomes in these 26 countries were extrapolated to all low- and middle- income countries.

Using the Global AIDS Monitoring reports compiled by UNAIDS, the researchers identified the current mix of funding that supports HIV services in each country and modelled three scenarios up to 2030:

• funding continues at 2024 levels
• prevention and community testing funding cut by 24% by 2026 but treatment and health facility testing sustained by domestic funding
• prevention and testing funding cut by 24%, plus PEPFAR is immediately discontinued.

Compared to the status quo, the second scenario would result in somewhere between 71,500 and 1.7 million new HIV infections between 2025 and 2030, and 5000-61,000 extra deaths, depending on the success of measures to mitigate the impact of the cuts.

The third scenario, including discontinuation of PEPFAR funding, would result in between 4.4 million and 10.8 million new HIV infections and 770,000 to 2.9 million additional deaths, depending on the success of mitigation efforts.

Key populations and children would be disproportionately affected by funding cuts. The rate of new HIV infections would be 30 to 60% higher in key populations compared to other populations outside Africa. If PEPFAR funding was discontinued, 880,000 new HIV infections and 120,000 deaths would occur in children in low- and middle-income countries between 2025 and 2030.

PEPFAR funding in the balance

As IAS 2025 closed, there was a small piece of good news concerning PEPFAR funding. The programme’s budget was already due to fall from $4 billion to $2.9 billion but last month the White House proposed a further cut of $400 million – which the US Congress last week voted down.