PEPFAR cuts close key population services and accelerate decline in children's HIV treatment

Cuts in US overseas funding for HIV treatment and prevention have led to widespread closure of community-based services and services for key populations, according to a survey of organisations that had been receiving US funds, presented this week at the 26th International AIDS Conference (AIDS 2026) in Rio de Janeiro, Brazil.

Research presented at the conference also showed that the number of children receiving HIV treatment is declining at a rate that cannot be explained by past successes in the prevention of vertical HIV transmission, raising the suspicion that funding cuts are affecting enrolment and retention of children with HIV on treatment.

The President’s Emergency Plan for AIDS Relief (PEPFAR) began in 2003 and since then has provided over $120 billion to support HIV treatment and prevention in more than 50 countries. By 2025, 20 million people depended on services funded by PEPFAR, but in January 2025 the second Trump administration froze foreign aid funding for 90 days and closed its development agency USAID, leading to cuts or delays in funding for thousands of PEPFAR’s implementing partners.

By July 2025, there was clear evidence of the negative impact of PEPFAR funding cuts on services in countries with high HIV prevalence. At IAS 2025, researchers from Mozambique and South Africa reported reductions in HIV testing and treatment activity.

To develop a global picture of the impact of PEPFAR funding cuts, researchers at amfAR carried out a survey of organisations funded by PEPFAR grants to provide services, asking them how their services and organisations had been affected.

The study surveyed 708 PEPFAR country-level implementing partners between April 2025 and April 2026 and received responses from 166 organisations in 46 countries. Some of the organisations which did not respond may have shut down entirely.

Of those who responded, 28% were international NGOs, 38% were local NGOs, 7% were national governments and 3% were international private contractors. National governments and private contractors together represented around 30% of PEPFAR implementing partners and were substantially underrepresented among respondents to the survey. Just over half of responses (55%) came from organisations in eastern and southern Africa.

Overall, 77% of respondents reported a delayed or terminated award and 52% reported at least one cancelled award. Almost three out of every four organisations (72%) providing services to key populations – groups at especially high risk, such as sex workers, gay and bisexual men, and people who inject drugs – reported that they were forced to close these services. In total, the survey found that 22 out of 42 organisations providing prevention services and 26 out of 39 providing outreach to key populations were forced to close.

Almost half of organisations providing community-based services (46%) reported closure of these services, including 17 of 41 providing community adherence clubs, 15 of 42 offering community pick-up of antiretrovirals and 23 of 37 organisations carrying out community-led monitoring.

Among prevention providers, 43% closed prevention services and 22% stopped offering HIV testing services. Just over one in five (21%) stopped providing HIV treatment services and 58% reported some disruption to treatment services.

Respondents reported the closure of 1714 service points, including 1010 public health facilities, 325 access points within larger services or facilities, and 126 drop-in centres or one-stop shops for specific populations.

The cuts in funding destabilised many organisations; 87% reported staffing reductions and only two respondents said that they had managed to replace all the funding lost. In the majority of cases (57%), PEPFAR funding had covered more than half the organisation’s budget. Local providers were hit harder than international NGOs; 62% of local providers reported at least one terminated award from PEPFAR, compared to 40% of international NGOs. Of respondents who had a sub-grantee, 64% had to terminate contracts with a sub-grantee due to loss of funding.

The impact of changes in PEPFAR policy went beyond cuts in funding. Three-quarters (77%) of organisations reported being asked to comply with new US policy restrictions as a condition of continued PEPFAR funding.

“Many of the programmes that bring people into care and keep them there have been stopped,” said Elise Lankiewicz of amfAR. “Treatment continuity now rests on a system that has lost many of its entry points.”

“Without dedicated support outside government systems, key population services are unlikely to return.”

Fewer children receiving treatment

A second study presented at the conference looked specifically at the number of children receiving treatment for HIV and asked whether funding cuts were affecting the number of children receiving treatment.

Due to the dramatic reduction in neonatal HIV transmission over the past 15 years, the number of children with HIV in need of treatment is shrinking. The number of children receiving treatment through PEPFAR-funded sites fell by approximately 100,000 between 2021 and 2024 as children who acquired HIV in infancy transitioned into adolescence and adulthood.

But when the researchers looked at publicly available data from the 55 countries supported by PEPFAR, they found that 77,163 fewer children with HIV received treatment in 2025 than in 2024, a decline of 14%. The number of children being treated declined by more than 15% in six of 21 countries reporting more than 1500 children on treatment. In five countries (South Africa, Haiti, Uganda, Kenya, and Zambia), the decline in children receiving treatment was greater than the average annual rate of decline observed over the past six years

“Ultimately, our findings are signals, not a verdict. But they do raise urgent questions about programme stability and potential downstream impacts, particularly given existing gaps in paediatric HIV treatment and emerging data that suggests that these gaps might be widening,” Ramona Godbole of Clinton Health Access Initiative concluded.