The future of the world’s largest global HIV initiative, the President’s Emergency Plan for AIDS Relief (PEPFAR), is facing growing uncertainty following the emergence of a draft plan by U.S. State Department officials to phase out the programme and transition its services to bilateral country relationships within as little as two to eight years.
Although Congress recently reinstated $400 million in funding for PEPFAR, the proposed roadmap—first reported by The New York Times—outlines an accelerated strategy to wind down the initiative, pivoting instead to a model focused on global outbreak surveillance and market development for U.S.-made health technologies.
“With targeted investment, PEPFAR’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 shift marks a significant departure from PEPFAR’s original mandate: to prevent new HIV infections and provide life-saving treatment and services in low-income countries. Since its launch in 2003, the programme has been credited with saving more than 25 million lives across sub-Saharan Africa and other regions severely affected by the HIV epidemic.
From Public Health to Political Strategy
The planning documents describe a vision in which HIV funding would be restructured to support U.S. strategic interests, including pandemic preparedness and market access for American biotechnologies.
“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.”
Countries like South Africa, Botswana, and Namibia could see their PEPFAR support end within two years. Others with high infection rates, including Kenya, Zambia, and Zimbabwe, are on a three- to four-year exit timeline. Fragile states such as Mozambique, Malawi, and South Sudan would be granted a slightly longer five- to eight-year window.
“Three years… it’s really a very short period for a heavy programme like the HIV programme in Zambia – it’s impossible.”
What’s at Stake?
One of the most immediate consequences has been the termination of funding for prevention programmes targeting key populations—sex workers, men who have sex with men, and discordant couples—despite these groups being central to epidemic control.
A twice-yearly HIV prevention injection, lenacapavir, was expected to reach two million people with support from PEPFAR. But the upheaval has left its future uncertain.
“Countless people will die if it is allowed to go forward.”
There are also serious concerns about data continuity. Under the plan, countries must immediately meet strict data standards or risk losing all support—putting immense pressure on fragile health systems.
A Divided Agenda
The proposed changes reflect deeper ideological divides. Congress has largely supported PEPFAR’s mission, while some former administration officials have argued that it encourages dependency and wasteful foreign aid spending.
“If the transition is too fast, all of our gains could be reversed.”
As the draft circulates and consultations with partner countries begin, the fate of PEPFAR hangs in the balance—its legacy and future shaped by decisions expected later this year.
