The Plan to Kill the World's Most Successful AIDS Program

The President's Emergency Plan for AIDS Relief (PEPFAR) stands at a critical juncture, having narrowly escaped a $400 million funding cut in July 2025 only to face a more existential threat: the Trump administration's quiet plan to fundamentally transform the world's most successful HIV/AIDS program. Leaked planning documents reveal an administration intent on dismantling PEPFAR as a public health initiative and reconstituting it as a disease surveillance and commercial enterprise platform. This transformation exemplifies the dangerous politicization of evidence-based health programs that threatens to reverse decades of progress and abandon millions of people living with HIV worldwide.

A Plan Revealed

While Congress celebrated blocking the proposed $400 million cut, leaked State Department documents obtained by The New York Times reveal a more comprehensive plan to end PEPFAR as we know it. The documents propose a 42% reduction in PEPFAR's current $4.7 billion budget and envision countries transitioning away from U.S. assistance within two to eight years. Countries closest to epidemic control—Botswana, Namibia, South Africa, and Vietnam—would see complete U.S. withdrawal within two years.

The proposed transformation fundamentally alters PEPFAR's mission. Rather than providing medicines and services to treat and prevent HIV, the program would focus on "bilateral relationships" centered on detecting disease outbreaks that could threaten the United States and creating "new markets for American drugs and technologies." The documents explicitly frame the transition as "the premier example of the U.S. commitment to prioritizing trade over aid, opportunity over dependency and investment over assistance."

The Human Cost of Disruption

The human consequences of PEPFAR's disruption are already measurable and devastating. In Mozambique, researchers found that viral suppression among children receiving HIV treatment dropped 43% between February 2024 and February 2025, directly attributed to PEPFAR disruptions. South Africa has closed 12 specialized HIV clinics and seen over 8,000 health workers in its national HIV program lose their jobs.

Enid Kyomuhendo, a sex worker in Kampala, Uganda, described her experience when her clinic closed just days after she needed her antiretroviral refill: "I got so worried. I started taking alcohol. I was thinking that anytime I am going to die. It became this life of hopelessness." After two months without medication, she developed a dark, itchy rash and now worries about drug resistance—a preventable complication that could worsen her condition.

Modeling studies project even more severe consequences. A 90-day PEPFAR funding pause could result in over 100,000 excess HIV-related deaths over a year in sub-Saharan Africa alone. More than 75,000 adults and children are estimated to have already died because of the effective shutdown that began less than six months ago.

The Politicization of Public Health

PEPFAR's current crisis reflects a broader politicization of public health programs that historically enjoyed bipartisan support. The program's 2024 reauthorization became entangled in abortion rights debates, resulting in an unprecedented one-year extension instead of the traditional five-year renewal. Representative Michael McCaul (R-Texas) captured the frustration: "I'm disappointed. Honestly, I was looking forward to marking up a five-year reauthorization, and now I'm in this abortion debate." McCaul also noted that "a lot of the Freedom Caucus guys would not want to give aid to Africa."

The evangelical community's response proves particularly revealing. Despite PEPFAR's alignment with pro-life principles and its prevention of millions of deaths, white evangelical leaders have remained largely silent about the program's dismantling. As one conservative pastor noted: "If a Democratic administration were doing this—callously, illegally, and completely unnecessarily destroying a cause prayed for, advocated for, designed by, and in many cases carried out by evangelical believers—I struggle to believe that the response would be any less immediate and strident than if they were to mandate states to permit abortion."

This selective moral outrage demonstrates how partisan loyalty can override stated principles, even when millions of lives hang in the balance.

The Innovation Paradox

The timing of PEPFAR's crisis creates a particularly cruel irony. Just as revolutionary prevention tools become available, the administration has restricted prevention programming to pregnant and breastfeeding women only, cutting off access for sex workers, men who have sex with men, and people in serodiscordant relationships.

In June 2025, the FDA approved lenacapavir, a twice-yearly injectable that proved 100% effective in preventing HIV among women and 96% effective among gay and bisexual men in clinical trials. This breakthrough represents the most significant advance in HIV prevention since pre-exposure prophylaxis became available, offering a discreet, long-acting option that could overcome adherence challenges.

Yet PEPFAR's disruption threatens access to this transformative intervention. The Global Fund and Gilead Sciences have committed to providing 2 million doses over three years, but this represents a fraction of global need. PEPFAR was expected to fund approximately half of the initial procurement, but the program's uncertain future has left this commitment in doubt.

Reform Proposals and Alternative Paths

Various stakeholders have proposed different approaches to PEPFAR's future, recognizing that some transition planning is necessary while arguing against the administration's rushed timeline. Duke University researchers have outlined reform proposals that could reduce program costs by 20% over five years while maintaining essential services and planning sustainable transitions.

The Center for Strategic and International Studies has called for a realistic five-year transition plan that would include binding bilateral compacts with clear milestones, graduated timelines based on country capacity, and maintained surge capacity for outbreak response.

However, the administration's leaked documents assume timelines that health experts consider unrealistic. Dr. Mwanza wa Mwanza, who has worked in senior roles in Zambia's HIV program for nearly a decade, noted that "three years, it's really a very short period for a heavy program like the H.I.V. program in Zambia—it's impossible."

Protecting Evidence-Based Public Health

PEPFAR's crisis extends beyond HIV/AIDS policy to represent a fundamental test of whether evidence-based public health programs can survive political weaponization. The program's documented success—26 million lives saved, nearly 8 million babies born HIV-free, and significant contributions to global health security—should make its preservation a nonpartisan priority.

Yet the administration's approach suggests that ideological considerations and commercial interests now outweigh public health evidence in policy decisions. This precedent threatens not only HIV/AIDS programs but the entire framework of global health cooperation that has made possible advances in pandemic prevention, disease elimination, and health security.

Congress retains the power to protect PEPFAR through appropriations and oversight, but sustained advocacy will be necessary to maintain political support. We must demand that policymakers prioritize evidence over ideology and recognize that global health programs serve both humanitarian and strategic American interests.

The fight for PEPFAR represents a broader struggle for the soul of American public health policy. Whether evidence-based programs can survive political polarization will determine not only the fate of millions of people living with HIV worldwide but also America's capacity to lead effective responses to future health crises.