Perspective

Introduction

The President’s Emergency Plan for AIDS Relief (PEPFAR) has been a significant contributor to the global HIV response since its inauguration two decades ago [1] The Joint United Nations Programme on HIV/AIDS. UNAIDS urges that all essential HIV services must continue while U.S. pauses its funding for foreign aid [Internet]. Geneva (Switzerland): The Joint United Nations Programme on HIV/AIDS; 2025 Feb 1 [cited 2025 Apr 11]. [about 3 screens]. Available from: https://www.unaids.org/en/resources/presscentre/pressreleaseandstatementarchive/2025/february/20250201_us-funding . PEPFAR has donated billions of dollars in aid to developing nations [2] Gaumer G, Luan Y, Hariharan D, Crown W, Kates J, Jordan M, Hurley CL, Nandakumar A. Assessing the impact of the president’s emergency plan for AIDS relief on all-cause mortality. PLOS Glob Public Health [Internet]. 2024 Jan 18 [cited 2025 Apr 11];4(1):e0002467. Available from: https://dx.plos.org/10.1371/journal.pgph.0002467 https://doi.org/10.1371/journal.pgph.0002467 , including Nigeria, to fight the HIV/AIDS epidemic, a gesture that is considered the most significant commitment by a country to tackle a single disease. Nonetheless, the sudden freeze on funding, in January 2025, by the United States Department of State for HIV programs in low- and middle-income countries (LMICs) has raised concerns about the health of people living with HIV (PLHIV) [3] Joint United Nations Programme on HIV/AIDS. Impact of US funding cuts on the global AIDS response: Weekly report [Internet]. Geneva (Switzerland): The Joint United Nations Programme on HIV/AIDS; 2025 Apr 8 [cited 2025 Apr 11]. 4 p. Available from: https://www.unaids.org/sites/default/files/2025-04/20250408-USstop-sitrep.pdf Download 20250408-USstop-sitrep.pdf . This abrupt decision sent shockwaves throughout the global health community, raising immediate concerns about the continuity of care for millions of PLHIV. The suddenness of this change disrupted ongoing care efforts and created immediate logistical challenges for service delivery [4] Gandhi AR, Bekker LG, Paltiel AD, Hyle EP, Ciaranello AL, Pillay Y, Freedberg KA, Neilan AM. Potential Clinical and Economic Impacts of Cutbacks in the President’s Emergency Plan for AIDS Relief Program in South Africa : A Modeling Analysis. Ann Intern Med [Internet]. 2025 Feb 11 [cited 2025 Apr 11]; ANNALS-24-01104. Available from: https://www.acpjournals.org/doi/10.7326/ANNALS-24-01104 https://doi.org/10.7326/annals-24-01104 , [5] Haug S, Novoselova A, Klingebiel S. Trump’s assault on foreign aid: implications for international development cooperation. IDOS Discussion Paper [Internet]. 2025 Apr [cited 2025 Apr 11];4/2025. Available from: https://www.idos-research.de/discussion-paper/article/trumps-assault-on-foreign-aid-implications-for-international-development-cooperation/ https://doi.org/10.23661/idp4.2025 . This commentary seeks to discuss the grievous effect of this funding pause on the HIV response in Nigeria and other developing countries. Its rationale is to highlight the significance of PEPFAR funding and the potential gaps that may arise from its withdrawal.

PEPFAR’s Contribution to HIV/AIDS Response

PEPFAR was established by the United States (US) government in 2003 as a way to combat the alarming increase in HIV acquisition. PEPFAR was built on available epidemiological data, such that countries with higher disease burden received more interventions [6] Lyerla R, Murrill CS, Ghys PD, Calleja-Garcia JM, DeCock KM. The use of epidemiological data to inform the PEPFAR response. JAIDS Journal of Acquired Immune Deficiency Syndromes [Internet]. 2012 Aug 15 [cited 2025 Apr 11];60(Suppl 3):S57–62. Available from: https://journals.lww.com/00126334-201208153-00003. Available from: https://journals.lww.com/00126334-201208153-00003 https://doi.org/10.1097/qai.0b013e31825d279a . While PEPFAR focuses on providing free HIV-related services such as testing, treatment, care, support for affected families, and training for healthcare workers and strengthens health systems in over 30 recipient  LMICs [7] Gaumer G, Crown WH, Kates J, Luan Y, Hariharan D, Jordan M, Hurley CL, Nandakumar A. Analysis of maternal and child health spillover effects in PEPFAR countries. BMJ Open [Internet]. 2023 Dec 21[cited 2025 Apr 11];13(12):e070221. Available from: https://bmjopen.bmj.com/lookup/doi/10.1136/bmjopen-2022-070221 https://doi.org/10.1136/bmjopen-2022-070221 , it also supports programs that address sexual transmitted diseases and related health issues such as Tuberculosis [8] Howard AA, Gasana M, Getahun H, Harries A, Lawn SD, Miller B, Nelson L, Sitienei J, Coggin WL. PEPFAR support for the scaling up of collaborative TB/HIV activities. JAIDS Journal of Acquired Immune Deficiency Syndromes [Internet]. 2012 Aug 15 [cited 2025 Apr 11];60(Supplement 3):S136–44. Available from: https://journals.lww.com/00126334-201208153-00013 https://doi.org/10.1097/qai.0b013e31825cfe8e and COVID-19 response [9] Golin R, Godfrey C, Firth J, Lee L, Minior T, Phelps BR, Raizes EG, Ake JA, Siberry GK. PEPFAR’s response to the convergence of the HIV and COVID‐19 pandemics in Sub‐Saharan Africa. J Intern AIDS Soc [Internet]. 2020 Jul 12 [cited 2025 Apr 11];23(8):e25587. Available from: https://onlinelibrary.wiley.com/doi/10.1002/jia2.25587 https://doi.org/10.1002/jia2.25587 while paying attention to HIV key populations and maternal health.

PEPFAR expanded antiretroviral treatment in LMICs through health system assessments, medical education partnerships, skills training, and global learning programs to strengthen HIV care and healthcare infrastructure [10] Patel-Larson A, Ledikwe JH, West T, Cheever L, Hauck H, Andrews G, Lipita F, Gugsa S, Life T, Perlman J, Wilson A, Phillips HJ, Haddad C. Looking back to see forward: multidirectional learning between the US Ryan White HIV/AIDS Program and the US President’s Emergency Plan for AIDS Relief. BMJ Glob Health [Internet]. 2024 Feb [cited 2025 Apr 11];8(Suppl 7):e013953. Available from: https://gh.bmj.com/lookup/doi/10.1136/bmjgh-2023-013953 https://doi.org/10.1136/bmjgh-2023-013953 . PEPFAR collaborated with Ministries of Health and partner organizations to provide family-based HIV care by decentralization of early infant diagnosis (EID) and pediatric HIV care, leading to a 6-fold increase in the number of infants receiving HIV care from 44,800 to 289,000 between 2006 and 2011 [11] Abrams EJ, Simonds RJ, Modi S, Rivadeneira E, Vaz P, Kankasa C, Tindyebwa D, Phelps BR, Bowsky S, Teasdale CA, Koumans E, Ruff AJ. PEPFAR scale-up of pediatric HIV services: innovations, achievements, and challenges. JAIDS Journal of Acquired Immune Deficiency Syndromes [Internet]. 2012 Aug 15 [cited 2025 Apr 11];60(Supplement 3):S105–12. Available from: https://journals.lww.com/00126334-201208153-00009 https://doi.org/10.1097/qai.0b013e31825cf4f5 , and a 44% reduction in HIV-related deaths in children aged 0-14 years between 2010 to 2016 [12] Abdool Karim Q, Baxter C, Birx D. Prevention of HIV in Adolescent Girls and Young Women: Key to an AIDS-Free Generation. JAIDS Journal of Acquired Immune Deficiency Syndromes [Internet]. 2017 May 1 [cited 2025 Apr 11];75(1):S17–26. Available from: https://journals.lww.com/00126334-201705011-00004 https://doi.org/10.1097/qai.0000000000001316 . PEPFAR supported the adoption of the 2015 ‘universal test and treat’ policy recommended by the World Health Organization in its recipient countries, which helped increase early detection, reduce delay in the initiation of antiretrovirals, reduce cases of opportunistic infections, and improve the quality of life of PLHIV [13] Bekolo CE, Ndeso SA, Gougue CP, Moifo LL, Mangala N, Tchendjou P, Mboh E, Ateudjieu J, Tendongfor N, Nsagha DS, Halle-Ekane GE, Choukem SP. The effect of the Universal Test and Treat policy uptake on CD4 count testing and incidence of opportunistic infections among people living with HIV infection in Cameroon: a retrospective analysis of routine data. Dialogues in Health [Internet]. 2023 Feb 26 [cited 2025 Apr 11];2:100120. Available from: https://linkinghub.elsevier.com/retrieve/pii/S2772653323000242 https://doi.org/10.1016/j.dialog.2023.100120 .

Immediate and long-term consequences of funds withdrawal

The withdrawal of US funding from PEPFAR and other HIV-related programs poses a significant threat to antiretroviral therapy (ART) accessibility for millions of PLHIV in Nigeria and other developing countries [14] Banigbe B, Audet CM, Okonkwo P, Arije OO, Bassi E, Clouse K, Simmons M, Aliyu MH, Freedberg KA, Ahonkhai AA. Effect of PEPFAR funding policy change on HIV service delivery in a large HIV care and treatment network in Nigeria. Ojikutu BO, editor. PLoS ONE [Internet]. 2019 Sep 25 [cited 2025 Apr 11];14(9):e0221809. Available from: https://dx.plos.org/10.1371/journal.pone.0221809 https://doi.org/10.1371/journal.pone.0221809 . PEPFAR alone supports approximately 20 million individuals on ART worldwide [15] Chun HM, Dirlikov E, Cox MH, Sherlock MW, Obeng-Aduasare Y, Sato K, Voetsch AC, Ater AD, Romano ER, Tomlinson H, Modi S, Achrekar A, Nkengasong J, CDC Global HIV Working Group, CDC Global HIV Working Group, Agolory S, Amann J, Baack B, Behel S, Date A, Hanson J, Killam WP, Patel H, Patel S, Pati R, Porter L, Warner A, Wuhib T, Zeh C, Faria E Silva Santelli AC, Guevara G, Morales RE, Ekra AK, Kitenge F, Bonilla L, Mazibuko S, Damena T, Joseph P, Upadhyaya S, Aitmagambetova I, Mwangi J, Usmanova N, Xaymounvong D, Asiimwe M, Alice M, Masamha GJ, Mutandi G, Odafe S, Romel L, Musoni C, Mogashoa M, Bolo A, Nabidzhonov A, Mgomella G, Lolekha R, Alamo-Talisuna S, Podolchak N, Nguyen CK, Quaye S, Mwila A, Nyika P. Vital Signs: Progress Toward Eliminating HIV as a Global Public Health Threat Through Scale-Up of Antiretroviral Therapy and Health System Strengthening Supported by the U.S. President’s Emergency Plan for AIDS Relief – Worldwide, 2004-2022. MMWR Morb Mortal Wkly Rep [Internet]. 2023 Mar 24 [cited 2025 Apr 11];72(12):317–24. Available from: http://www.cdc.gov/mmwr/volumes/72/wr/mm7212e1.htm?s_cid=mm7212e1_w https://doi.org/10.15585/mmwr.mm7212e1 .

In the immediate term, reduced funding may lead to treatment disruptions, drug stock-outs, and increased drug resistance, which would further worsen HIV-related morbidity and mortality [16] Glauser W, Simon B. Funding cuts spark fears about the rise of drug-resistant strains of HIV in Africa. Canadian Medical Association Journal [Internet]. 2010 Feb 23 [cited 2025 Apr 11];182(3):E165–6. Available from: http://www.cmaj.ca/cgi/doi/10.1503/cmaj.109-3149 https://doi.org/10.1503/cmaj.109-3149 . In Nigeria, previous reductions in PEPFAR funding have resulted in challenges for clinics in maintaining routine HIV services, with compromised quality of care and shortages of staff [14] Banigbe B, Audet CM, Okonkwo P, Arije OO, Bassi E, Clouse K, Simmons M, Aliyu MH, Freedberg KA, Ahonkhai AA. Effect of PEPFAR funding policy change on HIV service delivery in a large HIV care and treatment network in Nigeria. Ojikutu BO, editor. PLoS ONE [Internet]. 2019 Sep 25 [cited 2025 Apr 11];14(9):e0221809. Available from: https://dx.plos.org/10.1371/journal.pone.0221809 https://doi.org/10.1371/journal.pone.0221809 . Funding withdrawal also disrupts essential HIV prevention programs, including pre-exposure prophylaxis (PrEP), prevention of mother-to-child transmission (PMTCT), and harm reduction initiatives [17] Ren X, Xu J, Cheng F. Transition of HIV prevention in three Southeast Asian countries: challenges and responses to the withdrawal of the Global Fund funding. Global Health Journal [Internet]. 2021 Dec [cited 2025 Apr 11];5(4):194–7. Available from: https://linkinghub.elsevier.com/retrieve/pii/S2414644721000853 https://doi.org/10.1016/j.glohj.2021.10.001 . Studies indicate that PrEP scale-up significantly reduces HIV transmission in key populations [18] Grulich AE, Jin F, Bavinton BR, Yeung B, Hammoud MA, Amin J, Cabrera G, Clackett S, Ogilvie E, Vaccher S, Vickers T, McNulty A, Smith DJ, Dharan NJ, Selvey C, Power C, Price K, Zablotska I, Baker DA, Bloch M, Brown K, Carmody CJ, Carr A, Chanisheff D, Doong N, Finlayson R, Lewis DA, Lusk J, Martin S, Ooi C, Read P, Ryder N, Smith D, Tuck Meng Soo C, Templeton DJ, Vlahakis E, Guy R. Long-term protection from HIV infection with oral HIV pre-exposure prophylaxis in gay and bisexual men: findings from the expanded and extended EPIC-NSW prospective implementation study. The Lancet HIV [Internet]. 2021 Aug [cited 2025 Apr 11];8(8):e486–94. Available from: https://linkinghub.elsevier.com/retrieve/pii/S2352301821000746 https://doi.org/10.1016/s2352-3018(21)00074-6 , [19] Killelea A, Johnson J, Dangerfield DT, Beyrer C, McGough M, McIntyre J, Gee RE, Ballreich J, Conti R, Horn T, Pickett J, Sharfstein JM. Financing and Delivering Pre-Exposure Prophylaxis (PrEP) to End the HIV Epidemic. J Law Med Ethics [Internet]. 2022 Jul 29 [cited 2025 Apr 11];50(S1):8–23. Available from: https://www.cambridge.org/core/product/identifier/S1073110522000304/type/journal_article https://doi.org/10.1017/jme.2022.30 , but financial constraints might lead to reduced PrEP access in some African countries [20] Muhumuza R, Ssemata AS, Kakande A, Ahmed N, Atujuna M, Nomvuyo M, Bekker LG, Dietrich JJ, Tshabalala G, Hornschuh S, Maluadzi M, Chibanda-Stranix L, Nematadzira T, Weiss HA, Nash S, Fox J, Seeley J. Exploring Perceived Barriers and Facilitators of PrEP Uptake among Young People in Uganda, Zimbabwe, and South Africa. Arch Sex Behav [Internet]. 2021 May [cited 2025 Apr 11];50(4):1729–42. Available from: https://link.springer.com/10.1007/s10508-020-01880-y https://doi.org/10.1007/s10508-020-01880-y , [21] Zakumumpa H, Paina L, Ssegujja E, Shroff ZC, Namakula J, Ssengooba F. The impact of shifts in PEPFAR funding policy on HIV services in Eastern Uganda (2015–21). Health Policy and Planning [Internet]. 2024 Jan 23 [cited 2025 Apr 11];39(Suppl_1):i21–32. Available from: https://academic.oup.com/heapol/article/39/Supplement_1/i21/7578674 https://doi.org/10.1093/heapol/czad096 . Similarly, PMTCT programs that have achieved nearly 90% efficacy in preventing infant HIV transmission may experience service gaps, reversing hard-won progress [22] Abuogi LL, Humphrey JM, Mpody C, Yotebieng M, Murnane PM, Clouse K, Otieno L, Cohen CR, Wools-Kaloustian K. Achieving UNAIDS 90-90-90 targets for pregnant and postpartum women in sub-Saharan Africa: progress, gaps and research needs. Journal of Virus Eradication [Internet]. 2018 Nov [cited 2025 Apr 11];4:33–9. Available from: https://linkinghub.elsevier.com/retrieve/pii/S2055664020303435 https://doi.org/10.1016/s2055-6640(20)30343-5 , [23] Mutabazi JC, Zarowsky C, Trottier H. The impact of programs for prevention of mother-to-child transmission of HIV on health care services and systems in sub-Saharan Africa – A review. Public Health Rev [Internet]. 2017 Dec [cited 2025 Apr 11];38(1):28. Available from: https://publichealthreviews.biomedcentral.com/articles/10.1186/s40985-017-0072-5 https://doi.org/10.1186/s40985-017-0072-5 , [24] El-Sadr WM, Holmes CB, Mugyenyi P, Thirumurthy H, Ellerbrock T, Ferris R, Sanne I, Asiimwe A, Hirnschall G, Nkambule RN, Stabinski L, Affrunti M, Teasdale C, Zulu I, Whiteside A. Scale-up of HIV treatment through PEPFAR: a historic public health achievement. JAIDS Journal of Acquired Immune Deficiency Syndromes [Internet]. 2012 Aug 15 [cited 2025 Apr 11];60(Suppl 3):S96–104. Available from: https://journals.lww.com/00126334-201208153-00008 https://doi.org/10.1097/qai.0b013e31825eb27b .

In the long term, the erosion of donor support may undermine the structural gains achieved through PEPFAR, including investments in laboratory networks, healthcare worker training, and diagnostic capabilities [24] El-Sadr WM, Holmes CB, Mugyenyi P, Thirumurthy H, Ellerbrock T, Ferris R, Sanne I, Asiimwe A, Hirnschall G, Nkambule RN, Stabinski L, Affrunti M, Teasdale C, Zulu I, Whiteside A. Scale-up of HIV treatment through PEPFAR: a historic public health achievement. JAIDS Journal of Acquired Immune Deficiency Syndromes [Internet]. 2012 Aug 15 [cited 2025 Apr 11];60(Suppl 3):S96–104. Available from: https://journals.lww.com/00126334-201208153-00008 https://doi.org/10.1097/qai.0b013e31825eb27b . Funding cuts could weaken HIV testing coverage, impair viral load monitoring, and place additional strain on already fragile health systems [14] Banigbe B, Audet CM, Okonkwo P, Arije OO, Bassi E, Clouse K, Simmons M, Aliyu MH, Freedberg KA, Ahonkhai AA. Effect of PEPFAR funding policy change on HIV service delivery in a large HIV care and treatment network in Nigeria. Ojikutu BO, editor. PLoS ONE [Internet]. 2019 Sep 25 [cited 2025 Apr 11];14(9):e0221809. Available from: https://dx.plos.org/10.1371/journal.pone.0221809 https://doi.org/10.1371/journal.pone.0221809 [21] Zakumumpa H, Paina L, Ssegujja E, Shroff ZC, Namakula J, Ssengooba F. The impact of shifts in PEPFAR funding policy on HIV services in Eastern Uganda (2015–21). Health Policy and Planning [Internet]. 2024 Jan 23 [cited 2025 Apr 11];39(Suppl_1):i21–32. Available from: https://academic.oup.com/heapol/article/39/Supplement_1/i21/7578674 https://doi.org/10.1093/heapol/czad096 . In countries like Nigeria, clinics have reported shortages in trained personnel following past donor funding reductions [14] Banigbe B, Audet CM, Okonkwo P, Arije OO, Bassi E, Clouse K, Simmons M, Aliyu MH, Freedberg KA, Ahonkhai AA. Effect of PEPFAR funding policy change on HIV service delivery in a large HIV care and treatment network in Nigeria. Ojikutu BO, editor. PLoS ONE [Internet]. 2019 Sep 25 [cited 2025 Apr 11];14(9):e0221809. Available from: https://dx.plos.org/10.1371/journal.pone.0221809 https://doi.org/10.1371/journal.pone.0221809 . Without external funding, PLHIV may bear higher out-of-pocket costs for medications and healthcare visits, exacerbating poverty and health inequalities [25] Mahal A, Rao B. HIV/AIDS epidemic in India: an economic perspective. Indian J Med Res. 2005 Apr;121(4):582–600. PMID: 15817965 .

Potential Future Risks and Global Implications

Potential future risks include severe impacts on global HIV/AIDS programs, particularly in LMICs, hardest hit by the epidemic. Disruptions in the ART supply chain [26] Mwaura J. N. The impact of global programs such as pepfar, unaids, and the global fund on combating hiv/aids in east africa. IAAJSR [Internet]. 2024 Sep 24 [cited 2025 Apr 11];11(3):1–6. Available from: https://www.iaajournals.org/the-impact-of-global-programs-such-as-pepfar-unaids-and-the-global-fund-on-combating-hiv-aids-in-east-africa/ https://doi.org/10.59298/IAAJSR/2024/113.1600 could lead to treatment interruptions, increased viral loads, and rising HIV prevalence, which could lead to AIDS and increased mortality. Without HIV treatment, individuals with AIDS typically survive for approximately 3 years [27] Centers for Disease Control and Prevention. About HIV [Internet]. Atlanta (GA): Centers for Disease Control and Prevention; 2025 Jan 14[cited 2025 Apr 11]. [about 7 screens]. Available from: https://www.cdc.gov/hiv/about/index.html . The suspension would also halt condom distribution, a key prevention strategy for high-risk populations, likely increasing new infections [26] Mwaura J. N. The impact of global programs such as pepfar, unaids, and the global fund on combating hiv/aids in east africa. IAAJSR [Internet]. 2024 Sep 24 [cited 2025 Apr 11];11(3):1–6. Available from: https://www.iaajournals.org/the-impact-of-global-programs-such-as-pepfar-unaids-and-the-global-fund-on-combating-hiv-aids-in-east-africa/ https://doi.org/10.59298/IAAJSR/2024/113.1600 .

Additionally, restricted access to HIV treatment would heighten transmission risks within families and communities, worsening the public health crisis [28] Brawner BM, Kerr J, Castle BF, Bannon JA, Bonett S, Stevens R, James R, Bowleg L. A systematic review of neighborhood-level influences on hiv vulnerability. AIDS Behav [Internet]. 2022 Mar [cited 2025 Apr 11];26(3):874–934. Available from: https://link.springer.com/10.1007/s10461-021-03448-w https://doi.org/10.1007/s10461-021-03448-w . Vulnerable populations [29] Nawar EW, Andrinopoulos KM, Machekano RN, Carton TW, Bobrow EA, Placidie Mugwaneza, Dieudonne Ndatimana. A Longitudinal Assessment of Interruptions in HIV Clinic Visits and Virologic Failure among Pregnant and Postpartum Women in the Kabeho Study. Journal of AIDS and HIV Treatment [Internet]. 2023;5(1):34–40. Available from: https://pedaids.org/wp-content/uploads/2024/10/article-pdf-1698342864-1067.pdf , especially in underserved areas, would face even greater barriers to care due to infrastructural gaps left by the funding cut [28] Brawner BM, Kerr J, Castle BF, Bannon JA, Bonett S, Stevens R, James R, Bowleg L. A systematic review of neighborhood-level influences on hiv vulnerability. AIDS Behav [Internet]. 2022 Mar [cited 2025 Apr 11];26(3):874–934. Available from: https://link.springer.com/10.1007/s10461-021-03448-w https://doi.org/10.1007/s10461-021-03448-w . According to predictive models, disruptions to ART would likely result in a 60% increase in the risk of mother-to-child transmission of HIV [30] Jewell BL, Mudimu E, Stover J, Ten Brink D, Phillips AN, Smith JA, Martin-Hughes R, Teng Y, Glaubius R, Mahiane SG, Bansi-Matharu L, Taramusi I, Chagoma N, Morrison M, Doherty M, Marsh K, Bershteyn A, Hallett TB, Kelly SL. Potential effects of disruption to HIV programmes in sub-Saharan Africa caused by COVID-19: results from multiple mathematical models. The Lancet HIV [Internet]. 2020 Sep [cited 2025 Apr 11];7(9):e629–40. Available from: https://linkinghub.elsevier.com/retrieve/pii/S2352301820302113 https://doi.org/10.1016/s2352-3018(20)30211-3 .

As infection rates rise, healthcare workers and community health systems will face greater strain, increasing burnout and compromising care quality, leading to poorer health outcomes [31] Izdebski Z, Kozakiewicz A, Białorudzki M, Dec-Pietrowska J, Mazur J. Occupational burnout in healthcare workers, stress and other symptoms of work overload during the covid-19 pandemic in poland. IJERPH [Internet]. 2023 Jan 30 [cited 2025 Apr 11];20(3):2428. Available from: https://www.mdpi.com/1660-4601/20/3/2428 https://doi.org/10.3390/ijerph20032428 . This funding freeze would be catastrophic, undoing years of progress. Stigma, discrimination, and marginalization of affected communities would resurface, worsening healthcare disparities among PLHIV [32] Ai W, Fan C, Marley G, Tan RKJ, Wu D, Ong JJ, Tucker JD, Fu G, Tang W. Disparities in healthcare access and utilization among people living with HIV in China: A scoping review and meta‐analysis. HIV Medicine [Internet]. 2023 Jul 5 [cited 2025 Apr 11];24(11):1093–105. Available from: https://onlinelibrary.wiley.com/doi/10.1111/hiv.13523 https://doi.org/10.1111/hiv.13523 [33] Delpech V. The HIV epidemic: global and United Kingdom trends. Medicine [Internet]. 2022 Apr [cited 2025 Apr 11];50(4):202–4. Available from: https://linkinghub.elsevier.com/retrieve/pii/S1357303922000020 https://doi.org/10.1016/j.mpmed.2022.01.002 . Discontinuing PEPFAR would undermine efforts to end AIDS as a public health threat by 2030 [34] World Health Organization. HIV and AIDS [Internet]. Geneva (Switzerland): World Health Organization; 2024 Jul 22 [cited 2025 Apr 11]. [about 4 screens]. Available from: https://www.who.int/news-room/fact-sheets/detail/hiv-aids , increase drug resistance, and burden healthcare systems with more complex and costly cases [35] Tran DN, Ching J, Kafu C, Wachira J, Koros H, Venkataramani M, Said J, Pastakia SD, Galárraga O, Genberg BL. IInterruptions to HIV Care Delivery During Pandemics and Natural Disasters: A Qualitative Study of Challenges and Opportunities From Frontline Healthcare Providers in Western Kenya. J Int Assoc Provid AIDS Care [Internet]. 2023 Jan [cited 2025 Apr 11];22:23259582231152041. Available from: https://journals.sagepub.com/doi/10.1177/23259582231152041 https://doi.org/10.1177/23259582231152041 .

Moreover, disruptions in LMICs may facilitate the emergence of drug-resistant HIV strains and increase cross-border transmission, thereby threatening global health security and reversing progress shared by both LMICs and high-income countries (HICs) [36] Eshraghian EA, Ferdos SN, Mehta SR. The impact of human mobility on regional and global efforts to control hiv transmission. Viruses [Internet]. 2020 Jan 6 [cited 2025 Apr 11];12(1):67. Available from: https://www.mdpi.com/1999-4915/12/1/67 https://doi.org/10.3390/v12010067 .

Alternative Solutions and Mitigation Strategies

While the current situation poses significant challenges, even to the ongoing 2030 sustainability roadmaps, it presents an opportunity to rethink global health financing and governance in LMICs. One potential solution is to explore national and regional funding alternatives. This should include improvements in budgetary allocations for healthcare, drastic reductions in resource wastefulness, and concerted efforts to strengthen public-private partnerships. For example, Nigeria’s HIV Trust Fund of Nigeria (HTFN), launched in 2022, pools private-sector resources to support HIV program sustainability and offers a replicable model for other LMICs. On a regional level, countries can collaborate to pool resources and share expertise and best practices for tackling health challenges. Such collaborations have been noted in managing outbreaks, endemics, and even neglected tropical diseases [37] John TJ, Vashishtha VM. Eradicating poliomyelitis: India’s journey from hyperendemic to polio-free status. Indian Journal of Medical Research. 2013 May 1;137(5):881-94. . Strengthening relationships with international but non-PEPFAR-based sources, such as The Global Fund (which has been playing complementary roles in HIV programs), as well as non-US-based funding sources should also be considered.

An equally important strategy involves strengthening existing structures, such as community-led and locally driven systems. These include community-based organizations and community-led monitoring mechanisms. These mechanisms effectively deliver community-based healthcare across disease contexts [38] Tshuma N, Elakpa DN, Moyo C, Soboyisi M, Moyo S, Mpofu S, Chadyiwa M, Malahlela M, Tiba C, Mnkandla D, Ndhlovu TM, Moruthoane T, Mphuthi DD, Mtapuri O. The transformative impact of community-led monitoring in the south african health system: a comprehensive analysis. Int J Public Health [Internet]. 2024 Feb 14 [cited 2025 Apr 12];69:1606591. Available from: https://www.ssph-journal.org/articles/10.3389/ijph.2024.1606591/full https://doi.org/10.3389/ijph.2024.1606591 . Additionally, many recipient countries, for the sake of sustainability, have made significant efforts in setting up systems to manage HIV/AIDS programs in preparation for 2030 and beyond [10] Patel-Larson A, Ledikwe JH, West T, Cheever L, Hauck H, Andrews G, Lipita F, Gugsa S, Life T, Perlman J, Wilson A, Phillips HJ, Haddad C. Looking back to see forward: multidirectional learning between the US Ryan White HIV/AIDS Program and the US President’s Emergency Plan for AIDS Relief. BMJ Glob Health [Internet]. 2024 Feb [cited 2025 Apr 11];8(Suppl 7):e013953. Available from: https://gh.bmj.com/lookup/doi/10.1136/bmjgh-2023-013953 https://doi.org/10.1136/bmjgh-2023-013953 .

Other viable strategies include advocating for ARV production locally, sustainable long-term financing through policy advocacy, and brainstorming innovative but cost-effective HIV care models. These would cushion the impacts of partial or total fund withdrawal.