Two African countries saw major declines in HIV/AIDs prevention services after the United States abruptly froze foreign aid, according to an analysis published this month in The Lancet.
The President’s Emergency Plan for AIDS Relief (PEPFAR), created in 2003 under President George W. Bush, is the largest external funder of HIV services globally. Shortly after President Donald Trump returned to office in January 2025, his administration paused all existing foreign assistance awards, including PEPFAR, to reassess whether international aid was funding programs that aligned with the new “America First Global Health Strategy.”
The move was criticized for causing chaos and depriving vital HIV/AIDs prevention work of critical funding, and the Lancet analysis found the interruption indeed resulted in “severe, immediate, and sustained reductions in service delivery.”
The study used data from four non-governmental organizations (NGOs) in Uganda and Zimbabwe that received PEPFAR funding for HIV services and work with high-risk populations, including men who have sex with men, female sex workers, transgender people, and those who inject drugs.
Researchers found that the number of people receiving antiretroviral therapy (ART) dropped by 31.5%. ART turns HIV from a fatal condition into a chronic one, and it prevents transmission, which benefits the health of the wider community.
Overall, prevention services, including condom and lubricant distribution, decreased by 62.7%, and HIV testing fell by 63.8%. And among the three NGOs that provided data on use of pre-exposure prophylaxis (PrEP), a medication that greatly reduces the chance of getting HIV from sex or injection drug use, initiation and continuation of this treatment declined by 71.6%.
The results were weighted by the number of ART clients each NGO served in 2024.
Change in funding structure likely harms the more vulnerable
The US is resuming public health aid to some countries, including Uganda, through bilateral agreements that provide funding in exchange for things like mineral rights and patient data. Other governments, such as Zimbabwe’s, have turned down this money, saying the proposals violate national sovereignty.
In countries that accept these agreements with the United States, there’s concern that the most at-risk populations have lost services and are now further isolated, said lead author Henry Cust, PhD, a health economist specializing in HIV risk at the London School of Economics.
For example, any homosexual activity in Uganda can result in life imprisonment and, in certain instances, even death. Similarly, in a host of countries that benefit from US public health aid, there are major social and legal barriers for transgender people as well as those who use drugs or do sex work.
“They are literally the most vulnerable people in the world,” said Cust.
He warned that cutting these populations off from HIV care is not only problematic from an equity standpoint, but it might eventually affect the larger population, as people who use drugs, do sex work, or patronize sex workers have families and spouses.
While the study didn’t look at outcomes, Cust said that a drop in both HIV prevention and treatment is the first domino that leads to an increase in transmission, including maternal-fetal transmission.