Trump Administration’s PEPFAR Cuts Threaten HIV/AIDS Goals

Blantyre, Malawi – Earlier this year, MacDonald Phiri crashed his bike near his home in southern Malawi. Staying for several months, the 49-year-old relied on an outreach worker to deliver the HIV prevention medication he took daily. The service was provided through a specialized clinic run by the Center for Human Development (CEDEP), a group that supports gay men, like Ferry, as well as transgender women.

Before the incident, Ferry himself had volunteered as an outreach worker at CEDEP, so he understood that in a country where homosexual activity was illegal, the clinic was a lifeline.

“We are the Muscat Securities Market [men who have sex with men]“In our country it is difficult to be free,” said Phiri, who asked to use a pseudonym to protect himself from retaliation. “Here in Malawi, it is difficult to even go to the hospital. Some health professionals only talk about you.

At the beginning of the year, CEDEP operated four reception centres, including the one Ferry used. Almost all of the funding was provided through the US initiative PEPFAR, or the President’s Emergency Plan for AIDS Relief. Since its launch in 2003, PEPFAR has directed more than $100 billion to global HIV relief efforts, saving nearly 26 million lives.

Malawi has received at least $1.8 billion of this funding, which has been crucial in helping the country move towards the goal of ending the AIDS epidemic by 2030 – a goal set by the Sustainable Development Goals adopted by the United Nations in 2015.

However, since US President Donald Trump returned to office, his administration has reduced PEPFAR funding, including for Malawi, and reduced support for prevention efforts as well as services to remote and vulnerable communities that are essential to eliminating AIDS.

This included ending all support for CEDEP in March, prompting the organization to close two of its clinics. While the facility near Phiri’s home remains open, it has had to halt outreach efforts, leaving him without access to HIV prevention medications while he recovers. He was diagnosed with HIV just a few months later.

Ferry was angry, not so much about his diagnosis as about the dismantling of the program that had proven so effective: “Are we going to suffer? Are we going to die? I hate this president.”

In September, the Trump administration unveiled the “America First Global Health Strategy,” which outlines its vision for continued U.S. engagement in the global HIV response. The strategy pledges continued support to achieve the goals required to end the AIDS epidemic by 2030. However, it also restricts funding for certain programs and requires partner countries to take greater ownership of their efforts to combat HIV.

A Foreign Ministry spokesman said Foreign policy The United States intends to remain “the global leader in global health.” But experts warn that deep cuts in crucial HIV programs in countries like Malawi are too sudden for governments to close the gap quickly.

As a result, the progress made towards eliminating AIDS over the past two decades is now being reversed – one infection at a time.

In 2014, UNAIDS has set out a series of steps to guide countries towards ending the AIDS epidemic by 2030. At the heart of this plan were the “95-95-95” goals: by the end of 2025, 95% of all people living with HIV should know their status; 95% of people diagnosed should receive life-saving antiretroviral therapy; 95% of those who receive treatment must have their virus suppressed, rendering them virtually unable to transmit HIV.

By 2022, the United States had fully aligned PEPFAR with these goals, and last year, UNAIDS estimated that the world reached 87-89-94 respectively—the closest it has ever come to meeting UNAIDS goals.

Determined to meet the 2025 deadline, officials in Malawi worked closely with PEPFAR and were able to reach 95-95-95 a year ahead of schedule. In the process, Malawi has seen a dramatic decline in new HIV infections, as well as AIDS-related deaths, which fell from 80,000 cases in 2003 to 14,000 last year.

Trump’s return to office has Malawi fearing a setback. After freezing all US foreign aid in late January, US Secretary of State Marco Rubio issued a waiver allowing PEPFAR to continue a narrow set of programs considered “lifesaving” – specifically, HIV testing and treatment and preventing mother-to-child transmission.

Since then, the Trump administration has eliminated nearly every element of PEPFAR that does not meet this narrow definition of saving lives — and even some programs that do. In the words of global health expert Nina Schwalbe, “PEPFAR as we know it – as we knew it – is dead.”

In Malawi, Washington has cut off services to marginalized groups, including the clinic that Phiri relies on, even though it provides treatment that meets the administration’s standards. Programs serving sex workers, teenage girls, and young women — groups with the highest rates of HIV infection — have also been terminated.

“Achieving zero AIDS by 2030 depends heavily on ensuring these communities have access to compassionate services,” said Simon Sikwese, who runs a program for sex workers in Malawi.

The cuts imposed by Washington also affected services for rural and poor people in Malawi, ending support for volunteers who traveled to remote areas to deliver HIV prevention or treatment drugs and track down HIV-positive people who skipped their appointments at clinics.

“Now, if someone decides not to show up, it is difficult to follow up on them,” said Makhoney Kulisimba, an HIV testing and counseling provider in southern Malawi who has used these volunteer networks.

As organizations have learned over the years, adherence to HIV treatment often requires more than just access to medication. These additional services have also disappeared.

In 2024, the $60 million, five-year Ana ndi Achinyamata Patsogolo (Anapa) program is launched to prevent orphans and other vulnerable children in Malawi from contracting HIV. For those already infected, the project focused on keeping them under treatment. Staff quickly realized that doing so meant ensuring that children were safe, well-nourished and in school.

Veronica Bikoko, a child protection worker in Anapa, has helped children like Matthews Chisamala, who was born with HIV into a poor family in rural central Malawi. Now 18, Chisamala often skipped his medication because taking the medication on an empty stomach made him feel nauseous. But missing doses puts him at risk of developing drug resistance.

Bikoko enrolled Chizamala caregivers in the Anapa program to help them find work and ensure they can afford food. Once the family’s basic needs were met, Bikoko visited Chisamala regularly to ensure he was taking his medication. Her approach worked. By the end of last year, his virus had been suppressed.

“When we work with them, success comes,” Bicoco said. “They’re really changing.”

But the Trump administration closed several wraparound services in Anapa, including job and school enrollment support programs, because they did not meet its definition of life-saving. Bikoko was laid off in the downsizing, though she still tries to check on Chisamala when she can. He told her he was struggling to find enough to eat again.

Officials in Malawi and elsewhere have watched with horror as these services disappear. Without it, they warn, HIV will continue to spread, especially among the most vulnerable groups, leaving them mired in an endless epidemic.

“We are not sure what will happen in 2030,” said Beatrice Matangi, CEO of the Malawi National AIDS Commission. “Everyone is really unsure about 2030 and beyond. It’s as if in the middle of planning, a bomb was dropped on us.”

In the new America First Global Health Strategy The Trump administration affirms its commitment to the 95-95-95 goals. This came as a relief to many. UNAIDS even welcomed the plan as evidence of “the continued support of the American people and the United States government in the historic efforts to end AIDS.” But the strategy also indicates that Washington will not restore many PEPFAR programs that were cut, including outreach to vulnerable and remote communities. Without it, experts say the pledge to support the 95-95-95 goals is hollow.

The Trump administration has also made clear that it views PEPFAR as a symbol of unsustainable dependence on US foreign aid. As part of this strategy, one of the administration’s top priorities is to shift responsibility for HIV programs to the countries themselves.

To achieve this end, the strategy calls for the conclusion of bilateral agreements that would make future US funding conditional on countries increasing their financial contributions. Negotiations took place in several countries, including Malawi, in November, and agreements are expected to be finalized by the end of the year. A US State Department spokesperson said the goal is to ensure that each country develops a plan that addresses the unique needs of its population.

This push to nominally strengthen state ownership is consistent with what HIV advocates, international donors, local civil society organizations, and even governments of some countries have been seeking for years: a path to sustainability supported by domestic financing.

“If they can successfully move in this direction, it could be a win for countries to respond,” said Ramona Godbole, former deputy administrator for global health policy, programs and planning at USAID. But she warned that US officials need to “really think about each country’s realistic timeline for avoiding preventable illness and death.”

However, civil society in Malawi doubts that Washington is truly concerned about their illness or death. If US officials had been, they would not have spent the past 10 months ending programs that are critical to the shared global commitment to ending AIDS by 2030.

In the wake of the U.S. cuts, local officials and networks of people living with HIV rushed to maintain affected PEPFAR services while preparing to take on potential new obligations under bilateral agreements. The Government of Malawi has allocated $11 million to the Ministry of Health to hire new staff and an additional $1.7 million to restore HIV testing services.

But the government lacks the resources to replace everything lost. With Malawi’s public sector debt reaching 93% of GDP, servicing this debt eats up money that could be allocated to HIV programmes.

“Gone are the days when we had back-up funding for someone to track people,” Matangi said.

Even as the 2030 goal of eliminating AIDS threatens to slip beyond our reach, officials in Malawi say they are determined to keep up the fight, with or without PEPFAR.

“We have to see how we can close this gap. Not 100 percent,” said Maziko Matimba, who chairs the board of the Malawi Network of AIDS Service Organizations. “But at least to maintain some of the gains we have recorded as a country.”