The United States is dismantling the infrastructure that has defined its fight against HIV for more than 20 years, and the early data suggests the human cost is mounting fast.
In recent weeks, the government released what is likely its final comprehensive report from Pepfar, the President's Emergency Plan for AIDS Relief, as it shifts toward a fragmented system of country-by-country partnerships. The chief scientific officer of Pepfar resigned days later, signaling deep concerns about the direction.
While the total number of people on HIV treatment globally has held roughly steady at 20.3 million, that surface stability masks alarming drops elsewhere. Testing plummeted by 17 percent. New enrollments in preventive therapy fell by 33 percent. The healthcare workforce shrunk by nearly a quarter.
Most troubling: infant testing and treatment have collapsed. At facilities that lost their Pepfar funding, infant testing fell by 60 percent and infant diagnoses by 31 percent. Infants with untreated HIV face extraordinarily high mortality rates, making this decline what researchers call "particularly concerning."
"The number of people on treatment, while it looks stable, obscures a lot of changes that have been happening underneath," said Brian Honermann, deputy director of policy at amfAR, the Foundation for AIDS Research. "Where we see the really large disruptions is in all of the wraparound services that get people diagnosed, get them initiated on treatment, and retain people in care."
The shift away from Pepfar eliminates the rigorous data collection that has allowed the United States to track progress for decades. Under the new bilateral agreements with individual countries, researchers will need permission from foreign governments just to access information about how tens of billions in American taxpayer dollars are being spent.
Mike Reid, the departing chief scientific officer, warned that the pace of transition has introduced risks the system may not be equipped to handle. "The pace of the proposed transition, I think, has a real risk that will outstrip the systems needed to manage it safely," he said.
Reid also raised the specter of HIV support being weaponized for other policy goals. The New York Times reported in March that the State Department has considered using HIV assistance as leverage to pressure Zambia into resource extraction agreements. "I didn't want to work for an administration that potentially was predicating life-saving services on a minerals agreement," Reid said, who is also an associate professor at UCSF School of Medicine and an HIV physician in San Francisco.
The transition comes as key US agencies have been gutted. USAID was dismantled, and layoffs at the Centers for Disease Control and Prevention have hit global health work particularly hard. Many of the American experts who could have guided countries through the transition have been fired or forced out.
Countries in Africa are already straining under high fuel costs and other pressures exacerbated by global conflicts. Asking them to suddenly absorb all the functions that Pepfar performed without the institutional support, data infrastructure, or financial resources to do so may prove unrealistic.
"Assuming that countries will be able to maintain care and treatment programs and sustain them at the levels that we have been able to is optimistic," Reid said.
Honermann emphasized another risk: without detailed reporting requirements, no one will be able to identify which programs work and which are failing until infections spike and lives are lost. "We're really concerned that we've actually lost track of a large number of people," he said.
Pepfar, created in 2003 under President George W. Bush, has been credited with saving 26 million lives. Within days of the current administration taking office in January, the program was temporarily halted and later resumed only with restrictions, such as limiting preventive therapy to pregnant and breastfeeding women.
Reid acknowledged that accelerating country leadership was a longstanding goal and that the Trump administration moved quickly to advance that objective. But speed divorced from capacity and oversight carries its own costs.
"We have extraordinary scientific tools right now, like long-acting prevention tools like lenacapavir, and we should be raising our ambition, not narrowing it," Reid said.
Author James Rodriguez: "The US is gambling that countries can instantly absorb a 20-year operation without breaking it, and the collapsing infant testing numbers suggest that gamble is already losing."
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