When Kenneth Ngure thinks about the global effort to control HIV/AIDS, he says, he feels like he's flying.
"It's like an airplane that's traveling at cruising altitude, seeking its destination," says Ngure, the president-elect of the International AIDS Society and associate professor of global health at the Jomo Kenyatta University in Kenya.
That destination, he says, is a world in which HIV/AIDS is no longer a threat. Even though there are still more than half a million AIDS-related deaths each year, he used to feel as if this goal was within sight on his in-flight map. He says a large part of the credit goes to the enormous U.S. investment in combatting the virus.
"[Lawmakers in the U.S.] are the pilots. They are the drivers," Ngure explains. "They put in enough resources."
Then came an unexpected patch of severe turbulence.
On inauguration day, President Donald Trump announced that he was halting the vast majority of foreign aid. That was a jolt.
"You hit turbulence and you start losing altitude. And you don't know whether we are going to get to our destination," says Ngure. "Everybody was in a panic. Is it the end?"
But last week, he says, came the equivalent of a reassuring message from the pilot.
The U.S. effort to address HIV/AIDS had been part of the Trump administration's effort to claw back billions of dollars previously allocated by Congress to public media and foreign aid. The total pledged to PEPFAR, or the President's Emergency Plan for AIDS Relief, that was slated to be cut: $400 million. But, word came on July 15 that the Senate was plucking PEPFAR out of the rescission list and rejecting those cuts. The program has long had bipartisan support and leaders wanted to avoid a PEPFAR-inspired revolt to the package. The rest of the rescission package passed both the House and Senate, taking back $9 billion. But PEPFAR escaped unscathed.
When Ngure heard that PEPFAR had survived the attempted cuts, he says, he thought to himself: "There's hope, but still maintain your safety belts."
But this was just one small positive note in an increasingly bumpy flight. Was this bipartisan effort to help PEPFAR enough to steady the plane and ensure it reaches its destination? Rumors abound. Some say PEPFAR is doomed. Others are hopeful given its bipartisan history. What does the future hold?
PEPFAR's history
President George W. Bush created PEPFAR in 2003 — a time when HIV/AIDS was devastating communities in Africa and other parts of the world, killing about 3 million people a year.
"I saw very, very dark days — hospitals on a daily basis witnessing, honestly, excruciating deaths of young people in their late teens and 20s," says Dr. Charles Holmes, who worked in Malawi as a medical student in 1999 and then again in 2002 before PEPFAR was born. He later served as the program's chief medical officer during the Obama administration.
Holmes returned to Malawi in February and found himself "reminded of how far we had come." Since its founding, PEPFAR has put more than $120 billion into combatting the virus in more than 50 countries. The result of all that money and effort, it says, is clear, citing accomplishments that are widely accepted: 26 million lives saved, a plummeting of HIV infection rates and a rebounding of life expectancy, especially in Africa.
Yet that wasn't enough to protect PEPFAR from the foreign aid shakeup. When Trump started cutting international aid programs a lot of the PEPFAR clinics and services ceased overnight as stop work orders went out.
"Clients come to the clinic, and in some cases, have found that the doors are literally locked and their trusted clinicians aren't there to see them, and their drugs that they had anticipated receiving are not there," says Holmes, who now directs the Center for Innovation and Global Health at Georgetown University.
All the disruptions of the past seven months have had a real and severe impact, says Ngure. He points to a new study by researchers at National Institute of Health and the Ministry of Health in Mozambique that found, among children there who are on HIV treatment, the percent who were successfully keeping the virus at bay dropped by 43% from February 2024 to 2025. The researchers — who presented their findings at the International AIDS Society's 2025 meeting — attribute the drop to PEPFAR disruptions and the challenge of getting consistent medications.
Will PEPFAR change?
Holmes is not exactly optimistic. Even though Congress preserved the $400 million funding for PEPFAR in the current fiscal year, he says that the organization's future is far from secure.
"The President has proposed major funding cuts for next year," he says. "I don't think the program is out of the woods yet."
Others echo this uncertainty. Yap Boum II, of the Africa Centers for Disease Control and Prevention, says it's "premature for us to really know how [PEPFAR] will change."
Even if funding continues as in past years, Holmes says, a key question is what that funding goes toward. So far under Trump, the vast majority of HIV prevention work has stopped — with the limited exception of preventing mother-to-child transmission — as has much of the support the U.S. used to provide for millions of AIDS orphans. For example, PEPFAR has paid for the procurement and distribution of PrEP, a medication that prevents HIV infections in high-risk individuals such as couples where one is HIV-positive and one is HIV-negative. The Trump administration moved quickly after taking office to limit this medication to pregnant and breastfeeding women — and did not allow it to be provided to others.
ADD BACK SECOND PICTURE HERE
"Without prevention and without care for orphans and vulnerable children, PEPFAR will be much, much diminished," Holmes says.
A spokesperson for the State Department did not respond to specific questions about resuming PEPFAR's full range of prevention efforts as well as its care for AIDS orphans and vulnerable children. However, the State Department's Congressional Budget Justification for the upcoming fiscal year does emphasize the importance of "deploying targeted campaigns to reduce new HIV infections" and singles out new and high-effective HIV prevention shots.
An uncertain future
Experts say there are several reasons why it's hard to predict what PEPFAR will look like in the future.
For starters, PEPFAR's authorization from Congress expired in March and has not yet been renewed. That doesn't mean an end to PEPFAR operations — Congress can still provide funding even without authorization — but there are risks.
"Without an authorization, that can lead to special interests trying to insert things into funding bills that dilute the program," explains Holmes.
Another challenge is that PEPFAR usually puts out country and regional operations plans to outline the program's strategies and clarify what activities it will support in different parts of the world. That information has not yet been released for 2026. The State Department spokesperson did not answer questions about when such plans would be released.
However, an emailed statement to NPR said: "Secretary Rubio has stated that PEPFAR is an important and life-saving program that will continue. He has also said that PEPFAR, like all assistance programs, should be reduced over time as it achieves its mission."
And there's another concern about how PEPFAR can function in this vastly altered world of foreign aid: the interaction of HIV and other diseases.
"The biggest killer of people living with HIV is actually tuberculosis," says Holmes. And the U.S.'s tuberculosis program has been drastically cut," he says.
Not knowing what the rest of the global health landscape will look like makes it hard to know what the HIV/AIDS situation will be. "It is a time of such great uncertainty," he says.
"We're beginning to see a glimmer"
Still, some HIV/AIDS specialists are increasingly confident about the future of PEPFAR — even as they predict that the U.S. will likely be turning the reins over to other countries.
"I feel like we're seeing the resurgence of strong bipartisan commitment," says Susan Hillis, who spent seven years at PEPFAR. During Trump's first term, she was selected to lead a $100 million initiative to use faith-based groups to advance HIV/AIDS work. "We're beginning to see a glimmer of: Yes, it's possible to move forward in the same direction together."
Hillis has been meeting with lawmakers and, she says, people are starting to agree on some things, including working with countries to wean them off of PEPFAR money — gradually.
In the State Department's Congressional Budget Justification, the administration emphasized the U.S. plan to "accelerate the transition of HIV control programs to recipient countries and increase international ownership of efforts to fight HIV/AIDS," including a "responsible off-ramp."
Hillis admits nobody knows exactly what PEPFAR of the future will look like — and how long it will exist as an independent program.
Yet despite a turbulent year so far, Ngure isn't ready to parachute out. He says over the past several months other countries are trying to make sure that plane reaches its destination, even bringing in additional pilots. He says the HIV/AIDS plane "cannot go back."
Copyright 2025 NPR
