Back in 2003, at the peak of the global AIDS epidemic, President George W. Bush launched PEPFAR — the President’s Emergency Plan for AIDS Relief — giving people in lower-income nations access to an effective new class of antiretroviral drugs, as well as related HIV services such as testing and prevention. The program has been a humanitarian success, saving an estimated 26 million lives in 55 countries over the course of its 20-plus years in operation. PEPFAR was also a wise strategic move for the U.S., it has been argued, helping to maintain political order and American influence in nations that might otherwise have destabilized and bred extremism under the added strains of AIDS.
Every year since PEPFAR’s establishment, Congress has voted to continue U.S. funding for the program. But as the beginning of 2025 saw the second Trump administration hollow out USAID funding and other foreign assistance, HIV/AIDS advocates and funders feared for the future of PEPFAR and the people it protected.
So it came as some relief to HIV/AIDS care advocates when Congress voted in July to maintain funding for PEPFAR, despite the administration’s attempts to rescind the money. But PEPFAR’s immediate and long-term future is far from certain: The White House Office of Management and Budget has released only about half of the $6 billion Congress appropriated for PEPFAR’s fiscal year 2025 operations. That has led to significant cuts to PEPFAR programs. For many people with HIV, that has turned a manageable health condition into a fatal disease: Over 93,000 adults and 9,000 children have died since January because of PEPFAR-related service disruptions, according to Masen Davis, executive director of Funders Concerned About AIDS, an organization that works to coordinate philanthropic efforts to end AIDS.
“These funding cuts are much more than lines in a budget — they impact real people,” Davis said. “We saw that firsthand earlier this year during the foreign aid freeze.” It remains to be seen how future cuts or executive actions will impact PEPFAR service delivery, while the broader dismantling of foreign aid and public health infrastructure will likely make it harder for HIV services to reach those who need them most, he added.
The Trump administration has placed PEPFAR under the control of the State Department and has limited the program’s HIV prevention services to pregnant and nursing women, leaving countless people who don’t fit those criteria facing loss of access to care and more vulnerable to HIV infections. Although PEPFAR was launched by the U.S., which has been its largest funder, other nations have also contributed to the program’s work; some governments are increasing their participation in PEPFAR to make up for the drop in U.S. support.
This year’s news hasn’t been completely bleak. The FDA recently approved a new HIV pre-exposure prophylaxis drug, lenacapavir, developed by Gilead Sciences. The medicine has been shown to prevent 99.9% of HIV infections with just twice-yearly injections — a significant convenience over existing PReP drugs, which require daily pills or bimonthly injections, making it harder for people who should be taking them to adhere to treatment. Because of its simpler, twice-yearly shots, the new drug offers the possibility of more widespread use and is hailed by the HIV care community as potentially transformative in the fight against AIDS — if the people who need the drug can get it. PEPFAR has recently committed to distributing lenacapavir within countries with high HIV rates, which is good news, but is limiting that distribution to pregnant and breastfeeding women.
Experts warn against restricting access in this way. “If the U.S. says that only pregnant and breastfeeding women can get lenacapavir, that will not curb the pandemic,” said Jennifer Sherwood, the director of research and public policy at amfAR, the Foundation for AIDS Research. “If they were really serious about the pandemic, they would buy lenacapavir and give it to those most at risk, not just restrict it to certain populations.”
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Philanthropy’s response to diminishing U.S. funding of AIDS care
So how can philanthropy best take part in the global fight against AIDS given current challenges? It’s a question that funders working across both the HIV/AIDS space and the broader healthcare and biomedical research field have been attempting to answer since the Trump administration began taking a hatchet to scientific research support this year — not just cutting future funding, but clawing back already-committed NIH funding and other grants.
“Philanthropic dollars are not going to be able to put back the billions that are potentially disrupted from service delivery everywhere within the HIV/AIDS universe, or within the entire health and science universe,” Sherwood said. Funding cuts slow the long-horizon basic research that underpins innovation in biomedical care and treatment, but people with AIDS and other severe medical conditions have immediate life-or-death needs.
The speed with the U.S. altered the funding landscape has put the global AIDS care sector into full whiplash. “We’re trying to figure out how we can preserve the things we’ve invested in,” Sherwood said. Strategically directed philanthropy could ease the shock by maintaining ongoing research as well as the delivery of services, she suggested. But in the current ideologically charged environment, advocacy is just as important as research and medical care. This will involve advocacy within the U.S., but given the current administration, perhaps the greater need is for advocacy with other national governments to continue increasing financial and other forms of participation in AIDS care.
The situation, however, has been evolving quickly, and there have been some hopeful developments. Gilead Sciences is allowing six pharmaceutical companies to manufacture inexpensive generic copies of lenacapavir for sale in 120 low- and middle-income countries for as little as $40 per patient per year. The Clinton Health Access Initiative and the Gates Foundation have committed to making upfront investments and volume guarantees to enable the manufacture of the lower-cost generics.
Because the Trump administration pointedly took an anti-DEI axe to PEPFAR funding, philanthropy should also work to maintain services for the people most directly targeted by the cuts in services, namely the LGBTQ community, Sherwood said. “There are attacks across the board, but, for example, pregnant women are not being attacked in the same way as trans women or the LGBT community. Maybe philanthropy can’t fill some of these huge service delivery gaps but could be intentional about protecting the populations most under attack by the U.S. government.”
Funders Concerned About AIDS has for several years conducted annual surveys to measure AIDS-related philanthropy. In recent years, the surveys have typically shown a reduction in the number of funders steering grants to AIDS causes. But in 2023, total grantmaking grew to $722 million, Davis said, the highest level ever recorded, and particularly welcome after years of funding declines. Notable recent additions came from gifts out of MacKenzie Scott’s Yield Giving, which committed well over $10 million to organizations providing HIV and AIDS-related services. Meanwhile, major long-term donors include the Gates Foundation, drug maker Gilead, ViiV Healthcare, Wellcome Trust and the Elton John AIDS Foundation.
Ultimately, HIV/AIDS funders can and should do what best fits their resources and areas of expertise, Sherwood said. “There’s a role for everyone here,” she said. An extremely deep-pocketed foundation could purchase and provide a substantial quantity of PReP medication, for example. A funder with fewer dollars might be able to support the completion of a research study. “We have to be really smart about where we direct funders.”
