A new study published in The Lancet warns that if the US fails to continue funding the PEPFAR programme, it could lead to over 1 million new paediatric HIV infections and nearly half a million child deaths by 2030.

“The future of PEPFAR programmes hang in the balance. Losing stable, long-term support for PEPFAR programmes sets global progress to end HIV/AIDS back to the dark ages of the epidemic, especially for children and adolescents,” said co-lead author Prof Lucie Cluver of the University of Oxford (UK). “A sudden withdrawal of PEPFAR programmes, especially in the absence of a long term strategy to replace them, could lead to a resurgence of HIV infections and preventable deaths, and a dramatic rise in the number of children orphaned by AIDS in the coming years – a setback that could erode two decades of progress.”

PEPFAR (President’s Emergency Plan for AIDS Relief), launched in 2003, has been credited with saving over 26 million lives and preventing 7.8 million HIV infections in babies. But US President Trump’s executive order pausing foreign aid has disrupted many of its services since January 20, 2025.

AIDS orphans

The study’s estimates suggest that without PEPFAR, 2.8 million more children could be orphaned by AIDS, and adult life expectancy could fall significantly. “A sudden withdrawal… could lead to a resurgence of HIV infections and preventable deaths,” warned Cluver.

“Continued investments in PEPFAR programmes combined with progressive growth in African co-financing can create a sustainable transition for country-led ownership of HIV programmes and preserve the legacy of PEPFAR’s lifesaving work,” she added.

Co-author Dr Susan Hillis of Imperial College London said, “By eliminating many programmes PEPFAR supports for children beyond HIV treatment and prevention… many will slip through the cracks — increasing their chances of acquiring HIV.”

PEPFAR’s legacy includes cutting the number of AIDS orphans from 14 million in 2010 to 10.5 million in 2023. It has also boosted education, healthcare, and U.S.-Africa trade.

“Ending PEPFAR would create a void likely filled by other countries,” warned Gibstar Makangila, Executive Director of Circle of Hope, Zambia. “Reports indicate China and Iran are poised to assume global health leadership roles.”

The authors call for long-term strategies to close funding gaps and strengthen country-led ownership of HIV responses, noting African health system co-financing has already tripled from $13.1 billion in 2004 to $40.7 billion in 2021.

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