This story was updated July 18, 2025 after the votes in the U.S. Senate and House of Representatives had been passed. A previous version was reported prior to the vote. Additionally, a comment by Anne Neilan, MD, MPH, was added.
The United States President’s Emergency Plan for AIDS Relief (PEPFAR)—the HIV/AIDS prevention and care program that has saved more than 26 million lives around the world since its launch under President George W. Bush in 2003—was spared from the budget rescission package passed in a 51-48 vote in the U.S. Senate in the early hours of Thursday, July 17, 2025, followed by a 216-213 vote in the U.S. House of Representatives just after midnight on Friday, July 18.
The proposed $400 million cut to PEPFAR’s budget, which President Donald J. Trump requested, was taken out of the Republican-backed bill after significant opposition from Sens. Lisa Murkowski, R-Alaska, and Susan Collins, R-Maine. Under pressure to hold onto those two Republican swing votes, Office of Management and Budget Director Russell Vought told reporters on Tuesday the White House would acquiesce to a substitute amendment exempting PEPFAR from the rescission bill, which claws back more than $9 billion in congressionally approved federal spending on foreign aid and public broadcasting.
“It’s substantially the same package and the Senate has to work its will and we’ve appreciated the work along the way to get to a place where they’ve got the votes,” he said.
The Benefit of Fighting HIV
The $110 billion invested in PEPFAR over the past two decades is the largest commitment by any nation to address a single disease in history. It has dramatically changed the trajectory of the HIV/AIDS pandemic, particularly in low- and middle-income countries that are most severely affected by the disease. As of December 2024, 7.8 million babies had been born HIV-free as a result of PEPFAR’s interventions. In 2023, there were 52% fewer new HIV infections than in 2010 across PEPFAR-supported countries, with a 39% reduction across the globe. And in 2024 alone, PEPFAR reached 2.3 million adolescent girls and young women with comprehensive HIV prevention services, provided HIV testing services to 83.8 million people, and newly enrolled 2.5 million people on pre-exposure prophylaxis (PrEP) to prevent HIV infection. PEPFAR now accounts for more than 90% of PrEP initiations around the world.
“Throughout Africa, people will tell you about relatives and friends who are alive because of PEPFAR, because of the U.S. population’s support of PEPFAR,” said Carlos Del Rio, MD—a distinguished professor of medicine in the Division of Infectious Diseases at Emory University School of Medicine, the executive associate dean for Emory at Grady, the co-director of the Emory Center for AIDS Research and the co-principal investigator of the Emory-CDC (Centers for Disease Control and Prevention) HIV Clinical Trials Unit—in an interview with Infectious Disease Special Edition.
While working in Ethiopia in the early 1980s, Dr. Del Rio recalled riding in a taxi and seeing funeral homes virtually everywhere. His cab driver told him that because so many people were dying from AIDS, many new funeral homes had been set up to provide convenient access for those who couldn’t take off much time from work to attend the frequent funerals.
Years later, he rode through that same area, and the funeral homes were gone. Dr. Del Rio remarked on the change, and his cab driver asked him if he knew about PEPFAR. “People are not dying because of what Americans have done for us,” the driver said.
“That soft diplomacy has other consequences,” Dr. Del Rio said. “It improves our reputation around the globe and people want to buy our goods because they want to be reciprocal to America. To be appreciated globally because of PEPFAR is so important.”
A Disruption to Humanitarian Aid
The abrupt closure of the United States Agency for International Development, which managed much of the PEPFAR program, has already caused massive disruptions to PEPFAR’s services.
According to a report from the Joint United Nations Programme on HIV/AIDS issued on July 10, 2025, the cuts have “destabilized supply chains, led to the closure of health facilities, left thousands of health clinics without staff, set back prevention programs, disrupted HIV testing efforts and forced many community organizations to reduce or halt their HIV activities.”
At the 2025 Conference on Retroviruses and Opportunistic Infections in San Francisco on March 10, Chris Beyrer, MD, MPH, the director of the Duke Global Health Institute, in Durham, NC, warned there would be a 400% increase in deaths due to AIDS should PEPFAR remain paused indefinitely, which would double the number of AIDS orphans.
“The results were really staggering, with the potential for 6.4 million new infections, 1.7 million deaths in five years, and an additional 563,000 new pediatric infections and 148% increase in children’s lives lost with complete cessation of PEPFAR funding,” said Lynne Mofenson, MD, a senior HIV technical advisor at the Elizabeth Glaser Pediatric Gains Foundation and an advisor to the World Health Organization, during an April 1 media briefing on cuts to HIV funding with experts from the Infectious Disease Society of America. Dr. Mofenson previously served for more than three decades as chief of the Maternal & Pediatric Infectious Disease Branch of the Eunice Kennedy Shriver National Institute of Child Health and Human Development.
Those estimates align with projections made in an analysis published in Annals of Internal Medicine earlier this year, estimating the impact of PEPFAR cuts in one of the countries where the program is most active, South Africa. That analysis found that cutting PEPFAR funding by 50% would result in additional 286,000 new HIV infections over the next 10 years, while eliminating funding entirely would add 565,000 new infections. The investigators estimated that there would be 315,000 additional HIV-related deaths over the next 10 years with a 50% cut to PEPFAR’s funding, and 601,000 (Ann Intern Med 2025;178[4]:457-467).
“We estimated that the elimination of PEPFAR would result in 15 million years of life lost in South Africa over five years. For every year of life lost due to PEPFAR cuts, we would gain approximately $153 in budgetary savings, which is just an astonishingly low number,” said study co-author Anne Neilan, MD, MPH, an associate professor of pediatrics at Harvard Medical School and co-director of Harvard’s Center for AIDS Research (CFAR) Adolescence and HIV Scientific Program, in Boston. She noted that evidence shows that there is general agreement around willingness to pay at least $50,000 per quality-adjusted life year to save an American life (N Engl J Med 2014;371[9]:796-797).“Not renewing PEPFAR would imply being unwilling to pay even $153 to save a year of life for a South African.”
“Americans should be enormously proud of what PEPFAR has accomplished, and its impact,” Dr. Neilan said. “I hope that we can all appreciate how incredibly valuable it is. A lot of administrative harm—and ultimately human harm—has come from what’s happened so far, and there’s still a lot of scrambling to understand the extent. Do we have Congressional renewal of PEPFAR and a plan for another five years? That would be the ultimate goal: a budget and a plan. But I don’t think we’re seeing that yet.”
Marie Rosenthal, MS, contributed to the reporting.
