U.S. Quietly Drafts Plan to End Program That Saved Millions From AIDS

The federal program to combat H.I.V. in developing nations earned a reprieve last week when Congress voted to restore $400 million in funding. Still, officials at the State Department have been mapping out a plan to shut it down in the coming years.

Planning documents for the President’s Emergency Plan for AIDS Relief, obtained by The New York Times, call for the organization to set a new course that focuses on “transitioning” countries away from U.S. assistance, some in as little as two years.

PEPFAR, as the program is called, would cease to exist as an initiative to provide medicines and services needed to treat and prevent the spread of H.I.V. in low-income countries.

It would be replaced by “bilateral relationships” with low-income countries focused on the detection of outbreaks that could threaten the United States and the creation of new markets for American drugs and technologies, according to the documents.

“With targeted investment, PEPFAR’s H.I.V. control capabilities in these countries could be transformed into a platform for rapid detection and outbreak response to protect Americans from disease threats like Ebola,” the plan says.

A State Department spokeswoman said the document had not been finalized. “The referenced document is not reflective of the State Department’s policy on PEPFAR and was never cleared by Department leadership,” she said.

She declined to be identified and did not provide additional details.

The proposed plan has been under review for weeks, and word of it already has reached PEPFAR’s partners and governments in other countries. The draft obtained by The Times contains comments and edits from many senior staff members at the program.

PEPFAR was crippled during the chaotic first few months of the Trump administration, as Elon Musk’s cost-cutting initiative, the Department of Government Efficiency, slashed existing contracts, funding arrangements and government structures.

Created during the second George W. Bush administration, the H.I.V. treatment and prevention program has long enjoyed broad bipartisan support. It is often cited as the single most effective public health campaign ever, saving an estimated 26 million lives in low-income countries over 22 years.

The draft plan for shutting it down in coming years underscores ongoing tension between Congress, which has repeatedly indicated support for PEPFAR, and Trump administration officials who wish to sharply curtail or end it.

Previously, the organization’s guiding ambition was to end H.I.V. as a public health threat by 2030. But the Trump administration has targeted PEPFAR for sharp reductions, part of a broad move to cut foreign aid, which federal officials believe is wasteful and a misuse of taxpayers’ money.

The abrupt termination of congressionally approved funding for the nonprofit organizations that partnered with PEPFAR has already hobbled the program and crippled the global H.I.V. response.

Conservative critics say that PEPFAR-supported countries have for more than two decades relied on the United States to fund the bulk of their H.I.V. programs while spending too little themselves, and that PEPFAR has fostered a culture of dependence.

Secretary of State Marco Rubio has said that the cuts are justified because of what he says is fraud and waste in the program. Even on its sharply reduced budget, all essential lifesaving work will continue, he has said.

Last week, Congress cut $7.9 billion in foreign aid funding but rejected proposed cuts to PEPFAR, restoring a planned $400 million clawback for the 2025 financial year. Since the aid cuts began, Republicans such as Senator Susan Collins of Maine and Senator Lindsey Graham of South Carolina have said that PEPFAR should be maintained.

“Congress has shown that they want PEPFAR’s work to continue, it has broad support, and yet the administration is determined to plow ahead and shut it down regardless,” said Asia Russell, executive director of HealthGap, which lobbies for funding for global health.

“This proposal is a death warrant, and countless people will die if it is allowed to go forward,” she added.

The documents assume a 42 percent reduction in PEPFAR’s current budget of $4.7 billion, which Mr. Rubio has said is his goal.

PEPFAR’s budget is decided by Congress, not the executive branch, but it’s not clear that Congress would reject a significantly reduced budget for 2026.

The planning documents note that “no global health program in history has transitioned at this scale, and H.I.V. is a uniquely challenging disease to control without a cure or vaccine.”

They continue, “However, we believe that the transition of PEPFAR can become the premier example of the U.S. commitment to prioritizing trade over aid, opportunity over dependency and investment over assistance.”

Phasing out PEPFAR has been under discussion as a long-term goal for about a decade. But accomplishing a handover within a few years is a drastically accelerated timeline.

“It is entirely not feasible to phase out that quickly,” said Robert Black, a professor of international health at Johns Hopkins Bloomberg School of Public Health, who oversaw an evaluation of PEPFAR ordered by Congress.

“There will be some countries that can manage where the PEPFAR investment is not as heavy or as large a proportion of their total effort,” he added.

“But some of the African countries with enormous H.I.V. problems and national financial problems, debt and other development issues — I cannot see that they are going to be able to pick up all or even a large proportion of the costs in that kind of time frame.”

Since the early months of the Trump administration, prevention and treatment programs in PEPFAR-supported countries have fired staff and lost access to years’ worth of operational data.

Many partner organizations that PEPFAR relied on have shut down, after five months in which they did not receive support. Funding through the United States Agency for International Development was canceled, or grants that were nominally permitted to continue by the State Department never actually delivered funds.

Historically, annual PEPFAR planning documents have included guidance on topics such as reducing AIDS deaths in children and strengthening local health systems, and in a normal year, PEPFAR would have already sent its annual plan to Congress.

But the agency has been in disarray since President Trump’s inauguration and the flurry of executive orders that cut off U.S. assistance to developing countries. The documents obtained by The Times propose that the new PEPFAR plan go to countries for their input in October, and be sent to Congress for approval by December.

This plan would require countries to spend significantly more of their own money on H.I.V. programs.

In countries that delivered on their pledges, the documents say, PEPFAR would continue to fund the purchase of some medications and pay some health worker salaries at a declining rate over three to five years.

Countries that are close to controlling their epidemics, including Botswana, Namibia, South Africa and Vietnam, would see a shutdown within two years.

Nations that have high rates of H.I.V. infection and that now receive significant support, including Kenya, Lesotho, Zambia, Zimbabwe and Angola, would be on a three-to-four-year timeline.

Countries with conflict, very low income levels or fragile states would have five to eight years. They include the Democratic Republic of Congo, Haiti, Malawi, Mozambique, South Sudan, Tanzania, Uganda and Ukraine.

“Three years, it’s really a very short period for a heavy program like the H.I.V. program in Zambia — it’s impossible,” said Dr. Mwanza wa Mwanza, who has worked in senior roles in the H.I.V. program in Zambia for nearly a decade.

“New infections and deaths from H.I.V. disease are still too high,” he added. “If the transition is too fast, all our gains could be reversed.” Countries need to be involved in establishing how much time they will need, he said.

The plan acknowledges that the timelines are ambitious. There would be a “potential risk to global and U.S. health outcomes if the transitions were too rapid,” the documents say.

Some of the proposed changes would most likely be welcomed by countries that PEPFAR supports.

Assistance for H.I.V. would no longer be run separately, but rather be folded in with programs to counter malaria, tuberculosis and other health problems.

But PEPFAR has also operated gold-standard services that health ministries in many low-income countries have said they will not be able to maintain on their own. The plan eliminates those.

For example, the plan proposes walking away from an effort in which the organization has “spent billions of dollars developing” electronic medical records that “are in nearly every case unlikely to be financially sustained by the country government.”

The plan says little about one of the few clear shifts in policy on H.I.V. response under the Trump administration: an abrupt termination of funding for most efforts to prevent new infections.

Since early February, PEPFAR has funded H.I.V. prevention only for pregnant and breastfeeding women — cutting off sex workers, men who have sex with men and people in so-called discordant couples in which one person has the virus and the other doesn’t.

These key groups were receiving targeted services — such as free condoms or daily H.I.V.-blocking medication — in an effort to control the epidemic.

But there is a hint that this policy could change. The draft plan says PEPFAR will “make catalytic, market-shaping investments in biomedical tools, such as the new twice-a-year H.I.V. prevention injection that will curb new H.I.V. infections.”

African governments had hoped to start rolling out that new shot, called lenacapavir, by the end of this year. Officials and health care workers are excited about its promise: The drug protected 100 percent of participants from infections in a major clinical trial.

PEPFAR was expected to fund about half of an initial purchase of lenacapavir for two million people over the next three years — doses that are already in production by the drug’s manufacturer, Gilead Sciences.

Without U.S. funding, the future of this potentially transformative intervention has been in doubt.

The plan says PEPFAR should make commitments to generic producers that would allow them to make lenacapavir at $40 per patient per year by the end of 2028, and distribute the drug in eight to 12 priority countries in the meantime — implying PEPFAR might honor its original commitment to buy the Gilead product.

The planning documents do not explain how the shots would be distributed. Such medicines were provided in recent years through supply chains now crippled by the upheaval of recent months. The H.I.V. prevention programs are mostly gone.

The plan also would end the U.S. role in data collection, and countries would have to immediately begin to collect and provide data on their own that meets PEPFAR’s congressional reporting standards. If they failed to do so, their funding would end immediately.

The plan proposes ending the traditional character of PEPFAR as a public health response, shifting more H.I.V. care to private-sector providers who could be allowed to buy medications and diagnostics at the price PEPFAR has negotiated for the public sector.

The documents stress repeatedly that the success of PEPFAR withdrawal will depend on much of its current role being filled by the Global Fund to Fight AIDS, Tuberculosis and Malaria.

A PEPFAR employee offering comments in the document noted that there was no clarity on whether the United States, which has provided a third of the fund’s budget, was going to continue to contribute and thus what level of support the Fund may be in a position to offer countries.