On April 16, the U.S. State Department released its latest data for the U.S. President's Emergency Plan for AIDS Relief (PEPFAR)—offering the clearest snapshot yet of performance amid a period of volatility across the lifesaving program and the broader global health landscape.

After the disruptions of the past 18 months, these topline figures do reflect a degree of resilience. Treatment continuity, meaning the uninterrupted delivery of antiretroviral therapy (ART), has largely been maintained despite profound funding shocks. Compared to the previous fourth quarter (Q4) reporting period, the total number of individuals on treatment has remained relatively stable year over year—20.3 million in fiscal year 2025 Q4 compared to 20.4 million in fiscal year 2024 Q4—suggesting that core ART delivery strategies have held even as program funding was paused, delayed, and disrupted across the board.

PEPFAR's new statistics—covering events from July 1 through September 30, 2025—reflect the sustained effort of program implementers, frontline medical providers, managers, and data teams who worked around the clock to ensure continuity of care.

Yet resilience at the aggregate level can obscure deterioration where it matters most. The topline conveys what has held—but maybe not what has been lost. Beneath the treatment continuity headline, HIV testing, diagnoses, and prevention efforts declined sharply over the past year. PEPFAR-supported testing fell from 23.7 million to 19.6 million. Diagnoses dropped from 450,000 to 380,000.

Although fewer positive tests are sometimes framed as progress, a more plausible interpretation is reduced testing leading to lower case detection. In that scenario, infections are not necessarily declining; they are going unidentified, weakening the front end of the response and increasing the risk of delayed treatment and onward transmission.

A similar pattern is emerging in pediatric HIV. Declines in treatment are often attributed to prevention gains, but a new analysis from the Elizabeth Glaser Pediatric AIDS Foundation shows reductions across the entire pediatric cascade, including testing and treatment coverage. These trends suggest not a shrinking epidemic but weakening service delivery and reduced case identification among children, raising the risk that pediatric infections are being missed and left untreated.

The number of people initiating pre-exposure prophylaxis (PrEP) medication declined overall, even as programs increased uptake among vulnerable groups such as pregnant and breastfeeding women. At the same time, parts of the workforce that support service delivery have contracted.

Together the trends signal a system that has shifted into preservation mode—protecting treatment while scaling back the functions that sustain epidemic control, with fewer community and facility-based testing campaigns, reduced outreach to populations at highest risk of HIV acquisition, and slower initiation of new patients onto treatment, weakening the pipeline that identifies and links people to care.

This pattern repeats the recent past. During COVID-19 and earlier crises such as the 2014–15 Ebola epidemic, PEPFAR programs preserved treatment continuity while HIV testing and case finding declined. PEPFAR has long operated as a resilient platform, absorbing shocks and protecting core services.

Treatment is resilient in part because that system was built to withstand disruption. Multi-month dispensing of antiretroviral therapy allows patients to maintain several months of supply. Long-standing relationships between patients and providers further sustain continuity of care, helping stabilize treatment outcomes despite broader pressures.

A Thinning Pipeline—And a Loss of Visibility

Critically, however, this data expresses very little about those newly acquiring HIV during this period of disruption—and whether they are being diagnosed or linked to care at all. Nor do they capture the extent of advanced HIV disease (AHD) among those returning late for regular treatment or falling out of care. In many ways, AHD is the "canary in the mine"—the signal that a system is failing to reach people in time. If emerging field reports are borne out in program data, they could reveal a worsening picture of late presentation, rising opportunistic infections, increased HIV-related mortality, and a growing pool of undiagnosed and untreated individuals driving onward transmission.

But long-term HIV epidemic control requires more than what the current approach supports. We are now seeing the system of HIV responses thinning—especially at the margins. In the HIV response, the margins are where epidemic control is won or lost. They are where people first test, where prevention reaches those at highest risk, and where community support connects individuals to care providers.

After the 2025 funding disruptions—including the collapse of the U.S. Agency for International Development (USAID), the issuance of temporary stop-work orders, and widespread interruptions of health services—PEPFAR received a waiver to continue a narrow set of lifesaving projects. That waiver excluded key parts of the HIV response, particularly prevention. Programs such as voluntary medical male circumcision, the DREAMS partnership for adolescent girls and young women, and targeted services for key populations were scaled back or paused—even though these initiatives help populations at highest risk of HIV acquisition.

The new data reflects those policy decisions. Scaling back prevention and community programs weakened the front end of the response—leading directly to fewer tests, fewer diagnoses, and fewer people entering care. The stated declines are a direct result.

Although recent announcements by the State Department allude to increased U.S. ambition to procure long-acting prevention options such as the drug lenacapavir, these gains will translate into tangible benefits only if paired with robust testing. Identifying and linking individuals at risk remains the essential entry point for prevention. Yet the new program data suggests that testing volumes are declining. To realize the potential of ongoing lenacapavir rollout, this trend will need to be reversed—and quickly.

Doing so matters because HIV programs depend on a steady pipeline of people entering care through testing, diagnosis, and linkage. When that pipeline slows, the effects are delayed but predictable. Treatment is a lagging indicator; by the time treatment numbers decline, the underlying dynamics have already shifted. The deeper concern is not only the slowdown in people entering care but the loss of visibility into the pipeline itself—the public no longer knows who is entering care and who is being missed. Without that visibility, course correction becomes far more difficult.

That loss of visibility is most acute in community services—peer networks, outreach programs, and civil society partnerships—that have been the scaffolding of the HIV/AIDS response for the last two decades. The new data highlights how that scaffold has been dismantled, as the sharpest declines in testing came from community-based services. HIV diagnoses dropped by 13% in continuously supported facilities, but by 35% in community services and nearly 30% in intermittently supported facilities. Testing fell 17% overall, with even steeper declines in outreach settings. Early infant diagnosis declined by as much as 60% in disrupted sites.

What Bilateral Health Agreements Mean for PEPFAR's Next Phase

These trends suggest that the public is losing visibility into whether PEPFAR is reaching key HIV populations or others at highest risk of catching the virus. As PEPFAR programming shifts from a foreign aid model toward jointly financed health agreements with the United States, ensuring visibility could become domestic responsibility for partner nations. But the absence of granular data from the current reporting architecture is itself a sign—and a concerning one within the context of U.S. bilateral health agreements.

These data gaps illustrate deeper structural pressures in the current transition architecture from aid to bilateral financing. They also raise increasing concern about the fiscal constraints facing partner countries—suggesting that even if the U.S. government and partner countries meet their stated commitments under the new agreements, available resources will not be sufficient to sustain current systems.

At the same time, how the HIV response will be measured in the future is changing. The shift toward bilateral agreements and greater reliance on national reporting systems reflects a push for more country ownership, which is appropriate and overdue. But this move will come with trade-offs. PEPFAR's success has depended on granular, standardized, and publicly available data that enabled real-time course correction. As reporting becomes more variable—and potentially less transparent—the public risks losing the ability to detect problems early, particularly in prevention and community-based services.

This shift has implications beyond program performance. For more than two decades, PEPFAR's monitoring system has provided the United States with an unparalleled level of programmatic intelligence across high-burden settings. That visibility is now at risk. Although many of the bilateral agreements emphasize data sharing, they will rely on national systems under strain. Data-use agreements offer limited value if the underlying data is less complete, less granular, and less timely than the systems they replace.

A more immediate concern is that the metrics used to track transition under the bilateral health frameworks could be narrower, less deliberatively constructed, and less sensitive to early signs of system disruption. PEPFAR's monitoring architecture was built over years, with standardized indicators and quarterly reporting across countries to enable real-time tracking, comparability, and accountability. Replicating that rigor under current constraints—reduced staffing, compressed timelines, and shifting mandates—will be challenging.