For more than two decades, the President's Emergency Plan for AIDS Relief (PEPFAR) has been a global health success story, credited with saving more than 26 million lives and providing HIV treatment for more than 20 million people.
As of March 25, 2025, however, PEPFAR's congressional reauthorization has expired, raising key questions about its future. Prior to 2024, bipartisan support had secured five-year reauthorizations in 2008, 2013, and 2018. Last year, Congress allowed only a one-year authorization as political strife engulfed PEPFAR.
Without reauthorization, PEPFAR sits in purgatory—even though Congress appropriated funding through the end of September via the continuing resolution that passed this month. The expiration of its authorization introduces deep uncertainty about its long-term future, meaning that officials could now terminate or significantly curtail PEPFAR at any time.
Health ministries, implementing partners, and community-based organizations across PEPFAR-supported countries must try to deliver lifesaving care without the stability that long-term U.S. commitments once provided. At the same time, structural questions remain about how the State Department will operate PEPFAR amid reported proposals to create a new U.S. Agency for International Humanitarian Assistance. The question now is not just whether PEPFAR will continue, but also how it must evolve to remain effective in a drastically reshaped foreign aid landscape.
A Moment of Political Paralysis and Global Consequences
The expiration of PEPFAR's authorization is a symptom of a broader shift in U.S. foreign assistance policy. For nearly 22 years, the program stood as a rare example of bipartisan cooperation, launched under President George W. Bush and supported by successive administrations. As a legislative director to former Congresswoman Barbara Lee, I witnessed firsthand the Congressional Black Caucus's pivotal role in ensuring that the program remained a cornerstone of the global HIV response.
Today, congressional gridlock and the Donald Trump administration's shifting foreign policy priorities have complicated the path to reauthorization. A combination of partisan debates over reproductive health funding, skepticism over foreign aid spending, and competing global crises pushed PEPFAR off the legislative agenda.
Officials could now terminate or significantly curtail PEPFAR at any time
On January 20, 2025, President Trump's Executive Order 14169 added further uncertainty by pausing all U.S. foreign assistance programs for a 90-day review. Although some—but not all—critical health services were eventually exempted, the damage was inescapable. Governments and organizations reliant on PEPFAR funding scrambled to stay open, unsure whether their long-term plans would hold. Two months later, the World Health Organization warned that eight countries already face potential HIV medication shortages.
This turbulence arrives at a precarious moment for the global HIV/AIDS response. UNAIDS reports that competing global crises continue to rise in regions of the world outside sub-Saharan Africa, particularly among key populations such as young women, LGBTQ+ individuals, and people who inject drugs. Despite real progress, the HIV epidemic persists—and without PEPFAR reauthorization, lifesaving treatment and prevention services for millions hang in the balance.
What Expired Reauthorization Means in Practice
PEPFAR's programs will not disappear overnight, but the most immediate consequence of no reauthorization is instability. The work can continue under the annual appropriation of funds from Congress—though without a long-term legislative framework, PEPFAR officials lose their ability to secure cofinancing arrangements, make long-term strategic investments, or plan sustainability partnerships with governments and local actors.
Historically, the program's five-year cycle gave partner countries the stability to align their national HIV strategies with U.S. funding commitments through a process known as country operational planning (COP). Each year, PEPFAR engaged in a rigorous, transparent consultation to update its guidance based on the latest science and program data. This process ensured that countries received the necessary technical direction to adapt their programs, maximize impact, and stay focused on measurable outcomes.
Governments and implementing organizations now need to adjust to an unpredictable, year-by-year funding process. This instability makes it harder to secure long-term procurement contracts with drug companies for essential medicines, develop multiyear cofinancing commitments, or scale up emerging HIV prevention technologies.
Congressional reauthorization also provided key oversight mechanisms that have long shaped PEPFAR's priorities and ensured accountability. Critical funding allocation requirements that dictated how PEPFAR resources were spent have now expired. Previously, the law mandated that more than half of all bilateral HIV funding be directed toward treatment, care, and nutritional support for people living with HIV. Additionally, at least 10% of bilateral HIV funds had to be allocated specifically for programs supporting orphans and vulnerable children affected by the epidemic.
These provisions, last extended through fiscal year 2023, kept PEPFAR focused on delivering essential care. Over the past two decades, the treatment earmark ensured the long-term scale-up of HIV medication, helping put more than 20 million people on lifesaving antiretroviral therapy. Without these safeguards, funding decisions now rest solely with the executive branch, increasing the risk that shifting political priorities could disrupt the balance across treatment, prevention, and broader health system investments.
Another consequence of PEPFAR's lapsed reauthorization is the expiration of key provisions governing how the United States supports the Global Fund to Fight AIDS, Tuberculosis, and Malaria. For years, these provisions have set guardrails on U.S. contributions, ensuring that funding is allocated to promote transparency, accountability, and burden-sharing among donor countries. Without these restrictions, U.S. financial commitments to the Global Fund could shift, potentially altering how monies are distributed between bilateral and multilateral HIV programs—and weakening U.S. leverage to improve the Global Fund's performance and priorities.
This unpredictability comes as the Global Fund launches its new replenishment effort in 2025, seeking to secure $18 billion to sustain the global fight against HIV, tuberculosis, and malaria. Without a clear framework for U.S. contributions, concern is growing about whether the United States will maintain its leadership role in global health financing at this pivotal time.
Above all, the authorization lapse is a missed opportunity for Congress to strengthen and modernize PEPFAR for the future. Reauthorization could have codified critical reforms, including clear cofinancing commitments and a stronger push toward local control and sustainable, country-led solutions. These priorities now rest on shifting political dynamics, leaving them at risk of being deprioritized or diluted. PEPFAR faces greater vulnerability to budget cuts in future appropriations cycles as Congress navigates competing demands for domestic and foreign spending.
Key Considerations for PEPFAR's Future
The coming months will shape the future of PEPFAR. One of the biggest questions is how the ongoing evolution of the U.S. Agency for International Development (USAID) and its integration into the State Department will affect PEPFAR's operational model. PEPFAR has long relied on an interagency structure, and USAID played the most sizable role in program implementation. The USAID assault is already having far-reaching consequences on the implementation of PEPFAR funds, the management of programs, and decision-making both at headquarters and across nations.
Another major consideration is how PEPFAR allocates its funds between sustaining HIV treatment progress and scaling up prevention efforts. New innovations such as long-acting PrEP introduce questions about how to balance investments in both continuity for patients undergoing treatment and expansion within underserved areas. The administration's ongoing 90-day review—set to conclude by April 20—is expected to provide clarity on PEPFAR's future priorities and broader U.S. foreign aid strategy.
The administration's ongoing 90-day review is expected to provide clarity on PEPFAR's future priorities and broader U.S. foreign aid strategy
Additionally, PEPFAR needs to codify a clear long-term vision for how countries will take greater ownership of their HIV response. The push for reform and sustainability is not new—debates over how to transition PEPFAR from an emergency response to a long-term, country-led strategy have been ongoing since its early years. As far back as 2007, the Institute of Medicine underscored the program's need to shift from short-term relief efforts to strategic, sustainable planning.
Subsequent evaluations have repeatedly emphasized the value of structural reforms to ensure that partner governments gradually assume greater responsibility for their HIV programs. These efforts gained significant momentum under Ambassador John Nkengasong's leadership during the Joe Biden administration, when localization and sustainability became central priorities. Despite these advancements, no clear roadmap is in place for how PEPFAR will fully transition from a U.S.-led initiative to a model under which partner countries drive their own HIV programming.
The expiration of PEPFAR's reauthorization is more than a bureaucratic setback: It marks a pivotal moment for the future of the global HIV response.
The battle against HIV/AIDS is far from over, and PEPFAR remains one of the most powerful tools in that fight. But to maintain its leadership in global health, the program cannot remain stagnant. PEPFAR's next chapter needs to cover more than just survival: It must also encompass transformation, ensuring that the program is stronger, more sustainable, and better positioned to meet the future.
