The Impact of the United States Foreign Aid Freeze on HIV Service Delivery in PEPFAR‐Supported Countries: A Facility‐Level Analysis of 2024–2025 Programme Data

INTRODUCTION: On 24 January 2025, the U.S. government issued a stop-work order freezing foreign assistance, including support for the U.S. President's Emergency Plan for AIDS Relief (PEPFAR), although a limited waiver for selected "life-saving" interventions was subsequently granted. PEPFAR's official 2025 monitoring results, released 17 April 2026, included only fourth-quarter data, whereas an earlier inadvertent release contained data for all four quarters of 2025. Using both datasets, we conducted a systematic facility-level assessment of HIV programme performance while accounting for reporting disruptions. METHODS: Facilities were categorized by reporting between Q1 2024 and Q4 2025 (continuous, intermittent, dropped, new). We assessed changes in HIV treatment, testing, prevention of mother-to-child transmission (PMTCT) and HIV prevention across facility categories. We additionally analyse changes in human resources for health (HRH) reported by PEPFAR. RESULTS: The dataset included 31,628 facilities and community service sites. Most sites reported continuously (71.5%), while 16.7% reported intermittently, 3.9% stopped reporting, 3.1% were new in 2025 and 2.5% were community service sites. Between Q4 2024 and Q4 2025, the total number of people receiving HIV treatment declined by -1%. People on treatment increased 0.3% at continuously reporting facilities but declined -6.0% at intermittently reporting facilities. HIV testing declined by -18% overall. HIV diagnoses decreased by -13% at continuously reporting facilities, -32% in intermittently reporting facilities and -36% in community services sites. PMTCT infant testing declined by -6% at continuously reporting facilities and -60% at intermittently reporting facilities, while infant HIV diagnoses declined by -12% and -31%, respectively. Pre-exposure prophylaxis initiations declined by -33%, and the number of direct service delivery healthcare workers declined by -62,541 (-24%). CONCLUSIONS: Although HIV treatment remained relatively stable at continuously reporting facilities, substantial declines were observed in HIV testing, HIV diagnoses, treatment initiation, prevention services and the PEPFAR-supported workforce. These findings suggest that treatment coverage alone is an insufficient indicator of programme resilience. As countries assume greater responsibility for HIV programmes, sustained investment across the entire HIV care cascade coupled with transparent reporting and robust monitoring systems covering the full prevention, testing, treatment and health workforce landscape will be essential to maintain progress towards epidemic control.