One year ago, U.S. President Donald Trump signed an executive order to pause all U.S. foreign assistance, unleashing unprecedented disruption to HIV programs around the world.
In central Uganda, a warning came over the local radio stations: HIV services would shut down for 90 days, including the provision of lifesaving antiretroviral treatment. Juma Bwanika heard the report and started counting his pills. They would not last three months. In the 13 years since he started the daily treatment to suppress his HIV infection, Bwanika had never missed a dose. But after the announcement, he decided to cut back to one pill every three days.
Uganda was able to maintain basic HIV testing and treatment services despite the U.S. order, although other interruptions were wide-ranging. Among them, Trump’s directive shut down U.S.-funded community support efforts, including the local outreach workers in central Uganda who would have informed Bwanika that the announcements were wrong and services were still available.
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A month later, he started worrying about skipping doses. Though he could scarcely afford it, Bwanika took a day off from farming and walked the seven miles to see whether the HIV clinic at Kiboga General Hospital had reopened. He was astonished to find it had never closed. When a clinician learned Bwanika had been rationing his medicine, she ordered a test to see if the virus had rebounded. When he returned in early April for the results, they showed that it had.
Bwanika was devastated to learn he would need regular testing to determine whether the virus had developed resistance to his current treatment. He worried about his health, but also about how he would afford so many trips to the clinic.
“Ever since this order from Trump, I am seeing death near me,” he told Devex.
In the year since Trump’s initial stop-work order, his administration has sharply reduced support for HIV programs across Africa and around the world. Some advocacy groups have tried to quantify the human cost of those disruptions, including through tools such as the PEPFAR Impact Counter, which estimates that more than 157,000 adults have died as a result.
The counter is named for the President's Emergency Plan for AIDS Relief — long the primary channel for U.S. HIV assistance — which once supported 20 million people living with HIV across 55 countries.
Many of the impacts, however, are reverberating in ways that are harder to measure. Bwanika has returned to treatment, but the patchwork of community programs that did everything from conducting door-to-door HIV testing to ferrying treatment into rural communities has largely disappeared.
The U.S. government is now in the process of revising how it will fund HIV services. Officials have negotiated new bilateral health agreements with over a dozen African countries so far. These deals offer far smaller investments than before and tie funding to financial commitments from cash-strapped governments and to strategic U.S. interests, including access to mineral rights. Community leaders also warn that they are being excluded from the negotiations.
In Zambia, civil society organizations said they were called to a meeting by American embassy officials in Lusaka in late 2025. They were explicitly informed that funding for community programs, outside of services provided by faith-based organizations, would not be written into their country’s agreement. Instead, they were advised to ask their governments for support.
Even as domestic governments marshal additional resources, officials in Uganda, Malawi, Botswana, and Zambia have told Devex they are struggling to replace all that has been lost.
“The willingness to get back to where [the HIV response] was is there,” said Beatrice Matanje, CEO of Malawi’s National AIDS Commission. “But as a country, the question is, does the country have the capacity to do all these things?”
Zambia was on course to end the AIDS epidemic by 2030. The country had reached 2025 targets set by UNAIDS ahead of schedule: More than 95% of people living with HIV had been tested; at least 95% of those who tested positive were on treatment; and for more than 95%, that treatment had rendered the virus undetectable.
Now, those gains are in jeopardy. Fred Chungu, executive director of the Network of Zambian People Living with HIV and AIDS, said the past year’s disruptions mean the country will likely miss the 2030 goal.
“We don’t even know now if we might even go back to where the HIV started from,” he said, referring to the era before treatment was widely available. Surveying the landscape in January 2026, one year after the stop-work order, he sees persistent challenges.
Many countries still do not have a grasp on how severely they have been impacted by the cuts. Officials estimate there has been a rise in new HIV infections, in people becoming resistant to medicines, and in AIDS-related deaths, despite the U.S. government’s insistence that no deaths have resulted from the aid cuts. But officials cannot properly quantify the impact because of ongoing gaps in their data.
“We’re actually not going to have a good grasp of the real impact for many years to come,” Leora Pillay, the HIV prevention advocacy lead at Frontline AIDS, told Devex. “We’re not going to know even when we get to 2030 what new targets to set. We won’t have the data to tell us.”
The Trump administration also broadly eliminated support for locally rooted treatment, testing, and prevention programs tailored to the needs of specific groups of people. These included drug deliveries to rural clients or specialized clinics for vulnerable groups, including commercial sex workers, men who have sex with men, and people who inject drugs and who face discrimination at government facilities.
“The community, it has been erased,” Chungu said. Where community outreach does still exist, in places such as rural central Malawi, it is now sustained by volunteers, like Patricia Nkhoma.
Since early 2024, Nkhoma had done outreach for Chitedze Health Centre in central Malawi. The facility provides roughly 4,500 people with ARVs. In return for a monthly stipend funded by the U.S. Agency for International Development, she reached out to those clients who skipped their refill appointments.
When she tracked them down, they would say that the distance to the facility was too far and the transportation costs too steep. Nkhoma tried to help resolve their challenges. “People were happy whenever they saw me coming to advise them,” she said.
The outreach program collapsed following the stop-work order. The center saw an immediate spike in the number of people who stopped collecting their treatment, rising from 82 in the last quarter of 2024 to 115 in the first three months of 2025, according to facility records seen by Devex.
Clinic officials approached Nkhoma and other outreach workers to see if they might continue the work on a voluntary basis. She agreed, only to find that “some are losing faith because there are some rumors to say there are no services being offered,” she said. Her absence contributed to those rumors, which she is now struggling to dispel.
Kenneth Mwehonge, executive director of Uganda’s Coalition for Health Promotion and Social Development, warned in February, weeks after the stop-work order, that this would be one of the less tangible, but more significant consequences: The sudden disruption would shatter people’s trust in programs they had considered unshakeable.
Looking back eleven months later, Mwehonge said the Trump administration’s seemingly arbitrary actions in that period have only eroded trust further. In that time, the U.S. government lifted funding suspensions and then reinstated them and, in some instances, didn’t tell providers their contracts were not being renewed until after those contracts had expired.
This uncertainty trickles down to clients, Mwehonge said, leaving them to wonder why they should bother using services that could disappear overnight. As people lose faith in the system, he said, “they will definitely stay on the ground and die.”
A year after the stop-work order, trust in services is not the only thing that has frayed across sub-Saharan Africa. So has the belief in America’s commitment to end the AIDS epidemic.
America’s engagement began in earnest when former U.S. President George W. Bush launched PEPFAR in 2003. Since then, the U.S. has channeled more than $110 billion into the HIV response, saving more than 26 million lives. More of those resources have gone to sub-Saharan Africa, the region hardest hit by the disease, than anywhere else.
Then came the abrupt pause and the administration’s subsequent moves to terminate programs and withhold about half of the $6 billion allocated to PEPFAR in 2025. That has struck some in the region as a betrayal, particularly as the administration claims that funds were being misused or were misaligned with American values.
While the U.S. may have provided the money, African health workers, organizers, and people living with HIV converted those resources into programs that brought the world closer than ever to ending the AIDS epidemic.
Maureen Luba, a Malawian global health leader, said it was “unfair” for the Trump administration “just to frame it as if we are the only ones that have benefited when there was mutual benefit on both sides,” including HIV research conducted in Africa that has assisted people globally.
Still, David Kamkwamba wonders if the rupture might ultimately benefit Africa. Kamkwamba, director of the Network of Journalists Living with HIV in Malawi, disdained the abrupt nature of the Trump administration’s actions. But he is among the voices, including key African leaders, who acknowledged they had become too dependent on American resources.
“What Trump did was just to bring home that message to say we need to start living within our means,” Kamkwamba said. The recently signed bilateral agreements operationalize that point, obligating countries to commit domestic financing if they want to unlock ongoing American support.
Meanwhile, other donors are also in retreat, and the major alternative source of HIV support, the Global Fund to Fight AIDS, Tuberculosis and Malaria, fell short of its replenishment goals for its next funding cycle. That leaves the onus firmly on African governments to rebuild a response. If they are able to sustain it, Kamkwamba said that could cultivate new faith in the services.
For those who remain hardest to reach — the poor, the remote, and the marginalized — the reconstituted response still offers little assurance.
The search for any kind of work consumes much of Lebole Dilegang’s energy. She has trouble concentrating on tasks such as refilling her ARVs, particularly on the days when no jobs turn up, and she is unable to afford any food.
She felt lucky, then, to have been invited into a community adherence group near her home in Botswana’s capital, Gaborone. Through the group, organized by Humana People to People Botswana, she gained access to a community health worker, who would refill her HIV medicine or help her navigate the clinic when she had to do blood tests.
When the health worker was laid off in early 2025 because of the U.S. funding cuts, Dilegang strove to stay on top of her clinic schedule. But she told Devex in November that after 10 months, she was struggling and might accidentally run out of medicine.
Civil society leaders worry that these kinds of community-based interventions, built over decades, now risk being abandoned. That could give rise to stigma as people once again begin to associate an HIV diagnosis with a death sentence.
Given their limited resources, many governments have indicated that they will prioritize the affordability of facility-based services over community outreach for the foreseeable future, even as advocates warn that many people struggle to access services in state facilities. Following Trump’s stop-work order, the Ugandan government issued a circular requiring all stand-alone HIV services to be integrated into general outpatient clinics.
With their exclusion from the negotiations over the bilateral health agreements, activists have abandoned any hope that the U.S. might restore community services. Instead, they are looking to resurrect programs as voluntary services, such as the outreach efforts in rural Malawi.
“The success of any response is largely hinged on our ability to empower communities to make the right choices about their health,” Botswana HIV activist Cindy Kelemi told Devex. “Diseases start within communities, and they surely will end in communities.”