Budget Cuts Have Wide-Ranging Impact on PrEP Adherence at Home and Abroad

Budget cuts across the nation have been a topic of discussion in HIV for the past year, with budget cuts specifically to the President’s Emergency Plan for AIDS Relief (PEPFAR) affecting not just the US but other countries who rely on the aid to treat patientsliving with HIV. Combined with the One Big Beautiful Bill affecting the budget for the Supplemental Nutrition Assistance Program (SNAP), there are potential long-term consequences for patients with HIV living closer to the poverty line in the US.

In a session held at the Conference on Retroviruses and Opportunistic Infections 2026 and led by Jennifer Kates, PhD, senior vice president and director of global and public health policy at KFF, researchers shared their findings on how the budget cuts are affecting clinics in other countries and residents of the US 1 year after the Trump administration’s budget cuts to international and domestic aid.

PEPFAR Significantly Changed HIV Approach

Kates began the session with a brief summary of the past year, dedicating a portion to highlighting the differences in HIV treatment and prevention prior to PEPFAR coming into play.

“We all know that HIV prevalence was very, very high in sub-Saharan Africa, and very few people were on antiretroviral therapy,” she said. “After PEPFAR, HIV prevalence has gone down…21 million people are estimated to be on [antiretrovirals] in sub-Saharan Africa, deaths have fallen, life expectancy is rising, and the US funding envelope has risen to $5 billion just in bilateral support.”

Deaths related to AIDS also declined by nearly 60% from 2010, particularly after the introduction of PEPFAR. A little less than $5 billion per year just in bilateral support was used to fund PEPFAR each year between 2008 and 2025, according to a KFF analysis done in 2025.¹ This made the US the largest donor to global HIV efforts, contributing 80% of all global funding as of 2024.² PEPFAR primarily helped countries get HIV testing services, treatment, and care; provided a health workforce; and provided socioeconomic boosts to countries that received the aid.¹

This, said Kates, all changed in 2025 when an executive order was passed to reevaluate foreign assistance. “Every administration has the authority and ability to do that. I think what was not expected was that to lead to first a 90-day freeze in future work but then a stop order in the work that was already happening on the ground with people by organizations that were already paid or waiting to be paid,” she explained.

Although a waiver was passed, some of the services that were not resumed included providing pre-exposure prophylaxis (PrEP) for those at risk or already on PrEP for anyone not pregnant or breastfeeding. Kates emphasized that, with the decrease in budget, countries will have to do more to make up for the shortfall and some may not be able to do so. However, due to a lack of research, it remains unclear how the recent cuts are truly affecting the world. The other presenters aimed to solve that issue.

New Research Sheds Light on Real-World Effects of Funding Cuts

As the budget cuts were rolled out across the country, and the world, experts rose to the challenge to evaluate what the immediate impacts would be. Researchers presented their early findings during this session, highlighting different areas of concern across their breaking research.

Ellen Brazier, PhD, an investigator at the Institute for Implementation Science in Population Health at The City University of New York, presented her findings on the impact of the funding shifts through a survey of clinics and programs in 32 countries.³

“Stop work orders disrupted many PEPFAR-funded programs in early 2025, and while limited waivers permitted the subsequent resumption of certain services, early reports indicated that delays in authorization and funding uncertainties resulted in suspended services, along with clinic closures and staff layoffs in some settings,” explained Brazier.

The International epidemiology Databases to Evaluate AIDS consortium aimed to survey clinics around the world to evaluate the status of HIV-related care in those supported by PEPFAR and not supported by PEPFAR. The survey was conducted online from June to July 2025, and it asked clinics about any disruptions in care, resolutions to those disruptions, and mitigation strategies. Responses from 68 clinics and 8 programs across 32 countries were included in this analysis.

A total of 47% of the respondents reported a disruption in HIV-related care, of which 28% reported a disruption in medication availability, 34% to laboratory services, and 47% to clinic operations such as adherence support and record management staffing.

“There were substantial regional variation in the scale of disruptions and the extent to which they were fully resolved by the time of the survey,” Brazier explained.

She concluded by saying that the variation in the scale and resolution of the disruptions emphasized that signal functions of the HIV care continuum and underlying support systems needed to be identified and monitored.

Lindsey Filiatreau, PhD, MPH, an assistant professor at Washington University in St. Louis, expanded on these findings through her research in the consequences of foreign aid instability in South Africa. This study aimed to assess the impact of the foreign aid disruptions specifically in KwaZulu-Natal Province in South Africa.⁴ The researchers focused on staffing, clinic operations, and HIV service delivery.

A total of 36 province-representative clinics were chosen through probability proportion to size sampling. Preplanned facility audits were conducted starting in January 2025 to capture interruptions in clinic services operations and staffing. There were 180,000 people with HIV who were seen across the sampled clinics, which represented 1.6 million people with HIV after weighting.

Forty percent of the clinics reported service operation or staffing interruptions, with filing and data entry reported in 13% of the clinics and 10% of the clinics reporting client tracking and tracing interruptions. Staffing disruptions were experienced by 30% of the clinics and 10% of the clinics experienced testing or treatment services that were interrupted. Almost 30% of the clinics also had layoffs to nonclinical staff.

“These impacts were reported in clinics that did and did not report direct receipt of US government support, indicating that effects were widespread and felt beyond those clinics receiving direct funds,” said Brazier.

The public health response to these disruptions needs to keep the breadth of services that have contributed to the success of HIV response in sight, Brazier concluded.

The Impact of SNAP Cuts

In the last presentation, Aaron Richterman, MD, MPH, assistant professor of medicine in infectious diseases at the University of Pennsylvania, turned the focus toward the US and the budget cuts to SNAP and how adherence to antiretroviral therapy (ART) may be related.⁵

Adherence to ART, said Richterman, is worse among those who are experiencing poverty, potentially due to the scarcity theory that leads to an individual’s inability to engage in health behavior on a consistent level. However, this has limitations, and testing scarcity theory is challenging in a real-world setting. This study aimed to use SNAP as a method of testing that scarcity theory by following patients with HIV who received SNAP to measure their adherence.

The participants included needed to self-report that they had missed at least 2 doses of ART within the past 30 days. All participants were followed for 4 months and adherence was measured through pill bottle caps. The participants had a median age of 55 years, 74% of them were men, and 89% were Black individuals.

The researchers found that patients had increased adherence to ART when they were using SNAP. The overall adherence was 67%. “You can see the pattern, which is that adherence increases over time, so about to day 20, and then there’s a sharp drop off at the end of the benefit cycle,” explained Richterman.

The peak-to-trough decline was 12 percentage points and a change point at day 20 as well. The researchers concluded that ART adherence substantially improved when patients were given short-term poverty relief through SNAP. Monthly variations in this scarcity can influence daily behaviors, including adherence.

“Recent policy changes to SNAP make it very likely that many people will be losing these benefits, and our findings suggest that this will have consequences for HIV outcomes,” Richterman concluded.

Although many experts pointed to potential effects of the budget cuts when they were first announced, this new research highlights the wide-ranging effects that are linked to the decisions of the current administration, ranging from global to domestic consequences. With only more data collection in the coming years, it is unknown how the cuts will continue to effect these areas in the long-term.

References

1. The U.S. President’s Emergency Plan for AIDS Relief (PEPFAR). KFF. May 13, 2025. Accessed February 23, 2026. https://www.kff.org/global-health-policy/the-u-s-presidents-emergency-plan-for-aids-relief-pepfar/
2. Wexler A, Kates J, Lief E, UNAIDS. Donor government funding for HIV in low- and middle-income countries in 2024. KFF. July 2025. Accessed February 23, 2026. https://files.kff.org/attachment/Report-Donor-Government-Funding-for-HIV-in-Low-and-Middle-Income-Countries-in-2024.pdf
3. Brazier E, Maruri F, Ross J, et al. Impact of US funding shifts on HIV care: a rapid survey of clinics and programs in 32 countries. Presented at: Conference on Retroviruses and Opportunistic Infections 2026; February 22-25, 2026; Denver, CO. Abstract 1051.
4. Filiatreau L, Musiello F, Mody A, et al. Population-representative consequences of foreign aid instability for HIV services in South Africa. Presented at: Conference on Retroviruses and Opportunistic Infections 2026; February 22-25, 2026; Denver, CO. Abstract 1054.
5. Richterman A, Bair E, Ellingson N, et al. Short-term poverty relief and ART adherence: insights from a natural experiment of SNAP recipients. Presented at: Conference on Retroviruses and Opportunistic Infections 2026; February 22-25, 2026; Denver, CO. Abstract 1107.