PEPFAR’s Golden Era Is Over. It Urgently Needs a Five-Year Transition Plan

On January 20, President Trump announced a 90-day review of U.S. foreign assistance, which was later extended to 120 days. The review, which is set to conclude in the third week of May, was supposed to cover a wide range of development and global health programs, including the President’s Emergency Plan for AIDS Relief (PEPFAR).

As that largely performative review unfolded, the Department of Government Efficiency (DOGE), with active support from the White House, sprang into action in a quest to eliminate the U.S. Agency for International Development (USAID) and foreign assistance through rapid staff layoffs, the suspension of funding and programmatic partnerships, and the seizure of databases and finance systems. USAID, one of PEPFAR’s primary implementers, collapsed by April and is on a path to be formally folded into the U.S. Department of State. These actions quickly outstripped the foreign aid review and the plans laid out in Project 2025, which praised PEPFAR as “America’s most successful aid program.”

A realistic path forward for PEPFAR requires confronting hard truths. The five questions below clarify the impact of the foreign aid review, define what an achievable five-year transition entails, and explore how a leaner PEPFAR can remain dynamic, be strategically rebranded, and stay relevant beyond 2030. These questions lead us toward hard choices—not to restore the past, but to shape a future grounded in pragmatism and purpose, and to avert a worse outcome.

Q1: How has the foreign assistance review impacted PEPFAR?

A1: Secretary of State Marco Rubio granted a few exceptions to the wholesale stoppage, including narrow waivers for PEPFAR-supported HIV treatment and prevention programs for pregnant women. Actual implementation of the waivers was delayed and highly fragmented. The result was unprecedented operational chaos, funding lapses, the collapse of implementation partnerships, and, in many cases, clinic closures.

Amid the turmoil, PEPFAR’s statutory authorization lapsed on March 25, 2025. In the face of declining bipartisan interest, the program had lost its standing as a foreign policy priority, weighed down by growing skepticism of foreign aid in general; widely shared frustration over PEPFAR’s lackluster efforts over the previous decade to create an exit strategy; and the unraveling of the exceptional coalition that had launched and sustained PEPFAR, comprising advocates, private corporate interests, foundations, Congress, and the faith sector.

Now, deep uncertainty persists as the Department of State consolidates what little remains of U.S. global health efforts. Discretionary spending cuts proposed for fiscal year 2026 and the White House’s intent to pursue rescissions of at least $20 billion, likely to include the pipeline of prior appropriated PEPFAR funds, further threaten the program’s future viability.

The most urgent demand of this historic moment is to navigate PEPFAR’s reduced capabilities and mission with newfound realism, urgency, and pragmatism. There will be no restoration, no return to the status quo ante. A smaller PEPFAR is expected to operate in this next period at much reduced funding levels—perhaps at half of its previous budget.

At the same time, staff capabilities to manage countless grants have been reduced to negligible levels, while operating partnerships, interagency coordination, and data and financial systems are in disarray. A new management model—reliant on a very lean staff, aggregated financing commitments, and a strong hand from the Department of State—will be essential.

Calls for increased resources, like those recently championed by Bill Gates and others, should continue. But just as urgent is the need to launch a long-overdue reform effort that concretely details what a successful five-year transition to 2030 will require, backed by a five-year reauthorization of PEPFAR. Equally important is securing early bipartisan buy-in from key Republicans and Democrats in Congress. Advancing both goals should be immediate and overriding priorities.

If the State Department is to play a lead role, the secretary of state should publicly embrace these goals, designate and empower an experienced political department to lead and design PEPFAR’s transition, and set a robust timeline to deliver and begin implementation of the plan in the fall of 2025. It will be equally important that select Republican and Democrat leaders in Congress commit to supporting this reform effort.

Q2: What are the essential elements of a five-year transition plan?

A2: Transition and sustainability have been PEPFAR’s goals for a long time—but progress has been little more than lip service, inconsistent and sometimes superficial. Delayed reforms over the past decade have fueled skepticism and frustration. A moment of reckoning has arrived.

The question is no longer if transition will happen, but whether PEPFAR can manage it quickly in a way that enhances the program’s diminished credibility and builds bipartisan support for an orderly winding down over the next five years.

This effort must move with urgency and unwavering resolve—tempered by the foresight to avoid undoing decades of health progress or abandoning partner countries midstream. A sudden, permanent cutoff of U.S. funding would leave no time for adaptation; trigger a surge in preventable deaths and new infections; set off a cascade of setbacks that could undermine health systems for years to come; and ultimately pose serious risks to U.S. health security, economic interests, and geopolitical influence.

New directives from the Trump administration could accelerate action by introducing hard timelines, demanding cost-sharing, and imposing conditions on U.S. funding linked to measurable progress toward domestic ownership. But for any of this to succeed, PEPFAR’s congressional reauthorization must establish a five-year runway—the minimum time needed to absorb current shocks, ensure an orderly handoff, protect fragile supply chains, and unlock new sources of financing. A clear and urgent mandate from Congress is essential.

A successful five-year transition plan will rest on the rapid conclusion of new, binding bilateral compacts that clearly define time-bound milestones and the financial and policy reform obligations of partner governments and others. The plan should specify that several countries will graduate within the first two years, with the rest to follow by 2030. Most PEPFAR partners should have transitioned out of direct service delivery with U.S. funds by the end of the decade.

PEPFAR should codify and monitor localization to ensure that local partners receive a growing share of funding and responsibility. Financing approaches should be blended—combining donor funds with domestic resources, innovative finance mechanisms, and global health investments. A special focus should be on specifying how the private sector will play an enlarged role in service delivery. Finally, strong, quantifiable metrics are essential to track progress, drive accountability, and make course corrections as needed.

At the same time, PEPFAR should prioritize collaboration with the U.S. International Development Finance Corporation (DFC) to mobilize blended financing and de-risk private investments in HIV infrastructure. The administration should jump-start engagement with U.S. private companies in advancing diagnostics, AI platforms, and data systems. These partnerships can enhance precision and efficiency, ensuring faster, more accurate responses across public health interventions.

This effort will demand high-level diplomatic engagement from the State Department, close coordination with development banks and other donors, and sustained, high-level dialogue with ministries of health and finance. Admittedly, such an ambitious agenda will be very difficult to achieve, given PEPFAR’s reduced status and management capabilities. But it is nonetheless feasible, if backed by the secretary of state and bipartisan congressional leadership.

PEPFAR has built a credible foundation for an accelerated transition. PEPFAR-supported countries like South Africa, Namibia, and Vietnam have demonstrated successful models to take over U.S.-funded programs, including through increased domestic financing, integration into national systems, and high retention of care. Ongoing sustainability work with UNAIDS, along with recommendations from KFF, a health policy organization, and Duke University’s Global Health Institute, provides the blueprints for time-bound, criteria-driven graduation pathways. The focus now must be on formalizing those lessons into a five-year transition framework implemented through binding contracts, enforceable metrics, and cofinancing targets.

Special care is needed in how an aggressive and tough-minded—yet calibrated—winding down of PEPFAR is executed. For U.S. taxpayer dollars to be effective, transitions must be carefully sequenced to safeguard essential HIV services and supply chains. Hastily executed transitions could destabilize programs, erode trust, and risk HIV resurgence in many parts of the world, including in the United States.

Q3: What actions should a downsized PEPFAR prioritize to demonstrate renewed dynamism?

A3: The award terminations, the dissolution of USAID, and staffing cuts at the Centers for Disease Control and Prevention (CDC) mean that the old manner of managing PEPFAR programs will no longer exist. Nevertheless, PEPFAR can take measures to demonstrate resolve and achieve results, despite the formidable constraints under which it now operates.

Treatment remains the foundational pillar of PEPFAR’s success. The program currently supports more than 20 million individuals with life-saving antiretroviral therapy. Yet approximately 10 million people worldwide still lack access to treatment, and an estimated 1.3 million new HIV infections occurred globally last year. Compounding this, service disruptions over the past 100 days are projected to push millions off treatment and increase HIV infections in many PEPFAR countries. These realities reveal a persistent dual challenge: closing the treatment gap while scaling up effective prevention. Both are needed for epidemic control and to prevent backsliding.

While addressing these meta-demands is increasingly beyond PEPFAR’s reach, the program nonetheless can achieve greater precision, efficiency, and discipline by aligning its limited resources with interventions that demonstrably save lives. It can consolidate implementing partners, reduce overhead, and sunset lower-impact programs to focus on high-yield interventions, beginning in middle-income countries with low HIV prevalence. Deeper collaboration with the Global Fund to Fight AIDS, Tuberculosis and Malaria can expand joint, cofinanced programming in procurement, laboratory networks, and community-led monitoring.

Under Secretary Rubio’s leadership, the United States can prod host country governments, other bilateral donors, and global initiatives to step up to close prevention and service delivery gaps that PEPFAR can no longer bridge alone.

PEPFAR can use its purchasing power—even at radically reduced levels—to make strategic select investments in long-acting pre-exposure prophylaxis (PrEP) as part of a broader epidemic control strategy. Failure to sustain prevention momentum, particularly after a major scale-up in PrEP access in 2024, risks reversing results and allowing new HIV infections to grow unchecked. Targeted pilots in high-incidence settings are affordable, even under current financial conditions; can generate evidence for scale-up; and will demonstrate continued U.S. leadership.

Q4: How should the Trump administration rebrand PEPFAR?

A4: While the Trump administration works with Congress on an orderly transition of PEPFAR, it can at the same time work to rebrand the program. PEPFAR should reach beyond its legacy as a flagship emergency humanitarian HIV program to become a force for global health cooperation beyond 2030. It can reset its identity as a strategic instrument of U.S. economic diplomacy, finance, and technological innovation. It can become a foundation for time-limited, integrated assistance to key national partners.

Secretary Rubio should lead this effort. Under the proposed Department of State reorganization, the Bureau of Global Health Security and Diplomacy (GHSD) may no longer report directly to the secretary, but instead to the undersecretary for economic growth. While this change could limit PEPFAR’s direct access to top-level leadership, it could provide new diplomatic opportunities in trade, finance, and multilateral coordination.

Through the new structure, Secretary Rubio can make the case that PEPFAR advances core U.S. interests by shoring up fragile health networks, defending against future pandemics, supporting economic resilience, and demonstrating U.S. generosity. As additional health programs transition into GHSD, PEPFAR can become the operational backbone for a broader, integrated U.S. development approach to key partner countries through bilateral compacts.

Q5: How should PEPFAR stay relevant beyond 2030?

A5: PEPFAR should not disappear in 2030. Instead, it should evolve—broadening its scope, updating its delivery model, and strengthening emergency response capacity. As PEPFAR countries graduate from direct delivery support, closer alignment with programs that target TB, malaria, maternal and child health, antimicrobial resistance, and pandemic preparedness will maximize impact and efficiency. Leveraging its extensive infrastructure—labs, workforce, and supply chains—PEPFAR can serve as a backbone for integrated, people-centered health delivery.

By 2030, PEPFAR should shift from direct service delivery to a catalytic role in technical assistance, disease detection, and knowledge transfer. Operating through compact-based agreements in a limited number of low-income countries, PEPFAR can help ministries of health and local implementers strengthen the continuity, ownership, and long-term resilience of their own HIV responses.

As national governments and their partners take on greater responsibility, PEPFAR should retain the capability to respond to urgent outbreaks. A small, agile surge capacity could monitor for epidemiological rebounds, rapidly deploy resources during crises, and respond to outbreaks that intersect with HIV—such as Mpox or Covid-19. This nimble posture will help safeguard progress and reinforce PEPFAR’s value in global health emergency response.

There is no path back to PEPFAR’s old model. But with political will and skilled leadership, an accelerated, concrete five-year transition plan—detailed, disciplined, and urgent—is possible.

Stabilization must come fast. This means hard choices: finalizing bilateral compacts; winning much higher commitments from partner countries to finance their share and soon assume full responsibility; expanding private sector engagement; and framing PEPFAR as a strategic asset tied to U.S. health security, economic diplomacy, and global influence.

This won’t be easy—or popular. But it’s the clearest path forward in a new era.

Jirair Ratevosian is a senior associate (non-resident) with the Global Health Policy Center at the Center for Strategic and International Studies (CSIS) in Washington, D.C. J. Stephen Morrison is a senior vice president at CSIS and directs its Global Health Policy Center. Katherine E. Bliss is a senior fellow and director of Immunizations and Health Systems Resilience with the Global Health Policy Center at CSIS.