PEPFAR Impact Tracker

The impact counters have been redefined in light of continuous peer review, now reflecting the total number of deaths that have occurred to date, rather than the anticipated lifetime impact of a disruption. Detailed information regarding the current methodology is provided below.

Number of adult deaths to date

For the current estimation, we utilized existing modeling research that assessed the impact of a six-month cessation of HIV services in sub-Saharan Africa, which resulted in an average of 679,000 deaths within one year [1]. To adjust these estimates for a three-month pause, we halved the reported number of deaths, resulting in 339,000 deaths (while taking half of the number of deaths may be an overestimate in the short term, this assumption takes into account that a significant proportion of people who interrupt treatment will likely face some delay in restarting and therefore be off ART for three months or more). In this analysis, we assumed a complete disruption over a three-month period and averaged the results across five mathematical models. Given that PEPFAR funds approximately 47% of HIV programs in PEPFAR countries in sub-Saharan Africa, [2], we estimated that 47% of the deaths would be attributable to a complete suspension of PEPFAR funding, leading to a total of 159,000 deaths over one year if the disruption results in an average 3 month interruption of ART. It is important to note that these results pertain solely to sub-Saharan Africa and do not include PEPFAR investments made outside this region.

Why does pausing treatment services result in deaths?

The recovery of the immune system among individuals living with HIV through antiretroviral therapy can take several years. However, this recovery is quickly compromised when the virus begins to replicate in the absence of treatment [1],[3],[4].

What was not included?

In addition to adult deaths to date from the sudden cessation of life-saving medication, HIV treatment also stops HIV transmission. Without antiretroviral therapy, individuals are more likely to transmit the virus, leading to new infections. These new cases have a multiplicative effect, driving further HIV transmission and resulting in additional future HIV infections and deaths.

Number of additional infants infected with HIV

In countries receiving PEPFAR support, approximately 920,000 women are utilizing prevention of mother-to-child transmission (PMTCT) services [5]. The transmission rate of HIV to infants from untreated pregnant or breastfeeding women is approximately 40% [6]. Conversely, when antiretroviral treatment is administered, the transmission rate significantly decreases to about 1% [7]. The projected number of new infections without PEPFAR support over three months would be calculated as follows: 920,000 multiplied by the difference between 40% and 1%, divided by four, resulting in 90,000 infant infections if all were supported by PEPFAR. Assuming PEPFAR accounts for 47% of HIV-related expenditures in these countries [2], we multiply the estimated infant infections by 47%, yielding a total of 42,300 infant infections attributable to the cessation of PEPFAR funding. This estimate is conservative, as it is likely that PEPFAR finances more than 47% of PMTCT services.

Number of infant deaths to date

We further assumed that infants would be born uniformly over a period spanning day one to day ninety. Of the infants born with HIV who do not receive treatment, 20% are expected to die within the first three months of life [8]. For this calculation, assuming the midpoint of the three-month period, we estimate that 10% of infants born during this 90-day interval will die due to lack of access to PEPFAR-procured antiretroviral treatment. This results in an estimate of 4,230 deaths over the three-month period.

How many new infections will occur because the stopping of PrEP for anyone other than pregnant and breastfeeding women?

Pre-exposure prophylaxis (PrEP) consists of antiretroviral drugs that can be taken to prevent HIV infection. In 2024, an estimated 2,500,000 individuals were receiving PrEP through PEPFAR-supported programs [9]. Of these, only 6% were pregnant or breastfeeding women, who remained covered under a waiver.

To estimate the number of new primary HIV infections resulting from the discontinuation of PrEP for more than 2.3 million individuals, we first determined the average expected HIV incidence among PrEP users in each country [10],[11],[12]. We then estimated the total number of person-months covered by PrEP per individual based on recent literature [13]. The reduction in HIV incidence during PrEP use was assumed to be 74%, reflecting the estimated effectiveness of PrEP in routine care settings [14].

Notably, this is a conservative estimate, as we do not include the total number of infections through onward HIV transmission that are also likely to occur.

How will this tracker change in the future?

As services resume following clarification of the waiver, these impacts will be reassessed, and the counters will be adjusted to reflect the restoration of services.

The calculations on this website have been endorsed by several independent modellers working as part of the HIV Modelling Consortium (http://hivmodeling.org/) (Andrew Phillips, Rowan Martin-Hughes, Paul Revill, John Stover, Edinah Mudimu)

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