On January 20, 2025, a US federal executive order froze all foreign aid programs for 90 days, including the President's Emergency Plan for AIDS Relief (PEPFAR) — the largest single-program commitment by any nation to combat a specific disease. Eighteen months later, the peer-reviewed literature and program-level analyses are quantifying what that pause and the funding cuts that followed produced in real-world terms.

The Modeling Studies

The most specific estimate for PrEP — pre-exposure prophylaxis, a daily medication that prevents HIV infection in high-risk individuals — comes from Stone et al. (2025), published in The Lancet HIV. That study isolates the 90-day pause's effect on oral PrEP programs and projects 10,313 additional HIV infections over a five-year horizon from a single year of PrEP removal. The article has been cited 14 times since publication.

A broader modeling effort by Hontelez et al. (2025) in eClinicalMedicine finds that the sudden end of PEPFAR funding likely results in tens of thousands of HIV deaths and new infections. That estimate has garnered 53 citations — the highest citation count among the studies examined here.

From Projection to Observation

The real-world consequences are now being documented beyond models. Filiatreau et al. (2026), published in The Lancet Africa Health under the title "PEPFAR interrupted: real-world consequences of U.S. …," examines observed outcomes from the disruption. That article has been cited three times. Together, these studies move the discussion from projection to measurement: Stone and Hontelez quantify what the interruption could cause; Filiatreau begins to document what it did cause.

Program-level data corroborate the clinical literature. The Center for Global Development (CGD) reported on February 24, 2026, that millions of people lost access to PEPFAR-supported HIV drugs during the US foreign assistance pause. A separate CGD analysis of USAID program disruptions, published September 17, 2025, found that PEPFAR treatment capabilities were completely eliminated by the termination of programs. A further CGD analysis published October 20, 2025, estimated that nearly one in four targeted patients may potentially be without access to PEPFAR-supported HIV treatment at the national level.

Court-Documented Cancellations

The terminations were not abstract. Plaintiff declarations filed in federal court (Case 1:25-cv-10814-BEM, dated April 14, 2025) document a specific PEPFAR program award of $99,974 terminated on March 21, 2025. The same filing records the termination of an HIV PrEP award under PEPFAR. These cancellations form the procedural backbone of the disruption the studies describe.

Country-level responses are also shifting. Following the January 2025 funding cuts, Uganda's Ministry of Health announced it would move HIV care and treatment delivery away from HIV-focused programs — a structural reorientation that mirrors the broader pattern of health systems adapting to PEPFAR's contraction.

The Reauthorization Gap

J. Ratevosian, writing in The Lancet in 2026, framed the moment as one where "fundamental PEPFAR reform risks a period of structural vulnerability in the HIV response." That article, cited four times, references UNAIDS 2026 data and argues that the continued lack of long-term PEPFAR reauthorization by the US Congress has allowed further programmatic and structural changes to proceed unchecked. A Lancet editorial echoed that assessment, noting that the absence of reauthorization has permitted changes to advance without the stabilizing framework that a multiyear authorization would provide.

The broader context here is that the gap between projection and observation is narrowing. Stone et al. model 10,313 infections from PrEP disruption alone; Hontelez et al. project tens of thousands of deaths and infections from full cessation; CGD's programmatic analyses document treatment elimination at scale. When the Filiatreau study's real-world findings align with these models, the range of uncertainty around the human cost narrows considerably.

The structural dimension matters as much as the epidemiological one. Uganda's decision to reorient delivery away from HIV-specific platforms reflects a transition that could outlast the funding disruption itself. If HIV care is integrated into broader health systems during a period of resource contraction, the question is whether those systems can sustain the clinical quality that PEPFAR's focused programs were designed to deliver. The Ratevosian article and the Lancet editorial both identify this as the core risk: not just the immediate loss of services, but the institutional reshaping that follows when a longstanding funding architecture is removed without a replacement.

Citation Patterns

The citation trajectories are worth noting. The Hontelez study's 53 citations suggest the modeling community has converged on its estimates as a reference point. Stone et al.'s 14 citations indicate active engagement with the PrEP-specific findings. Filiatreau's three citations, while lower, reflect the fact that real-world consequence data is only beginning to emerge — the study is recent, and the events it documents are ongoing.

What remains unresolved is whether the policy environment will stabilize. Congress has not passed a long-term PEPFAR reauthorization. The executive order's 90-day freeze has elapsed, but program terminations documented in court filings continued into March 2025 and beyond. The CGD's February 2026 reporting on millions losing drug access confirms that the operational effects persisted well past the formal freeze period. For governments and implementers navigating this landscape, the evidence base now available — epidemiological modeling, program-level analysis, court-documented cancellations, and emerging real-world data — provides the tools to assess the trajectory. Whether that trajectory reverses depends on decisions in Washington that the scientific literature can document but not determine.