BLANTYRE, Malawi—Earlier this year, McDonald Phiri crashed his bike near his home in southern Malawi. Laid up for months, the 49-year-old relied on an outreach worker to deliver the HIV prevention medicine that he took daily. This service was provided through a specialized clinic run by the Centre for the Development of People (CEDEP), a group that supports gay men, such as Phiri, as well as transgender women.

Before the accident, Phiri himself had volunteered as an outreach worker for CEDEP, so he understood that in a country where homosexual activity is illegal, the clinic was a lifeline.

“We, the MSM [men who have sex with men], it’s tough in our country to be free,” said Phiri, who requested to use a pseudonym to protect himself from retribution. “Here in Malawi, it’s tough even to go to the hospital. Some of the health workers are just talking shit about you.”

At the start of the year, CEDEP operated four drop-in centers, including the one that Phiri used. Almost all of the funding was provided by the U.S. initiative PEPFAR, or the President’s Emergency Plan for AIDS Relief. Since its launch in 2003, PEPFAR has channeled more than $100 billion into global HIV relief, saving nearly 26 million lives.

Malawi has received at least $1.8 billion of this funding, which has been crucial in helping the country move toward the goal of ending the AIDS epidemic by 2030—a target set by the Sustainable Development Goals that the United Nations adopted in 2015.

However, since U.S. President Donald Trump’s return to office, his administration has slashed PEPFAR funding, including to Malawi, and cut support for prevention efforts as well as the services for remote and vulnerable communities that are crucial to ending AIDS.

This included terminating all support for CEDEP in March, causing the organization to close two of its clinics. While the facility near Phiri’s home remains open, it was forced to shut down its outreach efforts, which left him without access to his HIV prevention drugs as he recuperated. He was diagnosed with HIV only a few months later.

Phiri is angry, less about his diagnosis and more about the dismantling of a program that had proved to be so effective: “Are we going to suffer? Are we going to die? I hate this president,” he said.

In September, the Trump administration unveiled its new “America First Global Health Strategy,” outlining its vision for ongoing U.S. involvement in the global HIV response. The strategy pledges continued support to meet the targets required to end the AIDS epidemic by 2030. Yet it also restricts funding to certain programs and obligates partner countries to take greater ownership of their own HIV efforts.

A spokesperson for the State Department told Foreign Policy that the United States intends to remain “the world’s global health leader.” But experts warn that in countries such as Malawi, the deep cuts to crucial HIV programs are too abrupt for governments to fill the gap quickly.

As a result, the progress made toward ending AIDS over the past two decades is now being reversed—one infection at a time.

In 2014, the Joint United Nations Programme on HIV/AIDS (UNAIDS) outlined a series of steps to guide countries toward ending their AIDS epidemics by 2030. At the heart of this plan were the “95-95-95” targets: By the end of 2025, 95 percent of all people living with HIV should know their status; 95 percent of those diagnosed should be on lifesaving anti-retroviral treatment; and 95 percent of those on treatment should have their virus suppressed, making them virtually unable to transmit HIV.

By 2022, the United States had fully aligned PEPFAR with these goals, and last year, UNAIDS estimated that the world reached 87-89-94, respectively—the closest it has ever come to meeting the UNAIDS targets.

Determined to meet the 2025 deadline, officials in Malawi worked closely with PEPFAR and were able to reach 95-95-95 a year ahead of schedule. In the process, Malawi saw a dramatic drop in new HIV infections as well as AIDS-related deaths, which fell from 80,000 in 2003 to 14,000 last year.

Trump’s return to office has Malawi fearful of a setback. After all U.S. foreign aid was frozen in late January, U.S. Secretary of State Marco Rubio issued a waiver that allowed PEPFAR to continue a narrow set of programs deemed “lifesaving”—namely, HIV testing and treatment and the prevention of mother-to-child transmission.

Since then, the Trump administration has slashed almost every component of PEPFAR that does not meet this narrow definition of lifesaving—and even some programs that do. As global health expert Nina Schwalbe put it, “PEPFAR as we know it—as we knew it—is dead.”

In Malawi, Washington cut services for marginalized groups, including the clinic that Phiri depended on, even though it provided treatment that meets the administration’s criteria. Programs serving sex workers, adolescent girls, and young women—the groups with the highest HIV rates—were also terminated.

“The realization of ending AIDS by 2030 heavily depended on ensuring these communities are receiving friendly services,” said Simon Sikwese, who runs a program for sex workers in Malawi.

Washington’s cuts also affected services for rural and poor Malawians, ending support for the volunteers who traveled to remote areas to deliver HIV prevention or treatment medicine and to track down people living with HIV who had skipped their clinic appointments.

“Now, if someone has decided not to come, it’s difficult to follow him,” said McHoney Kulisemba, an HIV testing and counseling provider in southern Malawi who utilized these volunteer networks.

And as organizations have learned over the years, adherence to HIV treatment often requires more than just access to medication. Those additional services are also gone.

In 2024, the $60 million, five-year Ana ndi Achinyamata Patsogolo (Anapa) program was launched to prevent orphans and other vulnerable children in Malawi from acquiring HIV. For those already infected, the project focused on keeping them in treatment. Staff quickly realized that doing so meant ensuring that the children were safe, well-fed, and attending school.

Veronica Bikoko, an Anapa child protection worker, assisted children such as Mathews Chizamala, who was born with HIV into a poor family in rural central Malawi. Now 18, Chizamala often skipped his treatment because taking medication on an empty stomach made him nauseous. But missing doses put him at risk of developing drug resistance.

Bikoko enrolled Chizamala’s caregivers in an Anapa program to help them find work, ensuring that they could afford food. Once the family’s basic needs were met, Bikoko visited Chizamala regularly to make sure he was taking his medicine. Her approach worked. By the end of last year, his virus was suppressed.

“Working with them, that’s when the success comes,” Bikoko said. “They really change.”

But the Trump administration shut down many of Anapa’s wraparound services, including the job support and school enrollment programs, because they didn’t meet its definition of lifesaving. Bikoko was laid off in the downsizing, though she still tries to check in on Chizamala when she can. He tells her he is struggling to find enough to eat again.

Officials in Malawi and elsewhere have watched in dismay as these services have disappeared. Without them, they warn that HIV will continue to circulate, particularly among the most vulnerable, leaving them mired in an endless epidemic.

“We’re not sure what will happen in 2030,” said Beatrice Matanje, the CEO of Malawi’s National AIDS Commission. “Everyone is really uncertain about 2030 and beyond. It’s like in the middle of planning, a bomb has been dropped on us.”

In the new America First Global Health Strategy, the Trump administration affirms its commitment to the 95-95-95 targets. That came as a relief to many. UNAIDS even welcomed the plan as evidence of “the continued support of the American people and the US Government in the historic effort to end AIDS.” But the strategy also signals that Washington will not restore many of the PEPFAR programs that were cut, including the outreach to vulnerable and remote communities. Without them, experts say the pledge to support the 95-95-95 targets is a hollow one.

The Trump administration has also made it clear that it sees PEPFAR as emblematic of an unsustainable dependence on U.S. foreign aid. As part of the strategy, one of the administration’s top priorities is to shift responsibility for HIV programs to the countries themselves.

To achieve this, the strategy calls for bilateral agreements that will condition future U.S. financing on countries increasing their own financial contributions. Negotiations in many countries, including Malawi, took place in November, and agreements are expected to be finalized by the end of the year. The U.S. State Department spokesperson said the goal is to ensure that each country develops a plan that addresses the unique needs of its population.

This push for greater country ownership nominally lines up with what HIV advocates, international donors, local civil society groups, and even some countries’ governments have been seeking for years: a path to sustainability backed by domestic financing.

“If they are successfully able to move in this direction, it could be a win for countries, for the response,” said Ramona Godbole, the former deputy director of global health policy, programs, and planning at the U.S. Agency for International Development. But she cautioned that U.S. officials need to “really be thinking about what a realistic timeline for each country might be to avoid preventable sickness and death.”

Yet, civil society in Malawi are skeptical that Washington is really concerned about their sickness or death. If U.S. officials were, they would not have spent the past 10 months terminating programs that are vital to the shared global commitment to end AIDS by 2030.

In the wake of U.S. cuts, local officials and networks of people living with HIV have scrambled to keep afloat the affected PEPFAR services while preparing to take on potential new obligations under the bilateral agreements. The Malawian government allocated $11 million to the Health Ministry to recruit new staff and an additional $1.7 million to restore HIV testing services.

But the government lacks the resources to replace all that has been lost. With Malawi’s public sector debt standing at 93 percent of its GDP, servicing that debt is eating up money that could be allocated to HIV programs.

“The days of having funding spare just for someone to trace people are gone,” Matanje said.

Even as the 2030 goal to end AIDS threatens to slip out of reach, Malawi’s officials say they are determined to continue the fight, with or without PEPFAR.

“We have to see how we can fill the gap. Not 100 percent,” said Maziko Matemba, who chairs the board of the Malawi Network of AIDS Service Organisations. “But at least to sustain some of the gains which we as a country have registered.”