Over the past several decades, a hopeful story has played out across southern Uganda.
The number of children who've lost a parent has plummeted, from nearly one in four in the early 2000s to just 6% in 2022.
New research suggests the decline in orphanhood – defined as the loss of at least one parent – was driven by HIV foreign aid programs.
"I'm about 70 now," says study co-author Dr. David Serwadda of Makerere University in Uganda. "I've never seen a program intervention that has had this huge impact."
Serwadda was working in Uganda during the mid-1990s, when the HIV pandemic was claiming more than 100,000 lives each year.
"I remember visiting what looked like an abandoned household, we just kept shouting 'is anybody home,' " he says. Three children came out, aged 9, 7 and 6. "We asked, 'Where are the parents?' The parents were gone."
Back then, a child whose mother had HIV was about 20 times more likely to become orphaned than a child with an HIV-negative mom. Kids orphaned by AIDS suffer many consequences, says Aleya Khalifa, an epidemiologist at Columbia University and study co-author. They're more likely to face stigma, drop out of school or live in poverty, she says. "You start to see a cycle of vulnerability."
U.S.-funded aid programs, primarily the President's Emergency Plan for AIDS Relief, or PEPFAR, broke that cycle for many kids, according to Khalifa and Serwadda's study published in The Lancet Global Health. Now, children living with HIV-positive moms are just twice as likely to be orphaned, down from 20 times more likely.
"The findings are just so clear," says Rachel Kidman, a social epidemiologist at Stony Brook University who wasn't involved in the research. While she says the study can't draw a definitive causal link, "this decline in orphanhood due to HIV is absolutely because adults have access to life-saving antiretroviral drugs."
The results also underline what's now at risk because of the Trump administration's cuts to foreign aid and uncertainty around the future of HIV funding, says Kidman.
"Domestic governments and charitable foundations only have so many resources to sort of plug those holes, and I'm not seeing other high income countries stepping up," says Kidman. "I think the consequences for children are going to be very dire."
Tracking orphanhood
To understand how HIV treatments affected orphanhood, Khalifa and her colleagues turned to a long-running study in Rakai District, a rural region of southern Uganda that abuts Lake Victoria. Since 1995, researchers there have been gathering data about births, deaths and HIV status among households. All told, the team followed over 90,000 kids, tracking the number of new orphans up to 2022.
Before 2004, these HIV treatments weren't available, and orphanhood in the area was very high. Afterwards, these drugs started to trickle out to communities, but only to the very sick. In 2014, the World Health Organization expanded eligibility to everyone living with HIV.
"That steep, steep drop was actually quite impressive to see after ART became universally available from 2014," says Khalifa.
Of course, parents can die from causes other than HIV. But roughly 70% of new orphans had HIV-positive parents before 2004. That dropped to about 11% after 2015.
"This outstanding paper is testament to the incredible impacts of PEPFAR, the Global Fund and the global HIV response," says Lucie Cluver, a social scientist at the University of Oxford who wasn't involved in the study. Over the past two decades, PEPFAR invested $3 billion dollars in Uganda — and over $100 billion around the globe.
But the future of PEPFAR is in doubt after the Trump administration's dismantling of foreign aid.
"Protecting PEPFAR now will protect millions of children from orphanhood," she says.
The future of PEPFAR
The Trump administration's abrupt and drastic cuts to foreign aid last year, disrupted many HIV treatment programs across Africa, including in Uganda.
"The speed at which this came down completely took us off guard," says Serwadda. Health care workers in these programs could no longer deliver drugs because they weren't getting paid, he says. "The drugs were in stock, but people were not available."
That meant many went without treatment, he says. Eventually, many programs resumed, he says, albeit with tighter budgets. Some programs completely shut down, he says. He and other researchers are assessing the fallout.
"I'll be very surprised if we don't see the impact, mainly through patients losing their treatment," he says – leading to a rebound of HIV that can increase transmission and death.
In a statement, the State Department told NPR that "PEPFAR continues to provide life-saving HIV testing, care, and treatment services for anyone living with HIV, and anyone already receiving treatment through PEPFAR can remain on treatment."
The statement added: "The most effective way to prevent HIV-related orphanhood is to keep parents alive. The new global health [agreements] do just that by prioritizing lifesaving HIV medicines – including antiretroviral therapies like Lenacapavir – and the frontline workers who deliver them."
The U.S. is currently negotiating health agreements with individual countries that transition responsibility for HIV program funding to national governments. In December, it signed an agreement with Uganda to invest up to $1.7 billion over the next five years to combat infectious diseases.
In terms of sheer dollars, it's about a 25-30% reduction compared to PEPFAR funding, says Serwadda. Major questions remain about how the transition could go, but he holds out hope.
"If, and this is a big if, this is actually implemented according to the memorandum, it will be very good for Uganda," he says, since country-level ownership of the program would make it more sustainable.
But he's worried. "Our valley of death is in the transition," he says. "There's so many things that can go wrong. It may not go at the speed it should be, or with the attention, the resources that we will need and the political support and leadership that it will require. Many dots need to be well aligned for us to do this."
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