Trump Administration Throws U.S. AIDS Support into Turmoil

President Donald Trump’s Jan. 20 executive order freezing foreign aid has sown confusion and uncertainty for AIDS programs around the world, and critics of the freeze say it could undermine years of efforts aimed at ending the AIDS epidemic.

Although a waiver was subsequently given to the largest global program focused on AIDS, The United States President’s Emergency Plan for AIDS Relief (PEPFAR), the extent of the waiver is not clear.

In a separate move, the Trump administration has largely shut down the U.S. Agency for International Development (USAID) and has announced plans to incorporate it into State Department. PEPFAR and USAID are intertwined. The New York Times has reported that two-thirds of PEPFAR’s grants are implemented through USAID and the Centers for Disease Control and Prevention.

A notice on the USAID today says starting tomorrow at 11:59 pm (EST) all USAID “direct hire personnel “will be placed on administrative leave, with exceptions of those “mission-critical functions, core leadership and specially designated programs.”

Jirair Ratevosian, Dr. P.H.

"This proposed takeover of USAID is playing out like an illegal coup. It’s reckless and no way to run the world’s premier development agency,” Jirair Ratevosian, Dr.P.H., a fellow at the Duke Global Health Institute and former chief of staff to the United States Global AIDS Coordinator, said in an email to Managed Healthcare Executive. “If USAID is folded into the State Department, it could seriously disrupt HIV/AIDS programs globally. USAID’s development expertise and partnerships are essential for delivering prevention, treatment, and care to the people who need it most.”

A waiver to foreign aid freeze issued on Jan. 28 by Secretary of State Marco Rubio stated that federal funding can continue for “lifesaving” humanitarian services such as “medical services, food, shelter, and subsistence assistance, as well as supplies and reasonable administrative costs.” The waiver also stated services such as abortions, family planning care or transgender surgeries are not included.

A subsequent waiver seemed to apply to PEPFAR, which had a $6.5 billion budget in 2024. The Joint United Nations Programme on HIV/AIDS (UNAIDS) put out a news releases that quoted its executive director as saying that the waiver would ensure that “millions of people living with HIV can continue to receive life-saving HIV medication during the assessment of US foreign development assistance.”

But the idea that the PEPFAR waiver would restore certainty and funding for U.S.-funded AIDS program has proven to be illusory.

Shortly after the waiver an anonymous source from a nonprofit told Managed Healthcare Executivethat funding had not returned. The source went on to say that they were skeptical, but hopeful, that PrEP would be included in the waiver. They went on to explain that the word “humanitarian” has different connotations in a legal setting and therefore could have a stricter interpretation.

After trumpeting the waiver, UNAIDS put out a news release on Feb. 1 warning that “many organizations providing services for people living with HIV that are funded, or partly funded, by PEPFAR have reported they will shut their doors due to the funding pause with lack of clarity and great uncertainty about the future.” The agency said it would share updates about the situation. Today UNAIDS put out a release about the interruption of AIDS services in Ethiopia. The pause in U.S. funding in the central African country means that tens of thousands of indivdiuals will no longer be able to access critical services such as HIV testing, antiretroviral treatment, pre-exposure prophylaxis (PrEP) for HIV prevention, and screenings for tuberculosis, sexually transmitted infections and support to address gender-based violence,” according to the release.

PEPFAR is the largest commitment by any nation in history to target a single disease. For most of its history the program, which was launched by former President George W. Bush, has enjoyed bipartisan support. Housed in the State Department, PEPFAR currently funds access to HIV and AIDS treatment and prevention across 55 countries and supports two-thirds of the 20 million people living with HIV globally, according to its official State Department website.

Since PEPFAR was established in 2003, the United States government has invested more than $100 billion in the global HIV/AIDS response, which has saved more than 25 million lives and increased PrEP initiation by more than 500% between FY 2020 and FY 2024, according to HIV.gov

"The limited waiver granted to PEPFAR leaves the majority of global PrEP funding frozen in place. Given that PEPFAR supports more than 90% of PrEP delivery worldwide, this decision delivers a crushing blow, ne that threatens to unravel years of progress and reignite the very HIV crisis we've struggled for decades to control,” Ratevosian said,

The Washington Post reported that Rubio said the waiver was clear and that raised the question whether groups were not acting to make a political point.

A Jan. 29 State Department news release about the foreign aid freeze and review said it is “already paying dividends to our country and our people.”

“We are rooting out waste. We are blocking woke programs. And we are exposing activities that run contrary to our national interests. None of this would be possible if these programs remained on autopilot,” the news release said.