Studying labor law was not why Dr. Caspian Chouraya went to medical school. For more than two decades he has worked in HIV treatment and prevention; he now oversees HIV programs in 12 African countries for the Elizabeth Glaser Pediatric AIDS Foundation. Lately, he spends time with legal advisors and poring over layoff rules because U.S. funding has arrived in fits and starts, undermining one of the U.S.’s most successful global health initiatives.
The work at the center of this effort is PEPFAR, the President’s Emergency Plan for AIDS Relief, credited with saving some 26 million lives since 2003. Congress pushed back on proposed cuts in 2025 and in 2026 appropriated nearly $6 billion for global HIV/AIDS work, funding PEPFAR at roughly the prior year’s level. Despite the money being available, officials and partner organizations say the State Department is deliberately withholding some funds, putting lifesaving programs at risk.
The Trump administration set a six-month timeline to build new health-aid systems under its “America First Global Health Strategy.” That process is running behind schedule, creating financial uncertainty that makes it impossible for many NGOs and local partners to plan or deliver services reliably. Bridge funding meant to preserve services while new bilateral agreements and implementation plans were drawn up arrived late or unpredictably for many partners.
Chouraya says U.S. funding cuts this past year forced the shutdown of many projects: teen support groups stopped meeting, cell phone plans for clinics were dropped, and trainings were scaled back. Even when funding is promised, the timing is so uncertain he is repeatedly left asking, “Am I in? Am I out?” He has had to give staff notice in case contracts end, worrying about legal exposure if funds fail to arrive.
The administration’s strategy shifts support from U.S. agencies and mixed partners toward direct contracts and memoranda of understanding with recipient governments, accelerating a long-term goal of transitioning financial responsibility to country governments. Policy experts say that transition carries risks if carried out too quickly or without adequate local capacity. The State Department told NPR that the transition aims to direct money “more strategically” with greater accountability and that characterizing it as wasteful is wrong.
The six-month deadline to complete new agreements expired amid ongoing delays. Many organizations report being told by CDC officials that bridge funding would be extended for short periods—sometimes three months at a time—and to slow spending in anticipation of funding lapses. That kind of rolling uncertainty harms program stability and workforce morale, experts say, because staff seek more reliable jobs and organizations cannot plan long-term interventions.
More than two dozen countries have signed bilateral agreements with the U.S., including Uganda, Rwanda, Nigeria, and Ethiopia. But developing detailed implementation plans—designing procurement systems, digital health strategies, and risk assessments—has been slower than the administration anticipated. Observers say the six-month timeline was unrealistic and left critical processes incomplete.
A key element of the dispute is which U.S. agency controls funds. Historically, Congress directed HIV/AIDS appropriations first to the State Department, which distributed money mainly to CDC and USAID. The Trump administration dismantled USAID’s previous structure and reorganized how aid flows. Critics say the State Department is now keeping more funds rather than forwarding the usual share to CDC, which has been responsible for technical oversight of HIV testing and treatment in many countries.
Public-health experts and current and former officials describe the effect as a squeeze on CDC-managed programs. “What the financial data shows is not an accident or an administrative delay,” a CDC official told NPR on condition of anonymity. “Congress appropriated these funds. The money exists. The State Department is simply not transferring enough of it to CDC to keep these programs running.” Another CDC official warned that CDC’s HIV work could run out of funds by June and called the outcome “a controlled demolition,” with millions of people living with HIV at risk of losing access to treatment.
The State Department disputes that characterization, saying funds are flowing as they have always been and that it is taking decisive steps to ensure continuity. The CDC said it is using available resources to support lifesaving work and referred additional funding questions to the State Department.
Legislators have pressed the administration on interruptions to PEPFAR services. Sen. Patty Murray (D-Wash.) said delays and uncertainty are cause for serious concern and that the administration has a legal responsibility to prevent interruptions to lifesaving services.
Observers caution that even if funding is ultimately disbursed, the repeated short-term stopgap measures reduce the return on investment and jeopardize long-term gains. Emily Bass, author of To End a Plague, said rolling short extensions “stresses the workforce” and lowers program effectiveness. KFF’s Jennifer Kates noted that while transitioning funding to countries has long been a PEPFAR goal, accelerating that transition without stable implementation plans risks backsliding.
Clinicians like Chouraya worry about the future of the field. The unpredictability makes HIV work a less attractive specialization and threatens the human resources needed to sustain treatment and prevention gains. For now, many organizations are operating in triage mode, prioritizing essential direct service delivery while cutting back on trainings and supportive activities—moves that may have downstream consequences for adherence, retention in care, and prevention efforts.
The reporting underscores a broader tension: the administration’s drive to reshape global health assistance, the practical limits of rapid transitions, and the day-to-day consequences in clinics and communities that have depended on predictable U.S. support for decades. Jonathan Lambert and Fatma Tanis contributed reporting.
