Dr. Caspian Chouraya did not go to medical school to become an expert in labor law, but that is part of his work now. For more than 20 years he has run HIV treatment and prevention programs; today he oversees projects across 12 African countries for the Elizabeth Glaser Pediatric AIDS Foundation. Recent uncertainty over U.S. funding has forced him into frequent consultations with legal teams and into constant planning for potential staff layoffs, because support from Washington has come unevenly and unpredictably.
At the center of the disruption is PEPFAR, the President’s Emergency Plan for AIDS Relief, which is credited with saving roughly 26 million lives since 2003. Congress rejected proposed cuts for 2025 and in 2026 appropriated nearly $6 billion for global HIV/AIDS work, effectively funding PEPFAR at about the prior year’s level. Despite those appropriations, officials and partner groups say the State Department has withheld or delayed portions of the money, putting critical services at risk.
The Trump administration set a six-month timetable to implement its “America First Global Health Strategy,” rebuilding how U.S. health aid is delivered. That process has lagged, creating financial uncertainty that makes it difficult for nongovernmental organizations and local partners to plan or sustain services. Bridge funding intended to sustain operations while new bilateral agreements and implementation plans were negotiated arrived late or in unpredictable installments for many partners.
Chouraya reports that funding disruptions forced closures and cutbacks: adolescent support groups stopped meeting, clinic phone plans were canceled, and training programs were scaled back. Even when funding was promised, the timing was so uncertain that he was repeatedly asking, “Am I in? Am I out?” He has had to give staff advance notice in case contracts end, concerned about the legal implications if funds fail to materialize.
A major policy change under the administration shifts support away from U.S. agencies and mixed partnerships toward direct contracts and memoranda of understanding with recipient governments, accelerating an existing goal to transfer more financial responsibility to country governments. Policy experts warn that hastening that transition without adequate local capacity or complete implementation plans carries real risks. The State Department says the change is meant to direct funds “more strategically” and increase accountability, and that critics are mischaracterizing the effort as wasteful.
The six-month deadline for completing new agreements has passed, and many organizations say planning for procurement systems, digital health platforms, and risk mitigation has proceeded more slowly than the administration assumed. Numerous partners report receiving short-term bridge extensions—sometimes for only three months—and being told to slow spending ahead of potential funding gaps. Those rolling, short-term measures undermine program stability and staff morale because employees look for more secure work and organizations cannot commit to long-term interventions.
More than two dozen countries have signed bilateral agreements with the United States, including Uganda, Rwanda, Nigeria, and Ethiopia. But signing agreements is only the first step; detailed implementation plans that govern how money will be spent and services maintained have taken longer to finalize.
A central dispute concerns which U.S. agency controls the funds. Historically, Congress appropriated HIV/AIDS money to the State Department, which then routed much of it to the Centers for Disease Control and Prevention (CDC) and USAID. The administration reorganized aid flows and dismantled some of USAID’s previous structures. Critics say the State Department is now retaining more funds rather than forwarding the usual share to the CDC, which has provided much of the technical oversight for HIV testing and treatment.
Public-health experts and current and former officials describe the result as a squeeze on CDC-managed programs. A CDC official, speaking on condition of anonymity, told NPR that the shortfall is not an accident: Congress appropriated funds, the money exists, and the State Department is not transferring enough to the CDC to keep programs running. Another CDC official warned that some CDC HIV work could be out of money by June and described the situation as a “controlled demolition,” with millions of people living with HIV at risk of losing access to treatment.
The State Department disputes that depiction, saying funds are flowing as they always have and that it has taken steps to ensure continuity. The CDC says it is using available resources to support lifesaving services but referred further funding questions to the State Department.
Lawmakers have pressed the administration over service interruptions. Sen. Patty Murray (D-Wash.) said the delays and uncertainty are deeply concerning and that the administration has a legal duty to prevent disruptions to lifesaving care.
Observers warn that even if appropriated funds are eventually released, repeated short-term stopgaps reduce the effectiveness of the investment and threaten long-term gains. Short extensions stress the workforce and lower program impact, experts say, and accelerating the transition to country-funded programs without stable implementation plans risks backsliding on treatment and prevention achievements.
Clinicians like Chouraya worry about the future of the field: unpredictability makes HIV work a less attractive career path and could erode the human resources needed to maintain hard-won gains. For now, many organizations are operating in triage mode—prioritizing essential direct services while cutting back on training and supportive activities—a strategy that may have negative consequences for adherence, retention in care, and prevention over time.
The situation highlights a broader tension between an administration intent on reshaping global health assistance and the practical limits of rapid transitions. The day-to-day effects are felt in clinics and communities that have relied on predictable U.S. support for decades. Jonathan Lambert and Fatma Tanis contributed reporting.