PEPFAR, USAID Hit Hard by Trump Administration Orders

The global public health community is raising significant concerns about recent Trump administration actions, including a funding freeze and stop-work order, as well as a large number of employees at a key foreign aid organization being placed on leave.

These actions will affect the lives of millions of people around the world, especially those living with HIV who will be unable to access life-saving medications, public health experts said.

On Jan. 20, the Trump administration ordered a 90-day pause on U.S. foreign aid as well as a review of programs, followed by a “stop-work order.” Not long after, around 60 high-ranking employees of the U.S. Agency for International Development (USAID) were put on administrative leave, and last night some 400 contractors for the agency were laid off.

The stop-work order “is literally pulling people out of clinics, pulling people out of office buildings,” Atul Gawande, MD, MPH, a surgeon and author as well as the former head of global health at USAID, who left the agency earlier this month, told MedPage Today‘s editor-in-chief Jeremy Faust, MD, in an Instagram Live over the weekend.

Gawande characterized USAID as the country’s largest “non-military operational capacity,” helping to manage things like disaster response, global health problems, democracy programs, economic development, and food security. Ceasing operations will have immediate and downstream effects, he said.

“Either you believe that we create our strongest good through cooperation on mutual goals around the world, or you’re transactional and you believe it’s us versus them,” Gawande told Faust. “Health is our best demonstration, consistently demonstrated over decades that when you cooperate, you get extraordinary accomplishments.”

Gawande detailed some of the broader public health implications of the stop-work order in a Bluesky thread, including that it stops “direct services for 6.5 million orphans, vulnerable children, and their caregivers affected by HIV in 23 countries,” not to mention halting work on managing deadly Marburg virus, bird flu, polio, tropical diseases like river blindness, as well as vital maternal and child health initiatives.

USAID is in charge of ordering the drugs used by the President’s Emergency Plan for AIDS Relief (PEPFAR) in its programs that keep 20 million people with HIV alive, Gawande said. This work stoppage means that pharmacy stocking in more than 25 countries suddenly stops, as do payments to partner organizations, which are mostly locally run.

On Tuesday, the Trump administration issued exemptions from the spending freeze, including “core lifesaving medicine,” which may apply to PEPFAR but was not immediately clear.

“PEPFAR provides lifesaving antiretrovirals for more than 20 million people – and stopping its funding essentially stops their HIV treatment. If that happens, people are going to die and HIV will resurge,” Beatriz Grinsztejn MD, PhD, president of the International AIDS Society (IAS), said in a statement.

“It makes no sense to suddenly stop this incredible catalyst of our global progress towards ending HIV as a threat to public health and individual well-being,” Grinsztejn said, adding that it is “a matter of life or death.”

IAS called on the government to restore funding to PEPFAR as the freeze “places millions of lives in jeopardy.”

Craig Spencer MD, MPH, of Brown University in Providence, Rhode Island, posted on X that “without access to treatment, HIV can rebound in less than a month.” Without PEPFAR, “HIV faces a global resurgence, just as we made substantial progress,” leading to more infections, the possibility of more resistant strains evolving, and thus greater risk globally, he wrote.

“All those people doing those programs don’t know what the future looks like — whether this will be turned back on in a day or a month or a year or never,” Spencer told MedPage Today. “People are already being laid off. People are already being turned away from clinics. … This is already happening today and will only get worse in the coming days.”

Rep. Gregory Meeks (D-N.Y.) and Rep. Lois Frankel (D-Fla.) urged the Trump administration to lift the freeze, citing PEPFAR and other global health programs as essential for providing life-saving healthcare to millions of people globally. “These lives depend on an uninterrupted supply of medicines, and your pause in funding will cost lives,” they wrote.

The World Health Organization also called on the federal government to “enable additional exemptions to ensure the delivery of lifesaving HIV treatment and care.”

PEPFAR, which was launched by President George W. Bush in 2003, has garnered broad bipartisan support and is credited with saving 25 million lives. However, Republicans have recently targeted the program, claiming it allowed some of its funding to be spent on abortions.

The findings came to light last year, when Congress renewed the program’s authorization for just 1 year. It is set to expire in March.

David Kramer, executive director of the nonprofit Bush Institute, said it’s common for new administrations to review existing programs like PEPFAR, as the four administrations since the program was funded have done — including during Trump’s first term.

“Like all other programs, PEPFAR should be subject to review, but a pause in its funding risks interrupting life-saving access to treatment, potentially placing millions of lives in danger,” Kramer told MedPage Today in an emailed statement.

“A successful, multi-year transition toward full country ownership of the effort has begun, but the mission is not complete,” Kramer said. “And we can’t stop now, because as President Bush reminded us at the outset of the program, all life is precious.”

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