The Trump administration’s pause on distributing foreign aid and domestic grants has spurred confusion among global health and HIV/AIDS experts, leaving them to wonder how and when HIV/AIDS-related treatment, prevention efforts, research and other programming will be affected.
Secretary of State Marco Rubio issued a memo implementing the pause for new and obligated State and U.S. Agency for International Development funding following President Donald Trump’s executive order calling for a 90-day pause to new foreign aid to allow the government to determine if programming aligns with current foreign policy.
Late Monday, the Office of Management and Budget similarly ordered a temporary pause on the federal disbursement of new grants and loans pending review.
[Trump White House orders freeze on federal grants, loans]
“This is very unprecedented,” said Jen Kates, a senior vice president and director of the Global Health & HIV Policy Program at KFF. “I’ve been working in this area for almost three decades. I’m not aware of this kind of expansive stop work pause ever occurring.”
It also comes as global HIV/AIDS efforts face a reauthorization deadline for two programs: the President’s Emergency Plan for AIDS Relief and participation in the Global Fund to Fight AIDS, Tuberculosis and Malaria. The fiscal 2024 appropriations law extended both the AIDS relief law and the global partnership through March 25, 2025.
PEPFAR is the largest international concerted effort to combat a disease. The bipartisan program was enacted during President George W. Bush’s administration.
The World Health Organization issued a statement Tuesday expressing “deep concern” about the United States’ pause to PEPFAR funding.
“We call on the United States Government to enable additional exemptions to ensure the delivery of lifesaving HIV treatment and care,” the organization stated. Trump issued an executive order last week withdrawing the U.S. from the WHO.
The global pause, Kates said, means that the nongovernmental organizations, local health departments and private organizations that rely on PEPFAR funding must stop using any U.S. federal funding. Some entities might have private funds for the interim, but others may face a difficult situation.
Kates said the impact will come in waves, with global partners seeing the effects in the next two weeks related to existing funding and new obligations, and as the administration’s review of PEPFAR gets underway.
Reviewing existing programming is further complicated by the fact that the Trump administration has put many senior officials on paid leave.
Trump announced his plan to end HIV within 10 years during his 2019 State of the Union address, leading to establishment of the Ending the HIV Epidemic initiative. House Republicans’ marked-up Labor-HHS-Education spending bills for fiscal years 2024 and 2025 both would eliminate the program’s funding. The stopgap funding bill that continues funding for this and other HIV programs faces a March 14 deadline.
Starting Monday evening, previously available PEPFAR datasets were no longer available at the agency’s data website.
The OMB documentation request issued Tuesday morning seeks additional information about several HIV-related programs at HHS:
- Acquired Immunodeficiency Syndrome (AIDS) Activity
- HIV-related training and technical assistance
- Health Systems Strengthening and HIV/AIDS Prevention, Care and Treatment under the President’s Emergency Plan for AIDS Relief
- Ending the HIV Epidemic
- Capacity Building Assistance (CBA) for High-Impact HIV Prevention
- Minority HIV/AIDS Fund HIV emergency relief project grants
- HIV care formula grants
- Ryan White AIDS dental reimbursement
- HIV Prevention Activities Health Department Based
- HIV Demonstration, Research, Public and Professional Education Projects
- Housing Opportunities for Persons with AIDS Program
- Human Immunodeficiency Virus (HIV)/Acquired Immunodeficiency Virus Syndrome (AIDS) Surveillance
A lobbyist who works with clinics for patients with HIV and AIDS said clients are panicked and feel uncertain about how the pause will impact them and their patients. The documentation request also includes an HIV/AIDS program at the Department of Defense.
The OMB directive asks programs to answer a number of questions including if the program would be implicated in the push to end “discriminatory programs,” including diversity, equity and inclusion programs, and if the programs “promote gender ideology” or “support in any way abortion or other related activities.”
HIV in the U.S. has disproportionately affected gay and bisexual men, transgender women and Black and Latino communities.
“HIV programs, by definition, are providing services and outreach to people who are LGBTQ, who are a diverse population,” said Kates. “Are they going to say that those parts of those programs should not continue because they’re not in line with what the president wants? We just don’t know.”
Unclear path
Hannah Johnson, senior program manager for global policy at the George W. Bush Institute, said the transition to a new administration is a “healthy” opportunity to revise what aspects have and have not been working.
“What is different this time around is, you know, the stopping or halting of programs like PEPFAR, especially,” said Johnson.
She and senior fellow Deborah Birx, a Trump administration alum, issued policy recommendations this month for a five-year reauthorization of the program.
“One of the cornerstones of the program’s success has been its programming surrounding treatment. We need to make sure that countries are stable and able to take on this programming themselves, but it’s also really critical to maintain that life-saving component of the program while there is a pause going into place,” said Johnson.
More than 12 million people use treatment through PEPFAR, and a large part of that uptake occurred between 2017 and 2020 under the first Trump administration, she said. Keeping up with treatment also reduces the spread of HIV. She pointed to how in 2023, there were more new infections outside of sub-Saharan Africa than within the continent for the first time.
Changes to domestic programming have also prompted uncertainty about the program’s future and the ability to serve key populations.
Carl Schmid, executive director of the HIV+Hepatitis Policy Institute, called Tuesday’s memo “extremely concerning.”
“People with HIV/AIDS depend on medications, health care and support services for the rest of their lives and we have to take steps to prevent HIV every day, we just can’t stop funding these programs,” he said. “These lifesaving programs serve a wide array of different populations, and HIV is an infectious disease with serious health consequences if not properly addressed — we can’t overlook any community and must serve everyone.”
“This directive halting funding, even if temporary, is more than a bureaucratic delay; it undermines the stability of programs that serve millions of Americans,” said Rachel Klein, deputy executive director of The AIDS Institute. “While new administrations are allowed time to ramp up their policy priorities and staff, they are not allowed to withhold funding appropriated by Congress and already allocated to communities, organizations, and people.”
Next steps
Some lawmakers have praised the recent moves as a way to ensure longstanding programs adhere to the values of the current administration.
Rep. Christopher H. Smith, R-N.J., praised the recent global funding executive orders as a way to reverse efforts to “hijack global health funding to promote abortion on demand around the world.”
The State Department announced earlier this month that some PEPFAR funds were misused in Mozambique to pay for abortions, in violation of the Helms amendment.
Other Republicans have also called for more oversight and review of the program in light of the misuse of funds, including House Foreign Affairs Chairman Brian Mast of Florida and Senate Foreign Relations Chairman Jim Risch of Idaho.
Smith, who led passage of the 2018 PEPFAR reauthorization law, had opposed more recent authorization efforts that did not include a reimplementation of anti-abortion regulations.
Jessie Hellmann contributed to this report.
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