Studying labor law is not why Dr. Caspian Chouraya went to medical school. For more than two decades he’s worked in HIV/AIDS treatment and prevention. He now oversees HIV programs in 12 African countries for the Elizabeth Glaser Pediatric AIDS Foundation. Lately, though, he’s spending his time with legal advisers and reading employment law because U.S. funding has arrived unpredictably, forcing layoffs and program cuts.
The core of this effort is PEPFAR, the President’s Emergency Plan for AIDS Relief, credited with saving about 26 million lives since 2003. Congress pushed back against proposed cuts in 2025 and in 2026 appropriated nearly $6 billion for global HIV/AIDS work — roughly the same as the previous fiscal year. Yet people inside and outside government say the State Department is withholding portions of those funds, putting critical HIV services on the brink of shutdown.
The Trump administration set a six-month deadline to implement a new global health aid system and moved to phase out the old model of partnerships managed through agencies such as USAID. That transition, called the America First Global Health Strategy, aims to shift financial responsibility to recipient countries and negotiate bilateral implementation plans with governments. The administration promised “bridge funding” during the transition so lifesaving activities would continue, and gave itself until March 31 to complete the shift.
But the timeline proved ambitious. Second installments of bridge funding intended for December were often late; for Chouraya’s programs in Côte d’Ivoire the tranche did not arrive until March, after his teams had already curtailed trainings and other activities to preserve essential services. He and others have had to issue layoff notices in anticipation of possible contract terminations. Small items that supported patient care — support groups, clinic phone plans, outreach — have been cut or suspended. “Am I in? Am I out?” he said of the uncertainty his teams face.
Jennifer Kates, senior vice president and director of Global Health & HIV Policy at KFF, says the administration is accelerating a longer-standing PEPFAR aim to transition funding to countries, but warns the way it’s unfolding carries risks. Emily Bass, author of To End a Plague, calls the repeated short extensions and stop-start funding “extraordinary” waste, arguing unstable financing reduces program effectiveness and drives away skilled workers who seek steadier employment.
More than two dozen countries have signed bilateral memoranda of understanding under the new strategy, including Uganda, Rwanda, Nigeria and Ethiopia. The State Department says it is directing funds “more strategically [and] with greater accountability,” and that the transition prevents money from “bypassing partner governments” and rewards lives saved rather than dollars disbursed. But developing the implementation plans — procurement systems, digital health strategies and risk assessments — is slow work, and experts say the six-month schedule was unrealistic.
Observers say the financial bottleneck has a political and organizational dimension. Historically, Congress required global HIV/AIDS funds to flow first to the State Department, which then allocated most of the money to the CDC and USAID. With USAID largely dismantled under the administration’s reorganization, the CDC has become the last intact technical pillar. Analysts including K.J. Seung, an associate physician working on global health equity, and Bass believe State is deliberately diverting less money to CDC, centralizing control and reshaping who leads implementation.
A CDC official who spoke on condition of anonymity said the pattern is not an accident or mere administrative delay. “Congress appropriated these funds. The money exists. The State Department is simply not transferring enough of it to CDC to keep these programs running,” the official said, adding that CDC-managed programs could run out of funds by June. “That’s not a funding cliff — that’s a controlled demolition,” the official warned, saying the people who will pay the price are the more than 12 million people living with HIV who depend on these programs.
Program managers on the ground say CDC-funded activities have faced the most severe unpredictability. Chouraya confirmed projects tied to CDC support have seen the most delays; in some countries, like Mozambique, programs report no funds remaining. The CDC told NPR it is using available resources to support lifesaving work but referred questions on funding transfers to the State Department. The State Department told NPR that funds are flowing “as they have always been” and that it is taking steps to ensure continuity.
Nonprofits and local partners report being advised by CDC contacts to slow spending in anticipation of lapses while continuing to use funds on hand. NPR received a text from a CDC official telling a partner organization to “slow spending in anticipation of this lapse in funding.” Many partner organizations agreed to speak only anonymously, fearing retribution from the U.S. government.
Experts say the uncertainty harms program effectiveness. Bass notes that repeatedly extending short-term bridge plans yields a lower return on investment than stable, long-term funding. Staff morale and retention suffer when salaries and contracts are uncertain, undermining the human resources required for durable HIV treatment and prevention. Chouraya said clinicians are now questioning whether specializing in HIV is a viable career path given the instability: “People are getting to a point where they’re saying, ‘I don’t think there’s a future in the field that I’m in right now.’”
Lawmakers are raising alarms. Sen. Patty Murray (D-Wash.) told NPR the delays and uncertainty are “cause for serious concern” and urged the administration to act immediately to prevent interruptions to lifesaving services, calling it the administration’s legal responsibility to ensure PEPFAR continues without interruption.
The State Department has sought to justify its approach as adding scrutiny and accountability to how U.S. global health dollars are used. But implementation has lagged, and partner countries and organizations reliant on U.S. funding face a precarious period in which services for people living with HIV could be reduced or lost. As the administration continues negotiating bilateral agreements and new procurement arrangements, many on the ground remain in triage mode, trying to keep essential treatment and delivery systems running while unsure when promised funds will arrive.