Dr. Caspian Chouraya did not go to medical school to study employment law. For more than 20 years he has run HIV treatment and prevention programs in Africa; today he oversees projects in 12 countries for the Elizabeth Glaser Pediatric AIDS Foundation. Lately much of his time has gone to lawyers and human-resources planning as U.S. funds meant to keep services running have arrived late or not at all, forcing layoffs and program cuts.
The funding at the center of the disruption is PEPFAR, the U.S. President’s Emergency Plan for AIDS Relief, credited with saving millions of lives since 2003. Congress rejected proposed cuts for 2025 and in 2026 appropriated nearly $6 billion for global HIV work, roughly the same as the prior year. Still, program managers and health officials say the State Department has been slow to release portions of those appropriated funds, leaving lifesaving services in jeopardy.
The Trump administration is implementing a new approach, the America First Global Health Strategy, intended to move away from the previous aid architecture and make partner countries more financially responsible for HIV programs. The administration set a tight six-month deadline to negotiate bilateral implementation agreements with recipient governments and promised short-term “bridge funding” to cover the transition until March 31.
But the schedule has proved overly ambitious. Bridge payments meant to arrive in December frequently came late; one tranche meant for Dr. Chouraya’s Côte d’Ivoire programs did not arrive until March. By then his teams had already curtailed training, paused outreach, and issued layoff notices to prepare for possible contract terminations. Small but crucial supports — peer support groups, clinic phone plans, community outreach — have been suspended. “Am I in? Am I out?” he said of the uncertainty confronting staff.
Observers say the administration is accelerating a longer-term PEPFAR goal of transitioning funds to local ownership, but warn the implementation risks lives if handled clumsily. Jennifer Kates of KFF says the change is an intensification of an existing transition, while Emily Bass, author of To End a Plague, describes the repeated short extensions and stop-start financing as wasteful and harmful to program effectiveness.
More than two dozen countries have signed memoranda of understanding under the new approach, including Uganda, Rwanda, Nigeria and Ethiopia. The State Department says it is directing funds more strategically and holding partner governments accountable, emphasizing measures that reward outcomes. But developing bilateral plans — revamping procurement, building digital health systems, and assessing risks — takes time, and experts say the six-month timetable was unrealistic.
There is also a political and organizational element to the delays. Historically, Congress directed HIV/AIDS appropriations through the State Department, which then distributed most funds to the CDC and USAID. With USAID reorganized under the administration, the CDC has become the main technical implementer left intact. Some analysts, including K.J. Seung and Bass, contend the State Department is diverting money away from CDC-managed programs to centralize control and reshape who leads implementation.
A CDC official who spoke on condition of anonymity said the issue is not mere paperwork. “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, warning that CDC-managed programs could run out of money by June. “That’s not a funding cliff — that’s a controlled demolition,” the official added, saying millions of people living with HIV depend on the services at risk.
Program managers in the field report the greatest unpredictability with CDC-funded activities. In some countries, like Mozambique, officials say CDC-linked programs have exhausted their funds. The CDC told NPR it is using available resources to support lifesaving work but referred questions about transfers to the State Department. The State Department responded that funds are being disbursed “as they have always been” and that it is taking steps to ensure continuity.
Nonprofits and local partners say CDC contacts have instructed them to slow spending to stretch available resources, while still trying to maintain essential treatment. One CDC official texted a partner organization that they should “slow spending in anticipation of this lapse in funding.” Many partner groups agreed to speak only anonymously, citing concern about U.S. government retribution.
Experts warn the stop-start funding model undermines program efficiency and staff retention. Repeated short-term extensions reduce the return on investment compared with steady, multi-year funding. Clinicians and program staff face uncertain salaries and contracts, prompting some to consider leaving HIV work for more stable employment. “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,'” Chouraya said.
Lawmakers have raised alarms. Sen. Patty Murray called the delays and ambiguity “cause for serious concern” and urged the administration to act immediately to prevent interruptions to lifesaving services, noting the government’s legal responsibility to ensure uninterrupted PEPFAR support.
The State Department says the new approach increases scrutiny and accountability for U.S. global health dollars. But while bilateral agreements and new procurement arrangements are still being negotiated, partners on the ground are in triage mode, trying to keep clinics open, maintain drug delivery, and preserve staffing with uncertain and sporadic U.S. funding. For the more than 12 million people living with HIV who rely on these programs, the coming months could determine whether essential services continue uninterrupted or are reduced just when continuity matters most.