This week saw a significant reorganization of the State Department and a delay in the foreign assistance “review process”. There were also new threats to PrEP programs, critical HIV services and health systems, and research in South Africa. Read on for key developments, implications, and resources for action.

Department of State Overhauled

The US administration initiated a significant reorganization of the US State Department, aiming to consolidate its 28 divisions into 15. This restructuring is part of a broader effort to streamline operations and reduce redundancy within the department. The plan situates the Bureau of Global Health Security and Diplomacy Office, which includes PEPFAR, under the undersecretary of State for economic growth and environment. This goes against the 2003 law that created PEPFAR, which placed PEPFAR and its Ambassador reporting directly to the Secretary of State.

​At the same time, the new Department of Government Efficiency (DOGE) implemented a “Defend the Spend” initiative, which imposes stringent new protocols on disbursing federal healthcare grants. The policy requires detailed justifications for each payment, effectively delaying or halting funding for programs such as salaries for healthcare workers at federal health centers. ​ 

IMPLICATIONS: The reorganization and funding constraints could affect the delivery of essential services, including those related to HIV prevention and treatment, both domestically and internationally and continue to raise concerns about potential disruptions to critical health services and the overall impact on public health infrastructure. And removing PEPFAR from the direct line to the Secretary of State potentially diminishes the program’s authority and visibility. 

READ:  

• Rubio unveils sweeping reorganization of State Department—Washington Post 
• How does butchering the State Department ‘make America great’?—The Hill 
• DOGE begins to freeze health-care payments for extra review—Washington Post 
• Rubio Downgrades PEPFAR in Proposed State Department Reorganization—Politico Pro

Foreign Aid Review Extended

The administration extended its supposed “foreign aid review” by an additional 30 days, pushing the conclusion to May 20. This follows the initial 90-day pause initiated by executive orders said to be assessing the alignment of US foreign assistance with the administration’s “America First” policy. An internal State Department email from Jeremy Lewin, the newly appointed Director of Foreign Assistance, indicated that the additional time would be used for further bureau feedback and to align recommendations with the upcoming budget proposal.​ 

IMPLICATIONS: This extension continues amid continued uncertainty around HIV and global health programs. Organizations reliant on this funding remain in limbo, hindering their ability to plan and deliver essential programs and services. The extension also raises concerns about the potential for further cuts or restructuring of foreign assistance. 

READ:  

• Trump administration extends foreign aid review for another 30 days—Devex

Federal Workers to be Reclassified (“Schedule F”) to Remove Their Protections

Approximately 50,000 federal employees will be reclassified under “Schedule F,” a designation that would strip them of longstanding civil service protections and render them “at-will” employees. These actions target career staff in policy-influencing roles across agencies like the Department of Health and Human Services (HHS), aligning with the administration’s broader agenda to reshape the federal workforce and consolidate executive control.  

IMPLICATIONS: This reclassification could undermine the nonpartisan expertise essential for effective governance, particularly in areas like health research and service delivery. The potential impact on global health initiatives is significant, as the loss of experienced personnel could disrupt programs critical to HIV prevention and pandemic preparedness. 

READ:  

• Thousands of federal workers would be easier to fire under Trump rule change—NPR  
• Trump imposes Schedule F to more easily remove federal workers—Fierce Healthcare

South Africa HIV Gains at Risk

Many news outlets and advocates this week are calling attention to South Africa’s HIV response, which is in crisis as the US funding freeze takes effect. Francois Venter argues in an opinion piece that key HIV services are collapsing, including community outreach, PrEP access, and clinic operations, leaving thousands without care. A pre-print journal article, The cost of the plunge, estimates that the termination of PEPFAR-supported services could result in over 13,000 additional deaths and more than 25,000 new infections each year in South Africa. The South African government’s response has been criticized for its lack of coordination and contingency planning, with civil society advocates calling for urgent action, increased transparency, and new domestic investments to prevent the collapse of two decades of progress against HIV.  

READ: 

• Our HIV programme is collapsing — and our government is nowhere to be seen—GroundUp   
• The cost of the plunge: The impact and cost of a cessation of PEPFAR-supported services in South Africa—medRxiv  
• Inside government’s confused response to the US funding crisis—Spotlight  

NIH Pauses HIV Research in South Africa

The US National Institutes of Health (NIH) has restricted research programs in South Africa from enrolling new participants in its major HIV clinical trial networks. South Africa is a leader in trial participation and lab analysis, has been a critical partner in advancing HIV prevention and treatment strategies and has one of the world’s largest HIV epidemics. Experts, including Glenda Gray of the South African Medical Research Council, warn that this action is “petty and punitive,” especially given South Africa’s longstanding contributions to US and global HIV guidance. 

IMPLICATIONS: This NIH decision, coupled with foreign aid cuts and the dismantling of USAID, risks sidelining one of the most capable research partners in the HIV field. It could slow progress in biomedical innovation, disrupt current trial pipelines, and further erode trust in US global health partnerships—at a moment when scientific collaboration and inclusive research are more critical than ever. 

READ:  

• NIH halts more collaborations with South Africa on HIV/AIDS trials—Science 
• We do the sums: The NIH funds $350-million (R6.65-billion) of research in SA—Bhekisisa

PrEP and Prevention at Risk in the US 

In the US, arguments just began in the Supreme Court on the Kennedy v. Braidwood Management case, which is challenging the Affordable Care Act’s (ACA) mandate that requires insurers to cover certain preventive services, including PrEP, at no cost. The case is brought by fundamentalist Christian business owners who oppose no-cost PrEP on religious grounds.  

IMPLICATIONS: If the Court strikes down the mandate, insurers may no longer be required to fully cover services recommended since 2010, including new long-acting PrEP options. This could severely limit access, raise out-of-pocket costs, and threaten hard-won public health gains in HIV prevention and beyond. 

READ:  

• What to know about the Supreme Court case that could take away your access to PrEP and other care—The Advocate  
• Use of No-Cost Preventive Services Jeopardized by Kennedy v Braidwood—JAMA

What We’re Reading

• After U.S. decimates PEPFAR and USAID, the struggle to save HIV services at one nonprofit in southeastern Africa—Positively Aware
• Researcher of 1918 flu virus takes over NIAID—Science
• New NIH director defends grant cuts as part of shift to support MAHA vision—Science
• Trump-Allied Prosecutor Sends Letters to Medical Journals Alleging Bias—The New York Times
• The U.S. needs an alternative organization to protect vaccine guidance from political interference—STAT
• Experts Say Abrupt and “Staggering” CDC Cuts Will Cost Lives—JAMA
• African leaders are rising to challenge of aid cuts, but debt holds them back—LinkedIn
• Fighting for funds: A new era of HIV activism—Bhekisisa
• More Than 220 Academic Leaders Condemn Trump ‘Overreach’—The New York Times
• NEJM Perspective: An HIV Vaccine in the Era of Twice-Yearly Lenacapavir for PrEP — Essential or Irrelevant?—NEJM
• Former Trump official warns president he’s at risk of ruining his legacy on ending HIV – STAT
• In a reversal, the Trump administration restores funding for women’s health study – NPR

Resources

• The Trump Administration’s Foreign Aid Review: Status of PEPFAR—KFF
• Analysis of USAID’s Active and Terminated Awards List: How Many Are Global Health?—KFF
• Scaling Back the Nation’s HIV Response? What the Trump Administration’s HHS Budget May Do—KFF
• Our Health ROI
• Tracking the Freeze: Real-Time Impact on Key Populations—GBGMC
• The Best Investment You Didn’t Know You Made: How NIH Funding Fuels Innovation and Economic Growth—amfAR

Just three months since the US presidential inauguration, and still more developments affecting the future of HIV prevention, global health leadership, and pandemic preparedness. From African women leaders demanding action to save HIV prevention, to escalating US foreign aid cuts and the fragile progress of WHO’s Pandemic Agreement, this issue break down what advocates need to know now. Read on.

Foreign Assistance Leadership in Flux

In another chaotic series of developments around foreign assistance, an internal State Department memo reports that Jeremy Lewin—a 28-year-old tech entrepreneur with no prior government or foreign assistance experience—has now been named Acting Director of the State Department’s Office of Foreign Assistance, following a few weeks as the Acting USAID Administrator—all in the wake of Pete Marocco’s brief, but devastating tenure in both positions. Lewin was a key figure in the Department of Government Efficiency (DOGE) and the dismantling of USAID. He is now overseeing what remains of US foreign assistance following USAID’s absorption by the Department of State.

IMPLICATIONS: Lewin’s inexperience and previous role raise serious concerns about the future of US global health and development, especially as so few staff remain with relevant expertise and relationships with governments and implementation partners.

READ:

• DOGE Staffer Takes Over at the State Department’s Office of Foreign Aid—Devex
• Trump Official Who Led Efforts to Dismantle USAID Exits State Department—The Hill

Further Cuts to Foreign Aid

The administration is advancing major efforts to continue cutting US foreign aid and dismantling USAID. A draft Fiscal Year 2026 budget proposes cutting the State Department by nearly 50%—over $30 billion—with foreign aid reduced by up to 75%, including the closure of at least 27 US diplomatic missions, primarily in Africa and Europe. At the same time, the White House is preparing a formal request to Congress to cut $9 billion of previously approved funds. The cuts are aimed at USAID, State Department and public broadcasting programs. A KFF analysis examined the implications of the cuts, and among other assessments, found HIV-related programs are disproportionately impacted.

IMPLICATIONS: If enacted, these cuts would deliver a major blow to US global health and development leadership, severely undermining programs focused on HIV and disease prevention, and further accelerating the administration’s efforts to dismantle USAID. As AVAC’s Mitchell Warren said in Science, “We are in the middle of a massive earthquake. And when buildings fall, we can’t just build back what we had before. We need a whole new global health funding architecture, but we won’t be able to build it fast enough to avoid significant harm.”

READ: 

• White House to Ask Congress to Cut $9B in Funds, Including for NPR, PBS, USAID—The Hill
• Trump Wants to Halve State Dept Budget, Slash Foreign Aid 75%—USA Today
• ‘What’s In’ and ‘What’s Out’ in USAID’s Global Health Programming—Devex
• Analysis of USAID’s Active and Terminated Awards List: How Many Are Global Health?—KFF
• Trump Has Blown a Massive Hole in Global Health Funding—And No One Can Fill It—Science

Restructuring HHS

A leaked HHS budget proposal this week outlines significant cuts to HIV programs in the US, including the elimination of the Ending the HIV/AIDS Epidemic Initiative (which was, ironically, started during President Trump’s first term and delivering results) and the Minority AIDS Initiative. The Ryan White Program under the new proposal would continue but with reduced funding, and the CDC prevention programs, including PrEP, face uncertainty due to consolidation. NIH’s HIV research funding could drop by 40%, jeopardizing progress in the fight against HIV.

READ:

• Scaling Back the Nation’s HIV Response? What the Trump Administration’s HHS Budget May Do—KFF
• Internal Budget Document Reveals Extent of Trump’s Proposed Health Cuts—Washington Post
• How Trump 2.0 is Slashing NIH-backed Research — In charts—Nature

WHO Warns of Budget Implications

At a press conference this week, WHO Director-General Tedros Ghebreyesus confirmed that health services in over 100 countries are being “severely disrupted” following the US’s withdrawal from the WHO and drastic cuts to foreign aid. He confirmed that there has been no formal dialogue yet between the new US administration and WHO. In his remarks, Tedros urged governments to protect the poorest and resist cutting public health funding. Moreover, WHO faces a $2.5 billion budget gap, which is forcing drastic downsizing and a massive restructuring of the agency.
 
IMPLICATIONS: In addition to the WHO, the US has also pulled out of pandemic treaty negotiations, citing false claims about sovereignty. This all points to reduced international pandemic preparedness, weakened surveillance systems, reduced access to vaccines, and growing health inequities—particularly in low-income countries most dependent on WHO support.

READ: 

• No Talks Between WHO and US Despite ‘Severe Disruption’ in Health Services Since Trump Slashed Aid—Health Policy Watch
• World Health Organization Reorganization Plan Developed with Boston-based Consultancy—Health Policy Watch

Pandemic Agreement Reached

Just over five years since the COVID-19 pandemic disrupted the world and after several years of negotiating, WHO member states finally reached agreement this week on a draft pandemic treaty that, if ratified, would be a legally binding accord that lays the foundation for future pandemic prevention and response, including real-time sharing of vaccines, treatments, and diagnostics. For three years member states negotiated critical issues, with pressure from civil society to embrace key provisions on equity and intellectual property. Some of those provisions have been addressed in the final text, with the precise language used remaining contentious. The agreement is expected to be adopted at the upcoming World Health Assembly (WHA) meeting in May. However, negotiations on an Annex detailing the new Pathogen Access and Benefit Sharing mechanism will continue with the aim of concluding at next year’s WHA. Sixty countries must adopt the Accord for it to be in full force.
 
IMPLICATIONS: The agreement marks a major step forward for multilateralism and health security—even as the US remains absent from negotiations. Advocates warn that without civil society input and sustained investment, including restored US funding, the agreement’s promise may fall short.

READ:

• Countries Say YES to Pandemic Agreement—Health Policy Watch
• The Pandemic Agreement is Here—Medicines Law & Policy
• MSF Welcomes Progress on Pandemic Agreement Negotiations: A step toward equity in future pandemics and health emergencies—MSF statement

NIH Indirect Costs and University Pushback

The administration’s proposal to cap indirect costs for National Institutes of Health (NIH) research grants at 15% is being challenged with lawsuits by universities and others. This week, several organizations representing research institutions announced efforts to develop alternative models for a streamlined, transparent approach to funding indirect costs that balance efficiency and sustainability. Specific proposals are still under discussion.

READ: Universities Begin Search for Indirect-cost Fix that Might Assuage Trump Administration—STAT

African Women Lead: A Call to Sustain HIV Prevention

The African Women Prevention Community Accountability Board (AWPCAB) issued a statement calling on global health institutions, African governments, donor countries, the private sector, and philanthropies to urgently address critical gaps to ensure a sustainable HIV response. AWPCAB is led by a number of AVAC partners and staff and represents a collective of women and girls committed to advancing HIV prevention.  The statement defines priority actions from local production to domestic financing and more. As they state clearly: “There is no ending AIDS by 2030 without prevention.”
 
READ: AWPCAB Calls for Urgent Action to Safeguard HIV Prevention and Centre Meaningful Community Engagement

What We’re Reading

• How the United States Became a Science Superpower — And How Quickly it Could Crumble—Nature
• NIH Cuts Triggered a Host of Lawsuits: Nature’s guide to what’s next—Nature
• HHS Systems Are in Danger of Collapsing, Workers Say—Wired
• Kennedy’s Deep HHS Cuts Threaten HIV/AIDS Response—The Hill
• At Harvard, Scientists Worry Over the Consequences of Resisting the Trump Administration: $2.2B in grants frozen—STAT
• R2.82-billion. That’s What We Need to Plug the US Funding Gap, For Now—Bhekisisa
• Zimbabwe’s HIV Crisis: US aid cuts leave millions at risk—Be In the Know

Resources

• The USAID List of Terminated Global Health Awards – What Does it Tell Us—KFF
• The Impact of Suspensions and Reductions in Health Official Development Assistance on Health Systems—WHO
• The Status of PEPFAR’s USAID Programming—amfAR
• Tracking the Freeze: Real-Time Impact on Key Populations—GBGMC
• The Impact of Suspensions and Reductions in Health Official Development Assistance on Health Systems—WHO
• The Best Investment You Didn’t Know You Made: How NIH Funding Fuels Innovation and Economic Growth— amfAR
• Quick Take: HIV Research Matters for America—O’Neil Institute and amfAR
• What Do Federal Staffing Cuts and HHS Restructuring Mean for the Nation’s HIV Response?—KFF
• Domestic Funding Contributions to Health: Comparing Changes in Domestic Financing in PEPFAR and Non-PEPFAR Supported Countries—amfAR

This week’s issue covers drastic cuts across the US Department of Health and Human Services (HHS), where a dramatic 20% downsizing effort is underway. On Tuesday, HHS began issuing reduction-in-force (RIF) notices across its agencies, triggering mass layoffs at the US Centers for Disease Control and Prevention (CDC), National Institutes of Health (NIH), and the US Food and Drug Administration (FDA). The ripple effects are vast—gutting HIV prevention, infectious disease research, and vaccine development, while threatening the stability and viability of the workforce that sustains US public health and biomedical research. Read AVAC’s statement on HHS here.  

This issue also covers growing legal, institutional, and global responses to these actions. 

Reduction-in-Force Notification at HHS

Tuesday, HHS began issuing reduction-in-force (RIF) notices across its agencies, with deep cuts at the CDC, NIH, and FDA. This effort is part of a sweeping reorganization announced by HHS Secretary Robert F. Kennedy Jr. last week, which aims to downsize HHS by 20%. Framed as a “painful period”, HHS leadership claim to be refocusing the agencies on rising chronic disease. Read more below for details.  

IMPLICATIONS: The dismissal of 20,000 public servants and leaders across every domain of global health research, policies and programs is absent of any clear plan to sustain life-saving work across these agencies. These ill-informed decisions dismantle the US capacity to advance and regulate science, medicine and health. They risk a resurgence of diseases like HIV and TB, reversing years of scientific advancement and bipartisan federal investment. They also mean the loss of an essential American brain trust in research and development, including the potential of a “chilling effect” in bringing in the next generation of young investigators.

CDC Developments

At the CDC, widespread layoffs have decimated critical divisions, including Reproductive Health, Population Health, and HIV and STD Prevention. Half of the employees at the Division of HIV Prevention received RIF notices. Jonathan Mermin, director of the National Center for HIV, Hepatitis, STD, and Tuberculosis Prevention (NCHSSTP), has been placed on administrative leave, and the Center has been cut, along with the tuberculosis elimination and research branches. The CDC is said to be among the agencies seeing the largest workforce cuts with 2,400 employees to be laid off. 

READ:

• The CDC Has Been Gutted—Wired
• These CDC Teams Were Hardest Hit by Trump’s Mass Layoffs—Medpage Today 

FDA Developments

Peter Marks, who led the FDA’s vaccine and biologics center and played a key role in COVID-19 vaccine approvals dubbed “Operation Warp Speed”, stepped down under duress. His resignation letter, which was made public, warned of dire consequences of the US government’s positioning on vaccines and the proliferation of misinformation, evidenced by the growing measles outbreak in Texas. Following his departure, HHS announced plans to cut about 3,500 full-time FDA positions. The agency stated that the layoffs will not impact drug, device, or food reviewers. The FDA has worked in conjunction with the CDC and the USDA to combat bird flu’s rapid spread. 

READ:  

• New FDA Commissioner Agreed to Oust Top Vaccine Regulator after Private Swearing-in—The New York Times

NIH Developments

Since Monday, directors of five NIH institutes, including NIAID’s Jeanne Marrazzo, and other senior leaders have received RIF notices, been placed on leave or offered reassignment. As the world’s largest funder of biomedical research, decades of NIH investments have driven the discovery and development of therapies and preventive interventions for HIV, tuberculosis, STIs, viral Hepatitis, other infectious and noncommunicable diseases. NIH-funded research contributed to the development of 354 of 356 drugs (99.4%) approved in the US between 2010 and 2019. 

The Adolescent Medicine Trials Network for HIV/AIDS Interventions (ATN)—created in 2001—revolutionized research by generating data to develop and deliver life-saving HIV and STI interventions for adolescents, an often-excluded group in research. However, the ATN grant was terminated, undermining decades of investment by NIH and American taxpayers to advance healthcare for adolescents. 

An analysis by amfAR shows the cascading economic harm, which will affect all 50 states. “Each year the NIH awards over 60,000 grants that support over 300,000 researchers at more than 2,500 institutions across the US. For every $1 of NIH funding received, a state generates $2.46 on average in increased economic activity.”            

READ:  

• Five NIH institute directors and numerous lab heads ousted in unprecedented shake-up—STAT
• The Best Investment You Didn’t Know You Made: How NIH Funding Fuels Innovation and Economic Growth—amfAR 

Top Researchers Sound Alarm Over Federal Attacks on Science 

Nearly 2,000 top US scientists have signed an open letter condemning the administration’s attacks on science, including funding cuts, censorship, and pressure to alter research. The scientists—all elected members of the National Academies of Sciences (NASEM)—warn that the latest actions threaten both public health and America’s global scientific leadership. They describe a “climate of fear” in research, where scientists self-censor to avoid political backlash. 

READ:  

• Nearly 2,000 Top Researchers Call on Trump Administration to Halt ‘Assault’ on Science—STAT

Crisis and Cuts at WHO

At a global Town Hall meeting of World Health Organization (WHO) staff, Director General Tedros Adhanom Ghebreyesus announced major cost-cutting measures, including staff reductions starting with senior leadership, and a restructuring based on a “prioritization exercise.” WHO is facing a deepening financial crisis, with a $1.9 billion shortfall in its planned $4.2 billion budget for 2026–2027, and an additional $600 million deficit through 2025. The crisis is largely due to the US withdrawal from WHO, it also includes $130 million of obligations owed from 2024 dues.  

READ: 

• Faced with $600M Income Gap, WHO to Scale Back on Work, Staff, Budget—Devex
• WHO Budget Crisis Bigger Than Previously Thought – $2.5 Billion Gap for 2025-2027—Health Policy Watch 

New Lawsuit Challenges NIH Grant Terminations

Scientists and organizations including the ACLU, Center for Science in the Public Interest, Ibis Reproductive Health and Protect Democracy filed a lawsuit against the US administration arguing that the NIH’s rationale of “not supporting agency priorities” is vague, arbitrary, and illegal under the Administrative Procedure Act and the Fifth Amendment’s due process clause. Many canceled grants involved research on topics politically opposed by the administration, such as transgender health, LGBTQ+ issues, and workforce diversity. The lawsuit contends that the terminations violate congressional mandates, undermine scientific progress, and could ultimately endanger public health.  

READ:  

• Lawsuit Aims to Overturn Many NIH Grant Terminations—Science

What We’re Reading

• RFK Jr. Mimics AIDS Denier Thabo Mbeki—The Washington Post (opinion)
• The Quiet Way the NIH Is Stalling Some Research Before It Starts—Chronicle of Higher Education
• HIV Cases More Than Double in Middle East and North Africa—The Telegraph 
• As US Cuts HIV Help, South Africa Turns to Miners, Insurer—Bloomberg Law
• Millions of Women Will Lose Access to Contraception as a Result of Trump Aid Cuts—The New York Times
• Dropping U.S. Biodefenses: Why Cuts to Federal Health Agencies Make Americans Less Safe—Just Security
• Rollout of ‘Miracle’ HIV Prevention Drug is Threatened by Trump Cuts to Global AIDS Relief Program—STAT
• International Scientists Rethink U.S. Conference Attendance—Science

Resources

• Domestic Funding Contributions to Health: Comparing Changes in Domestic Financing in PEPFAR and Non-PEPFAR Supported Countries—amfAR
• Impact of US Funding Cuts on the Global AIDS Response—UNAIDS
• The USAID List of Terminated Global Health Awards – What Does it Tell Us—KFF  
• Impact of PEPFAR Stop Work Orders on PrEP—AVAC

This week we’ve seen plans to terminate thousands more USAID awards and completely overhaul the US Department of Health and Human Services (HHS), which oversees the National Institutes of Health, the CDC and the FDA. This comes as US funding for vital scientific research in South Africa faces new threats and the future of PEPFAR remains uncertain, with its reauthorization expiring this week amid shifting priorities and budget cuts.

Termination of USAID Awards

Approximately 86% of global assistance programs (nearly $76 billion) have been or will be terminated by the US administration according to a spreadsheet USAID shared with Congress this week—this includes grants already terminated or earmarked for cancellation. Gavi’s $2.63 billion life-saving vaccine delivery work is among the hardest hit programs. Overall, the government said it will continue only 898 of USAID’s 5,341 awards. This news follows the ruling in AVAC’s lawsuit earlier this month requiring the government to pay USAID partners for foreign aid work completed before February 13. New financial obligations and programs beyond February remain uncertain. 

IMPLICATIONS: Funding for HIV and other health programs are allocated by Congress. The sweeping cuts by the executive branch subverts the will of Congress and as outlined in court challenges, is well beyond its legal authority.  

READ: 

• US to End Vaccine Funds for Poor Countries—The New York Times 
• The USAID Awards the Trump Administration Killed — and Kept—Devex  
• US to Finish $671 Million in Foreign Aid Payments Nearly Two Weeks After Court Deadline—Reuters 

Major Overhaul to Department of Health and Human Services (HHS)

The US Department of Health and Human Services (HHS), which oversees 13 agencies, including the Centers for Disease Control and Prevention (CDC), the Food and Drug Administration (FDA) and the National Institutes of Health (NIH) announced cuts to 20,000 jobs—reducing its workforce from 82,000 to 62,000—and streamlining 28 divisions into 15 to create a new “Administration for a Healthy America.” This sweeping reorganization, under Secretary Robert F. Kennedy Jr. aims to cut $1.8 billion annually.  

Coming out of Thursday’s announcement proposing major cuts and restructuring of HHS, no one at the CDC has received details on what it means for the agency. This comes after last week’s proposed cuts—between $700 million and $1 billion—of the CDC’s Division of HIV Prevention. A new analysis shows the historical importance of funding this Division and includes projections of the impact of cuts on new HIV infections, deaths, and costs.   

IMPLICATIONS: The cuts will hit the NIH, FDA and CDC especially hard. While officials insist “critical services” will remain unaffected, the FDA alone will lose 3,500 employees, raising concerns about the potential impact on food and drug oversight. HHS frames these changes as a necessary “painful period” to tackle issues like rising chronic disease. The CDC is expected to lose 2,400 employees, and NIH will lose 1,200 employees according to the HHS fact sheet.  

READ:  

• HHS Plans to Shutter or Downsize Several Health Agencies, Including at CDC—NBC News 
• Cuts to the CDC’s Division of HIV Prevention Will Lead to Dramatic Rise in Infections, Deaths, and Costs—amfAR  
• Here’s the Georgia HIV Prevention Work at Risk from Looming CDC Funding Cuts—Health Beat Atlanta

Jay Bhattacharya Confirmed as NIH Director; South Africa’s Research Funding Under Threat

Despite concerns over vaccine skepticism, AIDS denialism and racist views of immunology, Jay Bhattacharya was confirmed as NIH Director. At his confirmation hearing when questioned about the proposed cuts to indirect cost rates at US universities, Bhattacharya defended the policy, saying it would enhance research efficiency while sustaining vital infrastructure. Bhattacharya pledged to focus the NIH on chronic diseases, rebuilding public trust in science through transparency and debate, and undergoing structural changes to support innovative research. On Wednesday, the NIH instructed staff to list all grants and contracts focused on “fighting misinformation or disinformation.” 

NIH grant managers have also been ordered to “hold all [research] awards” for South Africa according to a leaked memo that categorizes South Africa as a “country of concern” alongside China. Programs related to diversity, equity, inclusion, vaccine hesitancy, and climate change will not be prioritized and are being terminated.  

IMPLICATIONS: The entire biomedical research enterprise is under serious threat, with major concerns about infrastructure, scientific agendas, and training of next-generation researchers. In South Africa, it is estimated that the NIH funds as much as 70% of medical research; this potential funding cut could severely undermine critical HIV and TB studies, cripple South Africa’s capacity to conduct vital research, weaken global scientific collaboration, and deepen health inequities.  

READ:  

• Trump’s picks to lead FDA, NIH confirmed by Senate—The Washington Post 
• Hours after NIH Director Confirmed, the Agency Tackles One of his Priorities — Ending ‘Censorship’ in Science—STAT  
• ‘Chaos and Confusion’ at the Crown Jewel of American Science—The New York Times 
• ‘People Will Die Based on these Decisions’: Trump administration cuts funding for dozens of HIV studies—CNN  
• ‘Orchestrated Assault’: New tsunami of NIH grant cuts hits South Africa hard—Science  
• South Africa Research Grants Potentially on Hold, Says Leaked Memo—Bhekisisa 
• NIH Cuts Halt 24-year Program to Prevent HIV/AIDS in Adolescents and Young Adults—STAT  
• Tracker of NIH Grant Terminations in 2025

Reauthorizing PEPFAR

This week marked an important turning point for the future of PEPFAR as its reauthorization expired Tuesday, leaving the program in a precarious situation amid shifting political priorities and congressional gridlock. Jirair Ratevosian, former chief of staff for PEPFAR, warns in an opinion editorial that without a long-term legislative framework, PEPFAR partner countries will struggle to assume ownership of their HIV programs and services, and decades of progress could be reversed. He calls for transformative reforms to modernize PEPFAR. 

READ/VIEW: 

• PEPFAR Misses Reauthorization Deadline: What’s Next for Global HIV Fight?—Think Global Health 
• The Role of PEPFAR in HIV Prevention: Protecting Black and Brown communities against foreign aid cuts—CBC Health Braintrust The Broadsheet 
• INFOGRAPHIC: Global PrEP Uptake and PEPFAR’s Role, 2016-2024—AVAC 

What We’re Watching and Reading

• Why I Left my Job Leading Public Health Messaging for the CDC—The Washington Post (opinion) 
• Impact of an International HIV Funding Crisis on HIV Infections and Mortality in Low-income and Middle-income Countries: A modelling study—Lancet HIV
• Better Engagement, Better Evidence: Working in partnership with patients, the public, and communities in clinical trials with involvement and good participatory practice—Lancet Global Health 
• Shadow Hearing – Thrown into Chaos: The Dismantling of USAID and its Real-Life Consequences—Foreign Affairs Committee
• Foreign Aid Is More Popular Than You Think—Newsweek (opinion) 

Resources

• KFF Analysis of Global Health Funding in the FY 2025—KFF
• Impact of US Funding Cuts on the Global AIDS Response—UNAIDS
• PEPFAR Watch Funding Freeze Tracker
• Project 2025 Tracker
• Litigation Tracker: A public resource tracking the legal challenges to the Trump administration’s executive orders, Just Security
• Federal Government Outlays—DataETC

By Jeanne Baron and Cat Verde-Hashim

In the months leading up to the US funding freeze, the HIV prevention field was slowly gaining momentum—expanding PrEP access, introducing new products like injectable CAB for PrEP (CAB-LA) and the dapivirine vaginal ring (DVR), and strengthening delivery systems to ensure the rollout of injectable LEN for PrEP (LEN) reached those most at risk. This progress has been as a result of years of investment, collaboration, and community engagement. But the freeze has brought this momentum to a halt. Service delivery has been disrupted, community-led programs suspended, and healthcare workers laid off. Stockouts loom, research has been paused, and demand generation efforts have gone silent—just as the sector was beginning to overcome longstanding barriers. Without urgent, coordinated action, the gains made in HIV prevention could be reversed, leaving communities more vulnerable and equity further out of reach.

The global health community ended 2024 with a historic opportunity in sight. With key lessons in hand from the rollout of oral PrEP, it is possible to get rollout right in 2025 with next generation long-acting PrEP and put the world on track to end the AIDS epidemic by 2030.

What’s more, ongoing research, presented at the Conference on Retroviruses and Opportunistic Infections, showcased the promise of new research and development in HIV prevention and PrEP. PrEPWatch offers a PrEP-specific conference round-up along with this summary article from Spotlight South Africa: A jab that could protect against HIV for a year at a time, and other highlights from major conference.

But as the new US administration took control of the government at the end of January and decimated every aspect of foreign assistance and global health, the impacts could set back the HIV response by decades, allowing the epidemic to resurge. Robust PrEP programs, beefed up to deliver long-acting PrEP, will be essential to delivering injectable Lenacapavir for PrEP and other long-acting PrEP. PEPFAR has been the foundation of PrEP delivery for the world, responsible for 79% of PrEP uptake globally in the last year. That number reached 83% by the end of September of 2024. 84% of surveyed PEPFAR implementers reported disruptions to their programs, many characterized as severe. See our new analysis—Impact of PEPFAR Stop Work Orders on PrEP—for an in-depth look at what’s at stake for PrEP as an instrumental tool in the effort to reach epidemic control.

Also documented by the PEPFAR Impact Tracker, PEPFAR Watch, amfAR, Lancet HIV, GBGMC, and HIV Modelling Consortium, the scale of the devastation is mind-numbing: Criminalized populations such as sex workers, transgender individuals and gay men are finding sites that once provided safe access to treatment and prevention shuttered. And governments fear blacklisting from future US government funding if they support these sites. A new UNAIDS analysis finds “there would be a 400% increase in AIDS deaths, amounting to 6.3 million deaths,” if PEPFAR is not re-authorized (which it was not) and no other resources fill the gap. The HIV Modelling Consortium finds without funding for prevention programmes in Africa, over the next ten years, incidence rates amongst adults could triple and vertical transmission is likely to double. See AVAC’s March PxWire for details.

PEPFAR’s goal had been to initiate 100,000 users across ten African countries on injectable cabotegravir (CAB) by the end of 2025. By the end of October 2024, they had initiated 5,000 users across four countries, but in January 2025, procurement for 2025 was paused. Projects studying CAB and DVR serving over 11,000 participants have been terminated, and other projects were suspended. In Kenya, 17% of total nurses (22,000) and (12,000) ancillary staff have stopped work; in Zambia and Malawi numbers rise to 20% (17,000) and 43% (4,500) of nurses, respectively.

With these threats to PrEP scale-up jeopardizing the HIV response, the ambitious announcement, made in December 2024, by PEPFAR and the Global Fund to reach 2 million people with LEN for PrEP over three years must be supported. Early in March, Global Fund Executive Director Peter Sands told the Bhekisisa Centre for Health Journalism, it will fund the rollout of LEN for PrEP with or without PEPFAR.

“We are still maintaining our ambition on lenacapavir for PrEP,” said Sands, “We see lenacapavir as a potential game changer in the fight against HIV as an injectable, long-acting PrEP solution that is pretty well 100% effective. It’s not going to be right for everybody, but we need to find out more from having people use it.”

Now what?

The field must not delay in the face of this destructive and lethal attack on global health and HIV prevention. Instead, the field must adapt to a significantly changed landscape for PEPFAR and beyond. Most countries are seeking alternative funding sources (Global Fund, government financing) and integrating service delivery (comprehensive care clinics and key population services) into public health systems. Those efforts are a start but will take time and will not be enough alone to rebuild the collapsed foundation that PEPFAR provided until January 20, 2025. Ongoing commitments from the Global Fund and Unitaid are essential but will also not be enough. An expanded role for the private sector and other innovations in delivering HIV prevention could be part of the solution. But more is needed. The solutions are out there, it will take courage and vision to work in solidarity to preserve existing programs that offer oral PrEP and expand with long-acting PrEP. The world must re-start and sustain the introduction of CAB for PrEP and the dapivirine vaginal ring (DVR) to make choice a reality. Investments by the Global Fund and Ministries of Health in PrEP must increase.

Peter Sands is pointing the way. The promise of HIV prevention is just as real as it was before the new administration took office. Only now we must find a new path. To stay on track will require trust, innovation, commitment and investment.

Let’s do it.

As the global research community confronts drastic cuts and extraordinary opposition to its work by the US government, the world cannot lose focus on the critical need for high-quality, impactful clinical research.

This Friday, The World Health Organization (WHO) will host a webinar to launch a series of articles to be published later today in Lancet Global Health, Shaping the Future of Clinical Trials.

At AVAC, we are especially pleased that one of the seven papers highlights the essential role of community engagement, referencing the Good Participatory Practice (GPP) guidelines, to improve research conduct and outcomes. This paper—Better engagement, better evidence: working in partnership with patients, the public, and communities in clinical trials with involvement and good participatory practice—is co-authored by AVAC’s Stacey Hannah and Jessica Salzwedel and partner, Catherine Slack of the HIV/AIDS Vaccine Ethics Group in South Africa. (For more about GPP, be sure to check out our online GPP Body of Evidence.) 

We hope you will look out for the series of papers later today and join the conversation Friday to learn more about WHO’s call to make engagement central to clinical trials. Together we will discuss systemic gaps, structural inequities, and solutions—including stronger policies, increased funding, better regulatory oversight, and a research culture that integrates GPP as essential to future clinical trials around the world.