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. 

From proposed elimination of the CDC’s HIV prevention program in the US to the uncertain future of foreign assistance around the world, the US administration’s sweeping policy changes threaten decades of progress in both domestic and global HIV efforts. This week’s newsletter examines these proposed cuts, ongoing lawsuits against the foreign aid freeze, plans to dismantle USAID, while also exploring the fate of NIH grants in South Africa and the mounting repercussions on communities and lives. Read on for more.

US CDC’s Uncertain Future

The administration is looking to slash an estimated $700M to $1B from the CDC’s Division of HIV Prevention (DHP), a vital pillar in the national fight against the HIV epidemic. These cuts mark a significant shift from the first Trump administration’s goal to end HIV in the US by 2030 when it launched the landmark US Ending the HIV Epidemic (EHE) initiative in 2019. In a sharp turn, the administration is now considering a proposal to defund many aspects of DHP and shift HIV prevention programs from CDC to the Health Resources and Services Administration (HRSA), which leads HIV care and treatment programs but has no HIV prevention experience.

IMPLICATIONS: Cuts to HIV prevention funding at the CDC would disrupt programs within each state, which rely on federal funding to carry out critical services. This can be expected to trigger a dramatic rise in HIV, STIs, and tuberculosis cases, reversing decades of progress and imposing heavy financial burdens on state healthcare systems. Moreover, key populations most vulnerable to HIV in the US may see disruptions in vital access to prevention services, in addition to the ongoing, systematic, erosion of rights of these communities. The cruel irony of dismantling the President’s own vision of EHE, is only matched by the tragic timing: as AVAC’s Mitchell Warren told The Well News, “So just as we are poised to deliver the newest innovation [with approval of injectable lenacapavir for PrEP expected in June] that could dramatically impact the epidemic and achieve the goal of his first term, the administration is pulling the rug out from under the whole ecosystem—in the US and internationally.”

READ: 

• Trump Administration Considers Scaling Back HIV Efforts at CDC—The New York Times
• Trump Administration Weighing Major Cuts to Funding for Domestic HIV Prevention—The Wall Street Journal
• Trump Administration Considering Plan to Eliminate HIV Prevention Program—The Well News

AVAC vs. Department of State and Other Court Cases

The AVAC vs. Department of State and Global Health Council vs. Trump twin lawsuits against the foreign assistance freeze made small steps forward this week. Following last week’s ruling requiring the government to pay USAID partners for billions of dollars in foreign aid work completed before Feb. 13, a new status report from the government, as required by the Court, indicates that payment for overdue bills has begun – slowly. Even though overall foreign assistance has yet to be restarted, more organizations report that they are finally receiving payments—new obligations beyond February remain uncertain. The Government is considering whether to pursue further appeals.

In related news, on Tuesday, a different US District Judge temporarily blocked the US DOGE Service from further dismantling USAID. The judge ordered the government to restore the agency’s headquarters and reestablish email access for thousands of employees.

IMPLICATIONS: It is unlikely that many of USAID’s implementing partners and programs will receive the funding needed to continue their critical work given the mass termination of contracts and jobs and overall dismantling of the agency. As Mitchell Warren told the New York Times, “We’ve got to snap out of any paralysis or any disbelief or shock, and we’ve really got to look at what needs to be built in the future.” The additional ruling about DOGE found the executive branch actions to eliminate USAID’s functions and issue mass layoffs to be a violation of the constitutional separation of powers. This ruling marks a critical setback for the administration. It remains in effect pending further court order.

FOLLOW ALONG: Follow progress of the case on our website.

READ: Maryland Judge Orders DOGE to Stop Efforts to Dismantle USAID—Washington Post

US Government’s New Plan for Restructuring Foreign Aid

A proposal to overhaul US foreign aid programs to “better serve strategic interests” appeared this week. The plan calls for renaming USAID as the US Agency for International Humanitarian Assistance—narrowing its scope to global health, food security, and disaster response—and moving it under the State Department. It also proposes merging the Millennium Challenge Corporation and the US Trade and Development Agency with the US International Development Finance Corporation to leverage private sector investment, counter China’s Belt and Road Initiative, and promote a more transactional approach to foreign policy. The proposal deems current aid efforts “inefficient and fragmented” and suggests that programs should have clear end dates, measurable success, and enhanced accountability through technologies like blockchain.

IMPLICATIONS: This restructuring could narrow the scope of assistance available to vulnerable populations and low-income countries and leave less room for long-term capacity building. 

READ:

• Trump Aides Circulate Plan for Complete revamp of foreign aid programs—Politico
• Exclusive: Inside the Closed-Door Meeting on USAID’s Future—Devex

Reauthorizing PEPFAR

In 2024, PEPFAR was reauthorized for just one year, breaking a 20-year trend of successive five-year reauthorizations that the lifesaving program has historically seen with strong bipartisan support in Congress. The current reauthorization expires next week, on March 25, amid unprecedented challenges. Champions of global health and evidence-based HIV prevention made clear the potential to end the epidemic or to lose decades of progress in fighting HIV at a March 13 US Congressional briefing.

Hosted by Congresswoman Robin Kelly (D-IL), the Congressional Caucus on Black Women and Girls, AVAC and the Global AIDS Policy Partnership (GAPP), participants all referenced the UNAIDS goal of ending AIDS as a public health threat by 2030. Angeli Achrekar, Deputy Executive Director of UNAIDS, described the grave risks of missing this moment: “The end is almost in sight. Yet, if we do not get to the end, we risk serious resurgence. Those gains, that have been made with so much investment and engagement by governments and American taxpayers, will be reversed. We risk backsliding in all this strategic engagement. It’s a reality we all have to face.” 

READ: PEPFAR: A Strategic Necessity for US Leadership and Global Health—AVAC

WATCH: Recording of the Congressional Briefing

The Impact of Funding Cuts and Frozen Aid

Nearly two months into the dismantling of foreign aid and funding for research, the threat to vulnerable communities is starkly evident. Last week, we highlighted how these cuts are affecting clinical trials and the development and rollout of new HIV prevention tools—such as long-acting injectables and HIV vaccines. This week, the World Health Organization, in a press conference, reported that the new administration’s pause on foreign aid has “substantially disrupted” HIV treatment supplies in eight countries, including Haiti, Kenya, Lesotho, South Sudan, Burkina Faso, Mali, Nigeria, and Ukraine, which will soon run out of life-saving medications.

Separately, former USAID Global Health director, Atul Gawande said in an interview that an estimated that 160,000+ will die from malaria per year, “hundreds of thousands [of the 20 million people dependent on HIV medicines] will die in a year” if USAID programs are not restored.

LISTEN: Atul Gawande on Elon Musk’s “Surgery with a Chainsaw”—The New Yorker Radio Hour

READ: 

• Nigeria and Kenya Among Nations Running out of HIV Drugs—BBC
• WHO Issues Starkest Warning Yet on Fallout from US Withdrawal of Aid for Global Health—STAT News

NIH Grants Involving South Africa at Risk

It has been reported that the new administration is considering terminating NIH grants that support work in South Africa. This comes after an executive order in February alleging discrimination against Afrikaners. The potential cuts could impact the extensive South African research infrastructure and top institutions like the University of Cape Town, University of the Witwatersrand, and Stellenbosch University. The latest slew of proposed terminations come amid NIH turmoil where many grants have already been cut, including any related to diversity and vaccine hesitancy.

IMPLICATIONS: This would severely disrupt critical HIV and tuberculosis research. Such abrupt funding cuts would halt or undermine clinical trials and have far-reaching global repercussions, while undermining decades of collaborative progress.

READ:

• Fear Spreads that NIH will Terminate Grants Involving South Africa—Science
• Fears Grow for R800 Million Cut to US Funding of Medical Research in South Africa—Spotlight

What We’re Watching and Reading

• ‘It’s Back to Drug Rationing’: The end of HIV was in sight. Then came the cuts—The Guardian
• ‘Fund Research not Tesla Trucks’: The HIV casualties of Trump’s war on science—Bhekisisa
• What will happen if Trump cuts the US’s Global Fund contributions? We work it out—Bhekisisa
• The sudden withdrawal of US foreign aid is unforgivable—The BMJ
• An Advocate Talks Bluntly about HIV in South Africa After PEPFAR—Positively Aware
• Seth Berkley Warns of an Era of ‘Polyepidemics’ as Cooperation Crumbles—Devex
• PEPFAR Cuts Hit Uganda’s Most Vulnerable—Foreign Policy
• Considerations for Capsid-targeting Antiretrovirals in Pre-exposure Prophylaxis—Trends in Molecular Medicine
• A Jab that Could Protect Against HIV for a Year at a Time, and Other Highlights from Major Conference—Spotlight (South Africa)

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

This week’s issue covers the latest developments in the AVAC vs. Department of State lawsuit, NIH’s termination of vaccine hesitancy research, new data revealing the deadly impact of foreign aid cuts on HIV, and renewed calls for African-led, sustainable health funding. Read on for more.

AVAC vs. Department of State

On Monday, US District Court Judge Amir Ali issued a 48-page ruling in AVAC vs. Department of State and Global Health Council vs. Trump, the twin lawsuits against the foreign aid freeze. The ruling orders the government to pay for work already completed and to spend congressionally appropriated funds for foreign assistance. However, Judge Ali’s order did not reinstate the mass cancellations of aid grants, leaving thousands of lifesaving programs in limbo. Lauren Bateman, lead counsel on AVAC’s case with Public Citizen Litigation Group, said “Today’s decision affirms a basic principle of our Constitution: the president is not a king. But we are painfully aware that, without unwinding the mass termination of foreign assistance awards, winning on the constitutional issues does not avert the humanitarian disaster caused by the Trump Administration’s freeze on foreign assistance. And it does not undo the damage that the freeze has already inflicted on millions of vulnerable people across the world. Deaths will continue to mount. While the courts have an important role to play in standing up for the rule of law, Americans need more than just the courts. We need Congress, which has always supported foreign aid on a bipartisan basis, to assert itself.”

IMPLICATIONS: Secretary of State Marco Rubio confirmed that 5,200 USAID programs—about 83% of the agency’s overall work—have been terminated, citing “tens of billions of dollars” spent in ways that allegedly “did not serve US interests”. The new administration will retain about 1,000 programs under the State Department’s oversight. Even if some contracts are eventually reinstated, the State Department has already eliminated a significant majority of USAID’s work and tens of billions of dollars in Congressionally approved spending. It is unlikely implementing partners and programs will receive the funding they need to start back up and continue their critical work.

FOLLOW ALONG: Visit our updated page summarizing the lawsuit.

READ:

• Judge orders Trump to pay USAID partners, rejects ‘unbounded’ power—Devex  
• Trump Avoids Worst-Case Ruling in Lawsuit Over USAID Defunding—Bloomberg 

NIH Cancels Grants on Vaccine Hesitancy

In a sweeping move, the National Institutes of Health (NIH) is terminating or scaling back dozens of grants focused on vaccine hesitancy and boosting vaccine acceptance, citing “misalignment with NIH funding priorities.” It is unclear whether new Department of Health and Human Services (HHS) Secretary, Robert F. Kennedy Jr. directed the cuts—his longstanding anti-vaccine views are concerning, especially since the Centers for Disease Control and Prevention (CDC) was recently instructed to revisit the debunked link between vaccines and autism. The NIH is also canceling grants tied to transgender issues, diversity, equity, and inclusion, and research involving Chinese institutions, reflecting the administration’s broader push to cut spending and reshape federal research priorities. 

IMPLICATIONS: Defunding these projects comes at a perilous time, given the reemergence of measles and declining immunization rates. By terminating research on vaccine hesitancy and acceptance, the NIH undermines efforts to build trust and increase uptake of essential prevention strategies, particularly among marginalized communities. This short-sighted approach risks widening existing health disparities and eroding decades of global progress toward equitable HIV prevention. 

READ:

• NIH to ax grants on vaccine hesitancy, mRNA vaccines—Science
• NIH to terminate or limit grants related to vaccine hesitancy and uptake—Washington Post

Reforming PEPFAR

Researchers are proposing strategic reforms to PEPFAR, which is up for reauthorization later this month. The recommendations would trim PEPFAR program costs by 20% in five years, and transition financial responsibility to local governments in high-burden regions. They focus on ramping up long‐acting PrEP as a key component of HIV prevention. As highlighted in the opinion piece by Jirair Ratevosian, PEPFAR has evolved far beyond its original “emergency plan,” becoming indispensable to global HIV prevention and treatment. Embracing these reforms, he writes, would ensure PEPFAR remains resilient and impactful amid rising infections, geopolitical strains, and domestic political uncertainty. 

READ:

• It’s Time for PEPFAR to Embrace Reform—Global Health Now 
• By executive order: The likely deadly consequences associated with a 90-day pause in PEPFAR funding—Journal of the International AIDS Society 

The Impact of Funding Cuts and Frozen Aid

Nearly two months into the dismantling of foreign aid and the research enterprise, the scale of the threat to vulnerable populations and global health is coming into sharper focus. New modeling data presented at CROI shows that nearly one in five children under one with HIV who experienced a treatment interruption in 2024 died, based on a review of over half a million children in US-funded PEPFAR programs. With major challenges to sustaining access to treatment since the new administration froze PEPFAR funds, the findings from this modeling study are a dire warning of the toll on lives to be expected from these policy changes. Meanwhile, clinical trials for new prevention tools, such as long-acting injectables and HIV vaccines, have been halted or scaled back, while organizations that built local research capacity and trust with communities now face staff layoffs and funding shortfalls.  

IMPLICATIONS: The loss of data from these canceled projects will undermine governments’ ability to sustain the HIV response, with or without U.S. support, and reduced investment in infectious disease research could drive up costs in the long run. 

READ:

• US funding cuts imperil search for HIV vaccine—Spotlight SA  
• PEPFAR study shows the deadly impact of stopping children’s HIV treatment—aidsmap  

Africa and Sustainable Health Funding 

Global health leaders are joining calls from civil society for African nations to break free from donor dependency by building self-sufficient, locally-driven health systems that prioritize their own needs and strategies. A rethinking of traditional aid models in favor of sustainable, equitable investments in health infrastructure and local research is needed and holding donor countries accountable for supporting true development rather than perpetuating reliance on external funding is imperative.  

READ:  

• After USAID: what now for aid and Africa?—BMJ  
• Africa’s defining moment: the time to lead the HIV response is now—Lancet Global Health

What We’re Reading

• Cuts to USAID-funded Research Another Blow to Global HIV Response—Devex
• US Funding Cuts Imperil Search for HIV Vaccine—Spotlight SA
• Opinion: Trump’s war on science imperils global development and cooperation—Devex
• Tuberculosis Resurgent as Trump Funding Cut Disrupts Treatment Globally—The New York Times
• Scoop: White House pulls CDC director nomination—Axios  

Resources

• Impact of US funding cuts on the global AIDS response—UNAIDS
• PEPFAR Watch
• Project 2025 Tracker
• Litigation Tracker—Just Security 
• Federal Government Outlays—DataETC

Many researchers and advocates are on their way home from San Francisco where the Conference on Retroviruses and Opportunistic Infections (CROI) just wrapped up. The science showcased the great promise and importance of research and made clear just how much is at stake. You can read more about the promise of scientific advances against the backdrop of the US government’s priorities here and here.